Effects of HIV prevention messages on treatment-seeking and adherence for HIV-infected children in Maputo,Mozambique: A qualitative study

As antiretroviral treatment (ART) becomes more readily available to children in sub-Saharan Africa (SSA), it is important that the experiences of children and their caretakers be carefully examined from more than just a logistical perspective. This paper is based upon an original exploratory and qualitative study that focused on ART in Mozambique. Through in-depth semi-structured interviews, the study examined the experiences of 26 caretakers—primarily mothers—of pediatric patients aged 3–12 receiving ART through the Pediatric Day Hospital of the Maputo Central Hospital (Mozambique) as well as those of their clinicians (7 physicians and 2 dedicated nurses).The interviews focused on the effect of standard HIV prevention communications on pediatric treatment-seeking and ART adherence via several mediating factors such as: 1) Caretakers' sources of HIV information and their perceived reliability; 2) Levels of trust and communication between providers and patients/caretakers related to the completeness of discussions dealing with HIV risk factors and modes of transmission (particularly for the 19% of mothers interviewed who were uninfected themselves) and; 3) The potential propagation of shame and fear through HIV prevention messages which may contribute to sub-optimal adherence (marked, for example, by fear of involuntary disclosure to others in the child's household).The results indicate that all three of these mediating factors deserve further attention as caretakers did, indeed, report adverse effects on initial treatment-seeking and adherence for the children in their care broadly linked with these factors. As patients and their caretakers often must progress through several counseling sessions before or during commencement of ART, there is ample opportunity for these interpersonal and psychosocial factors to be addressed without the need for further financial or human resource allocations.     

Perspectives on disclosure among children living with HIV in India

BackgroundFollowing the widespread uptake of anti-retroviral therapy (ART), young children living with HIV are entering adolescence and beyond, necessitating disclosure of HIV status. However, few studies have described children's experiences following disclosure.MethodsWe assessed disclosure status among children attending HIV clinics at two tertiary-care centers in southern India. Children who had disclosure were administered a pre-tested questionnaire assessing their knowledge about HIV, ART, experiences following disclosure, perceived stigma and ideas about their future. The association of the children's responses with social desirability bias was examined using a modified social desirability scale.ResultsTwenty-four caregiver-child dyads participated in this study. They constituted a subset of children who had been told of their HIV diagnosis from a larger study of 247 dyads. Mean age at disclosure was 10.9 ± 2.5 years. Medical personnel were responsible for disclosure to 14 children, parents/caregivers to 3 children, both medical and care personnel together to 4 children and other relatives to remaining 3 children. Disclosure was met with acceptance by one-third of the children. Despite disclosure, five children did not know how HIV spreads, and three were unaware about how infection could be prevented. Notwithstanding their positive status, 20 children felt that they were treated well at school and by their immediate relatives, although 11 children mentioned that they needed to hide while taking ART. Social desirability bias did not play a role in the responses given by these children.ConclusionsThe rate of disclosure of HIV status among children living with HIV in India was low, even among older children. Most children accepted their status, but knowledge about HIV and ART was inadequate. Disclosure was predominantly performed by medical personnel, rather than the primary caregiver. Incorporating disclosure into the care process for older children is likely to be beneficial, and should be recognized as an iterative process with a need for incorporating cultural sensitivities and a comprehensive approach to health education.     

Meeting the needs of adolescents living with HIV through home based care: Lessons learned from Tanzania

PurposeHome based care is central to HIV care and support throughout Africa. Most programs have not addressed the unique needs of adolescents living with HIV, who display lower retention in HIV care and treatment adherence. This study examined the experiences of adolescents living with HIV in Tanzania in order to identify ways to improve home based care to better meet their needs.MethodsWe conducted a qualitative study in Dar es Salaam and Tanga Region consisting of in-depth interviews with 14 adolescents living with HIV, 10 primary caregivers, and 12 providers assigned to their households. Interviews examined adolescents' experiences of growing up with HIV, perceptions of current home based care, and challenges in increasing acceptability of services.ResultsWe found the program did not align well with adolescents' expectations. Adolescents felt home based care to be more relevant to their caregivers and did not form independent relationships with providers. They expressed anxiety that participation might lead to inadvertent disclosure of their status and consequent discrimination. Both adolescents and their caregivers felt disappointment that no material or financial support was available despite widespread poverty, although they appreciated receiving psychosocial support and practical referrals. Providers demonstrated motivation to work with adolescents but acknowledged lacking requisite skills such as ways to communicate with young people and key messages to deliver.ConclusionsDespite challenges, we identified feasible adaptations to make home based care more adolescent-centered. These include actively engaging adolescents in program design, improving provider training in communication with adolescents, and proactively addressing unrealistic expectations. Finally, increasing referral links to a wider range of services could improve program effectiveness by integrating it into a broader development approach.     

