INTERSECTING VULNERABILITIES: THE IMPLICATIONS OF DISCLOSURE, STIGMA, AND MENTAL HEALTH FOR INDIVIDUALS LIVING WITH HIV IN SUB-SAHARAN AFRICA

Background: Living with HIV entails navigating complex structural, interpersonal, and intrapersonal realities within the healthcare system, peer and family relationships, and the community that can affect one’s psychosocial wellbeing. Disclosure of one’s HIV status can engender social support, but negative reactions to disclosure can contribute to stigma and poor mental health. These psychosocial aspects of living with HIV impact HIV treatment and overall wellbeing and require further scientific exploration with individuals throughout the life course to inform interventions in contexts where HIV is prevalent, especially sub-Saharan Africa. Methods: In Chapter Three, we provide a scoping review of the relationship between mental health and the HIV Care Continuum for adolescents living with HIV in sub-Saharan Africa. In Chapter Four, we characterize patterns of self-disclosure among adolescents living with HIV in Uganda and assess how choices of to whom to disclose are associated with depression and anxiety symptoms. In Chapter Five, we qualitatively explore gossip as a means of labeling people as living with HIV and as a form of HIV stigma in Botswana. Results: We found that adolescents living with HIV were assessed for mental health along the HIV Care Continuum disproportionately and primarily only at the “Engaged or Retained in Care” step. Adolescents living with HIV in Uganda chose to self-disclose their HIV status to their nuclear family members more often than to extended family or peers. This choice to self-disclose to nuclear family members was mostly associated with non-significant marginally fewer depression and anxiety symptoms compared to adolescents who did not self-disclose to these individuals. HIV gossip in Botswana was gendered and related to the cultural expectations of women and men in Setswana culture. Gossip removed one’s choice to self-disclose their HIV status, and both fear of gossip and experiencing gossip could lead to non-adherent behaviors to HIV treatment protocols. Conclusion: Further understanding of the experience of HIV through a biopsychosocial approach to inform resources and services that promote coping with living with HIV and strengthening social support for people living with HIV is necessary to improve quality of life and end the epidemic

Disclosure of same-sex practices and experiences of healthcare stigma among cisgender men who have sex with men in five sub-Saharan African countries

Background For men who have sex with men (MSM) across sub-Saharan Africa (SSA), disclosure of same-sex practices to family and healthcare workers (HCWs) can facilitate access to HIV prevention services and support, but can also lead to experiences of stigma. Methods We performed mixed-effects regressions on pooled data from MSM in Cameroon, Senegal, Côte d’Ivoire, Lesotho, and eSwatini to assess associations between disclosure and sexual behavior stigma in healthcare contexts; we used logistic regressions to analyze country-specific data. Results Compared to participants who had not disclosed to either family or HCWs, those who had disclosed only to family were more likely to have been gossiped about by HCWs (aOR = 1.70, CI = 1.18, 2.45); the association between having disclosed to family and having felt mistreated in a health center approached, but did not achieve, statistical significance (aOR = 1.56, CI = 0.94, 2.59). Those who had disclosed only to HCWs were more likely to have feared to seek health services (aOR = 1.60, CI = 1.14, 2.25), avoided health services (aOR = 1.74, CI = 1.22, 2.50), and felt mistreated in a health center (aOR = 2.62, CI = 1.43, 4.81). Those who had disclosed to both were more likely to have feared to seek health services (aOR = 1.71, CI = 1.16, 2.52), avoided health services (aOR = 1.59, CI = 1.04, 2.42), been gossiped about by HCWs (aOR = 3.78, CI = 2.38, 5.99), and felt mistreated in a health center (aOR = 3.39, CI = 1.86, 6.20). Country-specific analyses suggested that data from Cameroon drove several of these associations. Conclusions Research to determine the factors driving disclosure’s differential effect on healthcare stigma across contexts is needed. Ultimately, supportive environments enabling safe disclosure is critical to understanding HIV-acquisition risks and informing differentiated HIV-prevention, treatment, and testing services for MSM across SSA

Publisher Correction To: Disclosure of same-sex practices and experiences of healthcare stigma among cisgender men who have sex with men in five sub-Saharan African countries

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‘Mothers moving towards empowerment’ intervention to reduce stigma and improve treatment adherence in pregnant women living with HIV in Botswana: study protocol for a pragmatic clinical trial

Background With high rates of HIV and multiple vulnerable subgroups across diverse settings, there is a need for culturally based, HIV stigma reduction interventions. Pregnant women who are living with HIV are especially in need of services to protect not only their own but also their children’s lives. Uptake of HIV services worldwide is hindered by stigma towards persons living with HIV/AIDS. While cultural context plays a key role in shaping HIV stigma, these insights have not yet been fully integrated into stigma reduction strategies. By utilizing the “What Matters Most” stigma framework, we propose that an intervention to counter culturally salient aspects of HIV stigma will improve treatment adherence and other relevant outcomes. A pragmatic clinical trial in Botswana will evaluate the “Mothers Moving towards Empowerment” (MME) intervention, which seeks to address HIV stigma in Botswana and to specifically engage pregnant mothers so as to promote antiretroviral therapy (ART) adherence in the postpartum period. Methods This study will test MME against treatment as usual (TAU) among pregnant mothers diagnosed with HIV and their infants. Outcomes will be assessed during pregnancy and 16 weeks postpartum. Women who meet eligibility criteria are assigned to MME or TAU. Women assigned to MME are grouped with others with similar estimated delivery dates, completing up to eight intervention group sessions scheduled before week 36 of their pregnancies. Primary outcomes among mothers include (i) reducing self-stigma, which is hypothesized to mediate improvements in (ii) psychological outcomes (quality of life, depression and social functioning), and (iii) adherence to antenatal care and ART. We will also examine a set of follow-up infant birth outcomes (APGAR score, preterm delivery, mortality (at < 16 weeks), birth weight, vaccination record, and HIV status). Discussion Our trial will evaluate MME, a culturally based HIV stigma reduction intervention using the “What Matters Most” framework, to reduce stigma and improve treatment adherence among pregnant women and their infants. This study will help inform further refinement of MME and preparation for a future large-scale, multisite, randomized controlled trial (RCT) in Botswana. Trial registration ClinicalTrials.gov NCT03698981 . Registered on October 8, 201