Stigma and Judgment Toward People Living with HIV and Key Population Groups Among Three Cadres of Health Workers in South Africa and Zambia: Analysis of Data from the HPTN 071 (PopART) Trial.

Stigma and judgment by health workers toward people living with HIV (PLHIV) and key populations can undermine the uptake of HIV services. In 2014, we recruited health workers delivering HIV services from 21 urban communities in South Africa and Zambia participating in the first year of the HPTN 071 (PopART) cluster-randomized trial. We analyzed self-reported levels of stigma and judgment toward (1) PLHIV, (2) women who sell sex, (3) men who have sex with men (MSM), and (4) young women who become pregnant before marriage. Using logistic regression, we compared responses between three health worker cadres and explored risk factors for stigmatizing attitudes. Highest levels of stigma and judgment were in relation to women who sell sex and MSM, especially in Zambia. Heath workers did not generally think that clients should be denied services, although this was reported slightly more commonly by community health workers. Higher education levels were associated with lower judgmental beliefs, whereas higher perceptions of coworker stigmatizing behaviors toward PLHIV and each key population were associated with holding judgmental beliefs. Training experience was not associated with judgmental attitudes for any of the key populations. Our findings confirm a high prevalence of judgmental attitudes toward key population groups but lower levels in relation to PLHIV, among all cadres of health workers in both countries. Planning and implementing targeted stigma reduction interventions within health settings are critical to meet the needs of vulnerable populations that face more stigmatizing attitudes from health workers.

Development of parallel measures to assess HIV stigma and discrimination among people living with HIV, community members and health workers in the HPTN 071 (PopART) trial in Zambia and South Africa.

INTRODUCTION: Integrating standardized measures of HIV stigma and discrimination into research studies of emerging HIV prevention approaches could enhance uptake and retention of these approaches, and care and treatment for people living with HIV (PLHIV), by informing stigma mitigation strategies. We sought to develop a succinct set of measures to capture key domains of stigma for use in research on HIV prevention technologies. METHODS: From 2013 to 2015, we collected baseline data on HIV stigma from three populations (PLHIV (N = 4053), community members (N = 5782) and health workers (N = 1560)) in 21 study communities in South Africa and Zambia participating in the HPTN 071 (PopART) cluster-randomized trial. Forty questions were adapted from a harmonized set of measures developed in a consultative, global process. Informed by theory and factor analysis, we developed seven scales, with values ranging from 0 to 3, based on a 4-point agreement Likert, and calculated means to assess different aspects of stigma. Higher means reflected more stigma. We developed two measures capturing percentages of PLHIV who reported experiencing any stigma in communities or healthcare settings in the past 12 months. We validated our measures by examining reliability using Cronbach's alpha and comparing the distribution of responses across characteristics previously associated with HIV stigma. RESULTS: Thirty-five questions ultimately contributed to seven scales and two experience measures. All scales demonstrated acceptable to very good internal consistency. Among PLHIV, a scale captured internalized stigma, and experience measures demonstrated that 22.0% of PLHIV experienced stigma in the community and 7.1% in healthcare settings. Three scales for community members assessed fear and judgement, perceived stigma in the community and perceived stigma in healthcare settings. Similarly, health worker scales assessed fear and judgement, perceived stigma in the community and perceived co-worker stigma in healthcare settings. A higher proportion of community members and health workers reported perceived stigma than the proportion of PLHIV who reported experiences of stigma. CONCLUSIONS: We developed novel, valid measures that allowed for triangulation of HIV stigma across three populations in a large-scale study. Such comparisons will illuminate how stigma influences and is influenced by programmatic changes to HIV service delivery over time.

Evaluation of a mobile approach to gender-based violence service delivery among Syrian refugees in Lebanon.