Young people's views on safety and preventing abuse and harm in residential care: “It's got to be better than home”

Young people who live in residential care are at greater risk of experiencing sexual abuse and other forms of abuse than those living in other out of home care placements. To better understand how young people perceive and experience safety in residential care, and the things that they most need to be and feel safe, a qualitative study was conducted with 27 Australian children and young people for the Royal Commission into Institutional Responses to Child Sexual Abuse. This paper describes young people's perspectives on what makes residential care safe: supportive relationships, stability and predictability, fair rules, and having some control over their environment. Young people said that safety could be improved with: better appreciation of the risks in residential care; better matching, staffing and oversight; and better-designed responses that involve young people themselves. The findings provide critical insights from young people themselves and argue that adults and institutions need to appreciate their views of safety so as to adequately respond.     

Changing methods of disclosure. Literature review of disclosure to children with terminal illnesses,including HIV

More than 30 years after the first discovery of the deadly HIV virus, and in the wake of increased knowledge of transmission, treatment and behavioral intervention development, parents are still faced with the difficult task of whether, when and how to inform their child about her or his HIV status. Except for some general ethical considerations, there are no national or international guidelines available for handling HIV status disclosure to a child by parents and health professionals. Most studies on disclosure address the problem of stigma and the barriers to disclosure of HIV-positive status by adults to their sexual partners, caretakers, families and communities, but very few studies focus on disclosure to HIV-positive children. The majority of the studies that address disclosure to children limit themselves to stipulating reasons for barriers to such disclosure instead of the skills and knowledge necessary for effective disclosure to a child. Increasing availability of therapy for HIV across the world presses the issue of disclosure to the child. Even so, disclosure for children who are HIV-positive due to vertical transmission continues to be very difficult. There is a lack of interventions that consider guidelines for healthcare professionals, parents or persons involved with taking care of HIV-positive children. These interventions should be designed in an understanding manner towards the culture where they might be implemented and be as appropriate in the view of integrating different family structures and the child's development.     

The Influence of Relationship Power Dynamics on HIV Testing in Rural Malawi

Using the theory of gender and power (TGP) and data from the Tsogolo la Thanzi (TLT) study, we examined how relationship power shapes young people's decisions to test for HIV in rural Malawi (N=932), a high-HIV prevalence setting undergoing rapid expansions in testing services. We used generalized estimating equations (GEE) to examine associations among five constructs of relationship power (socioeconomic inequalities, relationship dominance, relationship violence, relationship unity, and mistrust), perceived risk, and receiving an HIV test over a 16-month period. The results indicate that young Malawians are testing for HIV at relatively high rates, repeatedly, and not just during pregnancy. Over the study period, 47.3% of respondents received at least one HIV test outside of TLT (range: 0–4). The GEE analysis revealed that men and women with higher levels of relationship unity were less likely to test for HIV. For men, being a victim of sexual coercion was an additional barrier to testing. Women's testing decisions were more strongly influenced by perceptions of a partner's risk for HIV than their own, whereas men relied more on self-assessments. The results highlight that testing decisions are deeply embedded within the relationship context, which should be considered in future HIV testing interventions.     

Sexual Identity Disclosure and Awareness of HIV Prevention Methods Among Black Men Who Have Sex With Men

Black men who have sex with men (BMSM) are disproportionately affected by the human immunodeficiency virus (HIV) epidemic, yet we know little about how HIV-negative BMSM of different sexual orientations access HIV prevention strategies. Identity development, minority stress, and disclosure theories suggest that for people of different sexual orientations, disclosure of sexual identity may be related to health behaviors. We performed a latent class analysis on a sample of 650 BMSM (M_age = 33.78, SD = 11.44) from Atlanta, Georgia, to explore whether sexual orientation, disclosure of sexual identity, and relationship status were related to HIV prevention strategies, including awareness of PrEP (pre-exposure prophylaxis) and PEP (post-exposure prophylaxis) and frequency of HIV testing. We found three distinct BMSM classes referred to as (1) closeted bisexuals, (2) sexual identity managers, and (3) gay, out, and open; all classes primarily engaged in casual sex. Classes differed in their awareness and access to HIV prevention strategies. The closeted bisexual class was least aware of and least likely to access HIV prevention. Findings have important implications for future research, namely the consideration of sexual identity and disclosure among BMSM. With this knowledge, we may be able to engage BMSM in HIV/sexually transmitted infection (STI) prevention services.     

