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Awareness of U=U increasing, but HIV-negative MSM still less likely to believe in its accuracy

Two recent US studies find growing awareness and acceptability of the Undetectable = Untransmittable (U=U) message among men who have sex with men (MSM). However, a misunderstanding of transmission risk remains, with many still believing that HIV-positive partners can transmit the virus sexually, despite having an undetectable viral load.


While over half of a large sample of MSM from around the US perceived U=U to be accurate, the majority of those who thought so were HIV-positive men, while nearly 50% of HIV-negative men and those who did not know their status still perceived U=U as not completely accurate. This research was carried out by Dr Jonathon Rendina and colleagues at City University of New York and published yesterday in the Journal of Acquired Immune Deficiency Syndromes. According to another recent study by Dr Steven Meanly and colleagues at the University of Pennsylvania and published in the November issue of Sexually Transmitted Diseases, 70% of the young HIV-negative (or unaware of their status) MSM sampled in the US Mid-Atlantic region were aware of the U=U message. However, just over a third rated the statement as completely accurate.

There is now wide-ranging scientific consensus that those on successful antiretroviral therapy (ART) for six months or more with a suppressed viral load cannot transmit the virus sexually. Treatment as Prevention (TasP) for HIV is supported by the World Health Organization, US Centers for Disease Control and Prevention and various public health organisations worldwide. Many researchers and activists have aimed to spread this message far and wide, with some proclaiming that TasP or U=U is a human rights issue. It has legal, social, behavioural and public health implications; it could potentially reduce stigma towards those living with HIV.

However, there has been limited research into the acceptability and perceived accuracy of the U=U message. Prior research with MSM in New York City found that while 70% perceived pre-exposure prophylaxis (PrEP) as offering “a lot of” or “complete” protection against HIV infection, only 39% said the same about being undetectable.

The studies

Both studies collected web-based survey data from men recruited from social media sites and hook-up apps such as Grindr.

Data for Rendina’s study were collected between 2017-2018. Regarding U=U, participants were asked: “With regard to HIV-positive individuals transmitting HIV through sexual contact, how accurate do you believe the slogan Undetectable = Untransmittable is?” with options ranging from completely inaccurate to completely accurate on a four-point scale and an option to indicate not knowing what undetectable meant.

The final sample consisted of 111 747 men. A majority were white (62%) and identified as gay (79%) and were recruited from a networking app (92%). Just over half reported an HIV-negative status and were not on PrEP, while 13% of the sample were on PrEP. Thirteen per cent reported an HIV-positive undetectable status, with 2% reporting being HIV positive and detectable or unsure. Recent recreational drug use was reported by 61%, recent condomless anal sex by 56% and 63% of the HIV-negative men reported an HIV test in the past six months. Eighty-eight per cent of HIV-positive men reported excellent adherence.

Meanly recruited participants between late 2018 and earlier this year; participants were eligible for inclusion if they were aged 18-25, identified as cisgender males, self-reported as HIV negative or unaware of their status, had sexual contact with a man in the past six months and were living in the Philadelphia, Baltimore or Washington DC areas. The final sample consisted of 264 men.

Participants responded to questions such as: “How familiar are you with the U=U campaign?” with options ranging from not at all to very on a four-point scale. Average age of participants was 22, the majority were white (64%), identified as gay (81%) and were college educated (62%). Similar percentages were either aware or PrEP and had no intention to use it, or had used PrEP (39% for both categories). There were high levels of both condomless anal sex in the last three months (75%) and HIV testing in the past six months (70%).

Rendina found that the majority of HIV-positive men (84%) perceived U=U to be somewhat or completely accurate. This was in contrast to only 54% of HIV-negative men and 39% of men who did not know their status. Nearly a quarter of HIV-negative men stated that U=U was completely inaccurate.

During the course of the study, the odds of increased belief in U=U increased each month by 2% for HIV-negative men (or men of unknown status) and 3% for HIV-positive men, indicating a growth in acceptability of the message over time.

Among HIV-negative men or those of unknown status, those not on PrEP were less likely to rate U=U as accurate (adjusted odds ratio 0.36 and 0.4 respectively) while HIV-positive men with detectable viral loads were also less likely to rate U=U as accurate (AOR 0.51). HIV-positive men who reported excellent treatment adherence were more likely to perceive U=U as accurate.

“HIV-negative men with more exposure to prevention and testing services are more likely to rate U=U as accurate.”

For HIV-negative men, recreational drug use, condomless sex and regular HIV testing were associated with higher levels of perceived accuracy of the U=U message.

Trust in U=U differed in relation to a partner who was insertive (top) or receptive (bottom): only 10% of the entire sample believed that there was zero risk when the top partner was undetectable during condomless sex, rising to 14% if the bottom partner was undetectable. For those who believed that U=U was completely accurate, these numbers only went up to 31% for the top partner and 39% for the bottom partner, indicating that many men still perceived some level of risk for contracting HIV.