As the landscape of humanitarian response shifts from camp-based to urban- and informal-tented settlement-based responses, service providers and policymakers must consider creative modes for delivering health services. Psychosocial support and case management can be life-saving services for refugee women and girls who are at increased risk for physical, sexual and psychological gender-based violence (GBV). However, these services are often unavailable in non-camp refugee settings. We evaluated an innovative mobile service delivery model for GBV response and mitigation implemented by the International Rescue Committee (IRC) in Lebanon. In October 2015, we conducted in-depth interviews with IRC staff (n = 11), Syrian refugee women (n = 40) and adolescent girls (n = 26) to explore whether the mobile services meet the support needs of refugees and uphold international standards for GBV service delivery. Recruitment was conducted via purposive sampling. Data were analysed using deductive and inductive approaches in NVivo. Findings suggest that by providing free, flexible service delivery in women's own communities, the mobile model overcame barriers that limited women's and girls' access to essential services, including transportation, checkpoints, cost and gendered expectations around mobility and domestic responsibilities. Participants described the services as strengthening social networks, reducing feelings of idleness and isolation, and increasing knowledge and self-confidence. Results indicate that the model requires skilled, creative staff who can assess community readiness for activities, quickly build trust and ensure confidentiality in contexts of displacement and disruption. Referring survivors to legal and medical services was challenging in a context with limited access to quality services. The IRC's mobile service delivery model is a promising approach for accessing hard-to-reach refugee populations with critical GBV services.

Individual and community-level risk factors for HIV stigma in 21 Zambian and South African communities: analysis of data from the HPTN071 (PopART) study.

OBJECTIVE: To describe the prevalence and determinants of HIV stigma in 21 communities in Zambia and South Africa. DESIGN: Analysis of baseline data from the HPTN 071 (PopART) cluster-randomized trial. HIV stigma data came from a random sample of 3859 people living with HIV. Community-level exposures reflecting HIV fears and judgements and perceptions of HIV stigma came from a random sample of community members not living with HIV (n = 5088), and from health workers (HW) (n = 851). METHODS: We calculated the prevalence of internalized stigma, and stigma experienced in the community or in a healthcare setting in the past year. We conducted risk-factor analyses using logistic regression, adjusting for clustering. RESULTS: Internalized stigma (868/3859, prevalence 22.5%) was not associated with sociodemographic characteristics but was less common among those with a longer period since diagnosis (P = 0.043). Stigma experienced in the community (853/3859, 22.1%) was more common among women (P = 0.016), older (P = 0.011) and unmarried (P = 0.009) individuals, those who had disclosed to others (P < 0.001), and those with more lifetime sexual partners (P < 0.001). Stigma experienced in a healthcare setting (280/3859, 7.3%) was more common among women (P = 0.019) and those reporting more lifetime sexual partners (P = 0.001) and higher wealth (P = 0.003). Experienced stigma was more common in clusters wherever community members perceived higher levels of stigma, but was not associated with the beliefs of community members or HW. CONCLUSION: HIV stigma remains unacceptably high in South Africa and Zambia and may act as barrier to HIV prevention and treatment. Further research is needed to understand its determinants.

Multilevel influences on acceptance of medical male circumcision in Rakai District, Uganda.

Despite access to safe medical male circumcision (MMC) and proven effectiveness of the procedure in reducing acquisition of HIV and other sexually transmitted infections, uptake remains suboptimal in many settings in sub-Saharan Africa, including Rakai District, Uganda. This study explored multilevel barriers and facilitators to MMC in focus group discussions (FGDs) (n = 35 groups) in Rakai. Focus groups were conducted from May through July 2012 with adolescent and adult males, with a range of HIV risk and reproductive health service use profiles, and with adolescent and adult females. Data were analyzed using Atlas.ti and an inductive approach. Participants' discussions produced several key themes representing multilevel influences that may facilitate or create barriers to uptake of MMC. These include availability of MMC services, economic costs, masculine ideals, religion, and social influence. Understanding how males and females view MMC is a crucial step towards increasing uptake of the procedure and reducing disease transmission.

An Evaluation of the CDC's Community-Based Breastfeeding Supplemental Cooperative Agreement: Reach, Strategies, Barriers, Facilitators, and Lessons Learned.

