Authors
- Gesesew, Hailay MPH, Epidemiology
- Gebremedhin, Amanuel MPH, RH
- Demissie, Tariku Dejene MSc
- Kerie, Mirkuzie MD, MPH
- Sudhakar, Morankar PhD
Abstract
Review question/objective: The objective of this review is to identify the best available evidence regarding the association between perceived HIV-related stigma and presentation for HIV/AIDS care in developing countries.
Background: The 2012 UNAIDS global report indicates that approximately 34 million (31.4-35.9 million) people were living with HIV at the end of 2011 globally.1 This report also stated that an estimated 0.8% of adults aged 15-49 years worldwide are living with HIV; although the burden of the epidemic continues to vary considerably between countries and regions. In 2011, Sub-Saharan Africa had one of the highest prevalence of HIV in the world; estimated at 4.9% of adults aged between 15 and 49. Following Sub-Saharan Africa, the regions with the highest prevalence of HIV were the Caribbean, Eastern Europe and Central Asia, where 1.0% of adults were living with HIV in 2011.
HIV infected patients in Europe and Africa are often diagnosed at advanced stages of disease due to multiple factors.2 There is no consensus on what should be considered delayed HIV care presentation and several definitions have been used to date. Some define when the diagnosis of an AIDS-defining condition occurs either before or concomitantly to an HIV diagnosis,3 during the subsequent six months,4,5 or during the following year of an HIV diagnosis.6 Other definitions use CD4 cell count of <200 cells/[mu]l,7 or <350 cells/[mu]l.8 According to the 1993 expanded AIDS-surveillance case definition, persons presenting with a CD4 cell count <200 cells/[mu]l and/or with an AIDS-defining disease are considered as delayed for HIV/AIDS care.9
Reducing the time that elapses between infection and the initiation of Anti-Retroviral Therapy (ART) is important to decrease progression of the infection and to facilitate immunological recovery. Furthermore, delays in HIV/AIDS care can have serious public health implications. For example, opportunities to prevent further transmission through effective ART are lost and initiating treatment for HIV infection at an advanced stage leads to poorer outcomes than with early treatment.10 It also has economic implications for health services and society.11 Of the multiple factors that contribute to HIV-infected patients presenting late for HIV/AIDS care (i.e. to be diagnosed, tested or treated), researchers suggest that perceived HIV-related stigma plays a major contribution.
Stigma can be explained as a process of devaluation that leads to shame and significantly discredits an individual in the eyes of others.12 HIV-related stigma is multi-layered, tending to build upon and reinforce negative implications via the association of HIV and AIDS with already-marginalized behaviors, such as sex work, drug use and homosexual and transgender sexual practice.13 A study from Botswana suggested that HIV-related stigma was a primary barrier to HIV testing in Botswana and other Sub-Saharan African countries.14 The study showed that 40% of patients reported that they delayed getting tested for HIV and of these, 51% reported fear of a positive result as the main reason for delay in seeking treatment, which was often due to HIV-related stigma.
A case-case comparison from Venezuela also reported that fear of HIV-related stigma was a main barrier for HIV testing,15 and a case control study conducted in South Wollo, Ethiopia in 2010 found that people living with HIV/AIDS who perceived HIV stigma were three times more likely to present late to HIV/AIDS care than those who did not perceive HIV stigma.16 However, a case control study conducted in south west Ethiopia reported that HIV-related stigma was not related with time to present for HIV care.17 Of course, the measurement of perceived HIV-related stigma varies within the literature. For example, the studies conducted in Ethiopia used a 23-item, four point Likert scale,18 whereas another used a nine-item scale.19 Given there is ambiguity surrounding the association between perceived HIV related stigma and presentation for HIV care, the role of stigma as a potential barrier to the diagnosis and treatment of HIV among cohorts of individuals enrolling for HIV care in developing countries will be reviewed.
Article Content
Inclusion criteria
Types of participants
This review will consider studies that include HIV-positive participants aged 15 years and older in developing countries; defined as those countries listed as "low human development" on the 2013 WHO human development index rankings. Patients receiving prior HIV/AIDS care will be excluded from this review.
Types of exposure(s)
This review will consider studies that evaluate HIV-related stigma. HIV-related stigma may be measured using any validated tool, either by self-administered questionnaire or interviewing method for people living with HIV, health workers, or the general population.
Types of outcomes
This review will consider studies that include the following outcomes:
Time at presentation for HIV care, measured by immune status or stage of HIV infection. Early presentation for HIV care is defined as WHO stage I or II and CD4>=200 cells/[mu]L. Late presentation for HIV care is defined as WHO stage III or IV or CD4<200 cells/[mu]L.
Types of studies
This review will consider both analytical and descriptive epidemiological study designs including prospective and retrospective cohort studies, case control studies and cross sectional studies for inclusion, conducted in developing countries i.e. countries listed as "low human development" on the 2013 WHO human development index rankings.20
Search strategy
The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of MEDLINE and CINAHL will be undertaken, followed by analysis of the text words contained in the title and abstract and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference lists of all identified reports and articles will be searched for additional studies. Studies published in English will be considered for inclusion in this review, while non-English studies will be excluded. No limitations will be placed on date of publication.
The databases to be searched include:
Medline (PubMed interface), EMBASE, WHO Databases and CINHAL
The search for unpublished studies will include:
Hand searches of studies and different sources of grey literature including UNM/Health Sciences Library and Informatics Center, Cochrane Reviews, Gray Literature in Health Research,MedNar, Open Grey and other sources.
Initial keywords to be used will be:
HIV related stigma and late treatment, late testing, late diagnosis, delayed diagnosis, delayed testing, delayed treatment, delayed care, late care, HIV infection, HIV care, HIV testing, HIV diagnosis, HIV treatment
Assessment of methodological quality
Papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix I). If there are any discrepancies, a third reviewer will be consulted. Authors of primary studies will be contacted to clarify missing or unclear data.
Data collection
Data will be extracted from papers included in the review using the standardized data extraction tool from JBI-MAStARI (Appendix II). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives.
Data synthesis
Quantitative data will, where possible, be pooled in statistical meta-analysis using JBI-MAStARI. All results will be subject to double data entry. Effect sizes expressed as relative risk for cohort studies and odds ratios for case control studies (for categorical data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed statistically using the standard Chi-square. Where statistical pooling is not possible, the findings will be presented in narrative form including tables and figures to aid in data presentation where appropriate.
Conflicts of interest
All the reviewers (primary, secondary, and associate) declare that they have no competing interests.
Acknowledgements
We would like to extend our gratitude to JBI for giving us the indispensable training on systematic review and for funding the budget for this study. We are also grateful to pass our thanks to Jimma University/The Ethiopian Malaria Alert Center for making a conducive environment for such a chance.
References
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Appendix I: Appraisal instruments
MAStARI appraisal instrument[Context Link]
Appendix II: Data extraction instruments
MAStARI data extraction instrument[Context Link]
Keywords: Protocol; Presentation of HIV care; Developing countries; Adult population