Timing and Sequence of Events: HIV Status Disclosure,Condomless Anal Sex,and Sexual Agreement Formation Among Same-Sex Male Couples

Despite the implications for human immunodeficiency virus (HIV) prevention and sexual health, little is known about the timing and chronological order of when same-sex male couples disclose their HIV serostatus, establish a sexual agreement, and first engage in condomless anal sex (CAS) in their relationships. Dyadic data from 357 dyads were used to describe when these respective events occurred; whether members of a couple concurred about when the events happened; and the chronological order of these events. For many, disclosure and CAS happened within the first month, whereas an agreement tended to occur much later (if at all). Couples’ concordance of when disclosure and agreement formation happened differed by their serostatus, whereas there was little difference by serostatus for CAS. The chronological order of these events revealed interesting patterns and varied substantially. Although two-thirds of partners reported disclosure had occurred first, some reported events happening on the same day. These findings reveal that the first few months in a same-sex male couple’s relationship is a critical time period for when information and decisions about sexual health occur. Suggestions are provided for how current and future HIV prevention efforts could assist couples with their sexual health needs.     

Fathers with HIV Disease and Disclosure to Children: Reported Experiences and Unique Characteristics

More than 1 million persons in the United States are living with HIV disease; many are parents. HIV-positive parents' decisions about whether to disclose their HIV status to their children has been of concern to social work researchers in recent years. Studies have focused almost exclusively on mothers; however, not only do HIV-positive fathers grapple with disclosure, they may possess unique characteristics that influence their decisions. This article describes the disclosure experiences of 41 HIV-positive custodial fathers of children ages 5 to 18. Biological, psychological, and social factors are addressed in the context of current disclosure theories.     

East African Mothers with HIV: Testing,Talking, and Transmission to Children

ABSTRACT

Experiences of African mothers with HIV can inform the development of services to prevent HIV transmission to children. A small qualitative study was conducted in Tanzania with six openly HIV-positive women. They suggest that counseling and HIV testing additionally benefit the mother beyond reducing HIV transmission to her child. They recommend that testing of couples would allow them to make plans and informed choices together concerning sexual behavior, childbearing, and prevention of HIV transmission to children.     

Embedded in relations—Interactions as a source of agency and life opportunities for care-experienced young adults

This paper explores how young people who have been in out-of-home care develop a positive agentic capacity. The analyses are based on longitudinal biographical interviews with 24 care experienced young people (age 16–32 years) living in Norway. At the time of the interviews, they were in the education system or working and described themselves as ‘doing well’. Through the application of a relational understanding of agency, this paper provides in-depth insights into how relations shape the biography, identity and decisions of young people with care backgrounds, scaffold positive possibilities and enhance their life opportunities.     

Social identity and alcohol in young adolescence: the perceived difference between youthful and adult drinking

This paper examines the evolving social identities of young adolescents in regard to alcohol and drinking culture in Norway. Detailed analysis of 29 focus group interviews and 32 individual interviews with 12–13-year-olds reveal a thorough negative attitude towards alcohol, especially when enjoyed by young people. Young adolescents found young people to be too irresponsible and immature to drink, while adults were portrayed as capable of enjoying alcohol without losing control or experiencing other negative effects. Through symbolic boundary work, they distanced themselves from adolescents who drank. The young adolescents rejected the idea that drinking alcohol was a sign of maturity; instead, they exhibited maturity by distancing themselves from drunk adolescents. We discuss how these findings reflect the participants’ socio-cognitive development, and how symbolic boundaries are often drawn against those closest in social distance. We conclude that boundaries between ‘adolescents’ and ‘adults’ are fundamental when understanding emerging adolescent social identities, especially when it comes to drinking and drinking culture.     

Marital Aspirations,Sexual Behaviors,and HIV/AIDS in Rural Malawi

We explore how marital aspirations are related to the sexual behaviors of adolescents and young adults in Malawi, where HIV/AIDS prevalence among adults exceeds 10%. We also consider whether the specter of AIDS is shaping ideals about marriage. By combining survey data (N = 1,087) and in‐depth interviews (N = 133) with young Malawians from the Malawi Diffusion and Ideational Change Project, we show that looking for and finding a suitable spouse are linked to sexual behaviors and, thus, HIV risks. Moreover, concerns about contracting HIV are closely tied to the ideal characteristics of a future spouse. Our findings draw long‐overdue attention to the importance of marital aspirations in understanding adolescent sexual behaviors and risks in the era of AIDS.     

Experiences of Young People with Harmful Sexual Behaviors in Services: A Qualitative Study

ABSTRACT

Young people are responsible for a significant number of the sexual offenses that are committed every year. These young people are generally referred to specialist services for treatment. This article explores the health characteristics and service experiences of 117 young people with sexual behavior problems, and the issues that services face when working with them. The study is based on analysis of 117 case files, identified from nine specialist services in the UK. The case files were thematically analyzed. Case files provided information on the following topics: the reasons why the young people were referred to harmful sexual behavior services; the young people’s personal characteristics; their medical and mental health problems; the young people’s interests and aspirations; their attitudes toward services and interventions; continued problematic sexual incidents in services; progress in services; and post-service experiences. Overall, the findings of the study indicate that these young people have a number of strengths, but often have problems across a range of personal and health domains. A number of them continue to remain sexually and generally violent in services, particularly in residential settings, which has risk management implications for staff.     