BACKGROUND: Community-based organizations (CBOs) have an important role to play in promoting breastfeeding continuation among mothers. The Centers for Disease Control and Prevention's Nutrition, Physical Activity, and Obesity Program's Cooperative Agreement Breastfeeding Supplement funded 6 state health departments to support CBOs to implement community-based breastfeeding support activities. OBJECTIVES: Study objectives were to (1) describe the reach of the Cooperative Agreement, (2) describe breastfeeding support strategies implemented by state health departments and CBOs, and (3) understand the barriers and facilitators to implementing community-based breastfeeding support strategies. METHODS: Qualitative and quantitative data were abstracted from state health departments' final evaluation reports. Qualitative data were analyzed for common themes using deductive and inductive approaches. RESULTS: Within the 6 states funded by the Cooperative Agreement, 66 primary CBOs implemented breastfeeding support strategies and reported 59 256 contacts with mothers. Support strategies included incorporating lactation services into community-based programs, training staff, providing walk-in locations for lactation support, connecting breastfeeding mothers to resources, and providing services that reflect community-specific culture. Community partnerships, network building, stakeholders' commitment, and programmatic and policy environments were key facilitators of program success. CONCLUSION: Key lessons learned include the importance of time in creating lasting organizational change, use of data for program improvement, choosing the right partners, taking a collective approach, and leveraging resources.

Attitudes Towards Power in Relationships and Sexual Concurrency Within Heterosexual Youth Partnerships in Baltimore, MD.

Sexual concurrency may increase risk for HIV/STIs among youth. Attitudes about gender roles, including power balances within sexual partnerships, could be a driver. We examined this association among Baltimore youth (N = 352), aged 15-24. Data were collected from February, 2011 to May, 2013. We examined whether index concurrency in male-reported partnerships (N = 221) and sex partner's concurrency in female-reported partnerships (N = 241) were associated with youth's attitudes towards relationship power. Males with more equitable beliefs about power were less likely to report index concurrency. Females with more equitable beliefs were more likely to report sex partner's concurrency. The relationship was significant in main and casual partnerships among females and main partnerships among males. The strongest associations were detected among middle-socioeconomic status (SES) males and low-SES and African American females. Implementing interventions that recognize the complex relationship between socioeconomic context, partner dynamics, gender, and sexual behavior is an important step towards reducing HIV/STI risk among youth.

Exotic Dance in Baltimore: From Entry to STI/HIV Risk.

Research has documented health risks associated with sex work, but few U.S. studies have focused on the exotic dance industry. We undertook this study to describe the factors that influenced women's entry into exotic dance and explored the relation of these forces to their subsequent sexually transmitted infection (STI)/HIV risk trajectory. Qualitative interviews (N = 25) were conducted with female exotic dancers from June through August 2009. Data were analyzed through Atlas-ti using an inductive approach. Economic vulnerability was the primary force behind women's initiation into the profession. Drug use, physical abuse, and enjoyment of dancing were often concurrent with economic need and provided a further push toward exotic dance. Social networks facilitated entry by normalizing the profession and presenting it as a solution to financial hardship. Characteristics of exotic dance clubs, such as immediate hire and daily pay, attracted women in a state of financial vulnerability. Women's motivations for dancing, including economic vulnerability and drug use practices, shaped their STI/HIV risk once immersed in the club environment, with social networks often facilitating sexual risk behavior. Understanding the factors that drive women to exotic dance and influence risk behavior in the club may assist in the development of targeted harm reduction interventions for exotic dancers.

Individual, partner, and partnership level correlates of anal sex among youth in Baltimore City.

Anal sex is an efficient mode of STI transmission and studies indicate that anal sex is common among heterosexuals, including adolescents. We examined the association between individual, partner, and sexual partnership-level characteristics with anal sex among a household survey of 263 individuals aged 15-24 years in Baltimore City, Maryland. We used weighted multiple logistic regression to examine correlates of anal sex in a heterosexual partnership by gender. Twenty-nine percent of males and 15% of females reported anal sex in a partnership in the past 6 months. For males, anal sex was associated with having two or more partners in the past 3 months (AOR = 13.93, 95% CI 3.87-50.12), having been tested for HIV (AOR = 0.30, 95% CI 0.12-0.72), and oral sex with a partner (AOR = 8.79, 95% CI 1.94-39.78). For females, anal sex was associated with reporting having a main partner (AOR = 6.74, 95% CI 1.74-23.65), partner meeting place (AOR = 3.03, 95% CI 1.04-8.82), partner history of STI (AOR = 0.20, 95% CI 0.05-0.85), and oral sex with a partner (AOR = 8.47, 95% CI 1.08-66.25). Anal sex was associated with inconsistent condom use for both males (OR = 5.77, 95% CI 1.68-19.79) and females (OR = 5.16, 95% CI 1.46-18.30). We conclude that anal sex is a prevalent risk behavior among heterosexual youth and is associated with a range of factors at the individual and partnership levels. These findings provide support for comprehensive sex education that includes information about anal sex; findings from this study can inform public health campaigns targeting youth at risk for STIs.

"This is our sanctuary": perceptions of safety among exotic dancers in Baltimore, Maryland.

Occupational safety researchers have increasingly recognized the important influence of social and structural factors on safety perception and behaviors in occupational settings. This qualitative study was conducted to explore the nature of the safety climate of exotic dance clubs in Baltimore, Maryland and the mechanisms through which this sexual geography informs dancers' perceptions of safety and experience of sex work. Structured observations and semi-structured qualitative interviews (N=40) were conducted with club dancers, doormen, managers, and bartenders from May through August, 2009. Data were analyzed using an inductive approach whereby themes emerged from the data itself. Atlas-ti was used for data analysis. Perceptions of safety within exotic dance clubs were born from an interplay between the physical, social, and symbolic environments. These perceptions were closely tied to dancers' construction of sex work inside versus outside the club. Understanding the contextual factors, which influence how dancers understand and prioritize risk in their work settings, is crucial for creating policies and programs, which effectively reduce risk in this environment.

More than a dance: the production of sexual health risk in the exotic dance clubs in Baltimore, USA.

Women who exchange sex for money, drugs, or goods are disproportionately infected with HIV and have high rates of illicit drug use. A growing body of research has underscored the primacy of environmental factors in shaping individual behaviors. HIV/STI rates among sex workers are influenced by environmental factors such as the physical (e.g., brothel) and economic (e.g., increased pay for unsafe sex) context in which sex work occurs. Exotic dance clubs (EDCs) could be a risk environment that is epidemiologically significant to the transmission of HIV/STIs among vulnerable women, but it is a context that has received scant research attention. This study examines the nature of the physical, social, and economic risk environments in promoting drug and sexual risk behaviors. Structured observations and semi-structured qualitative interviews (N = 40) were conducted with club dancers, doormen, managers, and bartenders from May through August, 2009. Data were analyzed inductively using the constant comparative method common to grounded theory methods. Atlas-ti was used for data analysis. Dancers began working in exotic dance clubs primarily because of financial need and lack of employment opportunities, and to a lesser extent, the need to support illicit drug habits. The interviews illuminated the extent to which the EDCs' physical (e.g., secluded areas for lap dances), economic (e.g., high earnings from dancers selling sex), and social (e.g., prevailing social norms condoning sex work) environments facilitated dancers' engaging in sex work. Drug use and alcohol use were reported as coping mechanisms in response to these stressful working conditions and often escalated sexual risk behaviors. The study illuminated characteristics of the environment that should be targeted for interventions.

Risks associated with crack cocaine smoking among exotic dancers in Baltimore, MD.

BACKGROUND: There is a dearth of research focusing on sex work in exotic dance clubs. We conducted a cross-sectional study to examine the prevalence and correlates of crack cocaine smoking among a sample of exotic dancers. METHODS: The "block," a historical red-light district in downtown Baltimore, MD, is comprised of 30 adult-entertainment establishments. Between 01/09 and 08/09, we conducted a survey with exotic dancers (N=98). The survey explored demographic, and drug and sexual/drug risk behaviors. Bivariate and multivariate analysis was conducted using Poisson regression with robust variance estimates to examine correlates of current crack smoking. RESULTS: Crack cocaine smokers compared to non-crack cocaine smokers were significantly more likely to report: older age (29 vs. 23 years, respectively, p<0.0001); being White (79% vs. 50%, respectively, p=0.008); having been arrested (93% vs. 67%, respectively, p=0.008); daily alcohol consumption (36% vs. 17%, p=0.047); current heroin injection (57% vs. 13%, p<0.001); and current sex exchange (79% vs. 30%, p<0.001). In the presence of other variables, crack cocaine smokers compared to non-crack cocaine smokers were significantly older, more likely to report current heroin injection, and more likely to report current sex exchange. DISCUSSION: We found high levels of drug use and sexual risk behaviors as well as a number of risks behaviors associated with crack cocaine smoking among this very under-studied population. Targeted interventions are greatly needed.