HIV Risk and the Freedom to Act Without Thinking: Alcohol Use and Sexual Behavior Among Adolescents on Probation

Through in-depth phenomenological interviews, 18 adolescents currently on probation describe how they make decisions about using alcohol and engaging in sexual behaviors. Two main threads emerge: they value spontaneity in sex and believe that they act spontaneously in regard to both sex and alcohol. At the same time, they describe being highly influenced by parents and peers. The researchers discuss the potential implications of these and other findings for HIV prevention and intervention.     

The invisibility of adolescent sexual development in foster care: Seriously addressing sexually transmitted infections and access to services

Adolescents residing in foster care are at higher risk for acquiring sexually transmitted infections (STIs) and human immune deficiency virus (HIV) compared to their non-foster care peers. A literature review was conducted to determine whether youth residing in foster care face different barriers to sexual health care compared to their peers in the general population and, if so, what those barriers are. The review revealed barriers common to adolescents in general as well as additional barriers specific to the ecosystem of adolescents in foster care. Systemic issues that decreased access to sexual health services included child welfare policies that were either missing or implemented without fidelity; complicated financial factors; barriers to service utilization; lack of collaboration between child welfare and medical professionals; and limited information provided to foster youth on their sexual health and development. Consent and confidentiality issues that foster youth face in seeking sensitive health services also need to be resolved. More research is needed on how to facilitate development of coherent policies and effective practices that promote sexual health care access for adolescents in foster care.     

Tell It Slant Sex,Disclosure, and HIV

Encounters with HIV can tell us much about how we as individuals communicate about and view our bodies and most intimate selves—how we view and approach truth, lies, sex, and trust. Better ways of handling issues of disclosure in conjunction with changed sexual practices can be crucial to thwarting the HIV pandemic. We interviewed in depth 59 HIV-infected and 18 uninfected gay, bisexual, and heterosexual men and women. Five strategies emerged for dealing with disclosure and safer sex. Clinicians and policymakers need to be as aware and sensitive as possible to the perspectives of men and women grappling with these issues.     

HIV Testing Among Heterosexual Young Adults: The Influence of Partners' Risk Behaviors and Relationship Dynamics

Using relational theory and survey data from the Toledo Adolescent Relationships Study (n = 665), this article examined whether individuals were tested for HIV while intimately involved in a current or recent heterosexual relationship. The analyses included the respondent's and partner's sexual risk factors (non-exclusivity and lifetime number of partners), relational variables, prior testing, and demographic characteristics. It was found that 39% of respondents had an HIV test while involved in their current or most recent sexual relationship, and women (47%), compared with men (29%), were significantly more likely to have been tested. Whereas some predictors operated similarly (number of sex partners and pressured to have sex), others displayed significant gender differences (partner's sexual exclusivity, sexual communication difficulties, and pregnancy), particularly related to women's testing behaviors. Excerpts from qualitative interviews with male respondents suggested that some relational dynamics, not well reflected in relational theory, played a role in their testing. Results highlight the need to consider gendered dynamics when targeting young adults for routine HIV testing.     

“You Still Need to Give Her a Token of Appreciation”: The Meaning of the Exchange of Money in the Sexual Relationships of Out-of-School Adolescents in Rural Southwest Uganda

This article challenges the pervasive assumption that exchanging gifts and money in adolescent sexual relationships is transactional. Data were derived from a multi-method, qualitative sexual health needs assessment of 31 out-of-school adolescents in rural southwest Uganda. Grounded theory analysis allows contextual meanings of exchange to emerge. Adolescents have developed gendered courting and exchange models that parallel marital relationships in this cultural context. Whereas exchange is considered transactional and immoral in some types of relationships, in adolescent relationships, it is not. Young women are not ashamed of, or stigmatized by, the exchange; they are proud of it. The exchange signifies several things: self-respect and a partner's willingness to wait for the relationships to become sexual and, therefore, that they are valued and respected by their partners. This demonstrates commitment from a partner, whose role is as a provider. To expect no gift or to have sex for pleasure are the hallmarks of the worst kind of woman—a malaya. “Need” is the only acceptable rationale for extramartial sex for any woman in this sexual value system. Interventions promoting longer courting and sustained support for one partner would encourage a delay in debut for young women and encourage greater monogamy in young men.