The study by Meanly with young HIV-negative MSM found high levels of overall awareness of the U=U message as 70% of those surveyed had heard about it. Awareness of U=U was associated with increases in age (OR 1.34), a college education (OR 1.74) and being on PrEP (OR 2.46), with those further along the PrEP continuum more likely to be aware of U=U. Recent HIV testing was also associated with increased U=U awareness (OR 1.94).

In terms of the perceived accuracy of the message, only 38% on men who had heard about U=U rated it as completely accurate, with just under 5% rating it as completely inaccurate. As with Rendina’s study, those on PrEP and those who had had a recent HIV test were more likely to rate the message as accurate.

While there appears to be growing awareness and acceptability of the U=U message, HIV-positive men continue to rate U=U as more accurate than HIV-negative men and those who do not know their status. Both studies reveal interesting findings regarding acceptability of U=U among HIV-negative men. Those with more exposure to prevention and testing services are more likely to rate U=U as accurate.

Steven Meanly concludes: “Because the U=U campaign’s aim is to dually combat HIV incidence and stigma through TasP, identifying how to strengthen the U=U’s campaign scale-up remains a priority, particularly among young MSM who are sceptical or exhibit stigmatizing attitudes toward people living with HIV.”


Author: Krishen Samuel


Communities can make – or break – strategies to curb HIV

They need greater recognition as equal partners in the fight against HIV as well as resources to continue doing the critically important work they are doing

Photo: Getty Images

Photo: Getty Images Photo: Getty Images

Communities have long played a critical role in the fight against HIV. Their activism and advocacy have greatly influenced the response to HIV/AIDS over the past four decades.

From the early 1980s, communities have fought for the rights and needs of those most affected. For example, faced with stigma and discrimination, gay communities in the US provided prevention advice, care and support. They also fought for treatment development and access.

By the mid-1980s the extent of the pandemic elsewhere in the world was becoming apparent. International, regional and local community activism became instrumental in fighting for access to treatment and stronger policy-level interventions.

Communities across Africa, as well as those representing vulnerable groups such as sex workers, began to demand inclusion in the fight against HIV.

Nowhere was this more pronounced than in South Africa, which continues to carry the highest burden of HIV in the world. By the late 1990s community mobilisation and activism were at the heart of much of the debate around HIV/AIDS.

The victories they secured were particularly notable. Fighting against an administration that denied the existence of a link between HIV and AIDS, communities and advocacy groups successfully mobilised action on a number of fronts. They fought for – and won – the provision of nevirapine to HIV-positive pregnant women and later fought for the provision of ARV treatment to all HIV positive people.

Communities continue to be vital in efforts to bring the pandemic under control, proving themselves as custodians and keepers of rich knowledge that creates the context in which HIV transmission occurs. They can also be the catalyst for the social change that is needed to reduce future HIV transmission in key populations. One such example is HIV infections among young women, who remain the most vulnerable group in southern Africa.

Social norms

Why are communities fundamental to future HIV prevention intervention designs? The answer lies in the fact that HIV transmission is profoundly social.

In sub-Saharan Africa, HIV is transmitted primarily in the context of heterosexual sex, which is shaped and controlled by social and cultural norms. Research highlights a host of social practices that hinder HIV prevention efforts. These include:

  • struggles to negotiate condom use in relationships,
  • the use of vaginal products to enhance sex,
  • issues of stigma, sexual violence and poverty, and
  • access to sexual and reproductive health care services.

Individual models of understanding risk don’t capture the full complexity of HIV transmission. This is because HIV transmission is rooted in social practices, and influenced by the broader context.


A good way to illustrate this is by considering factors that drive HIV transmission among young women. They are the most burdened by HIV in east and southern Africa and accounted for more than a quarter of new infections in 2018 – and yet they make up only 10% of the population.

Additionally, young women have higher rates of HIV infection than their male counterparts, acquiring HIV between five to seven years earlier than their male peers.

This gender imbalance in HIV infection is the result of many different factors that cut across the context in which women negotiate their lives. These range from biological vulnerabilities (including genital inflammation and the microbial diversity of the vagina), to relationships, their familial context, school completion rates and the broader socio-political world.

This means that preventing HIV transmission demands a deep engagement with the social, cultural, community and political factors that produce vulnerability and risk.

In HIV prevention this involves designing interventions that tackle the complexity of how young women come to be infected and what potential prevention efforts need to be taken.

But this can only succeed if there’s a deeper effort to include communities in the design of interventions that are responsive to local settings. This could, for example, include tackling harmful social norms, ensuring that women who need them have access to prevention technologies and treatment. They could also include empowering young girls, and tackling negative gender norms and gender based violence.

The roll-out

Communities have a critical role to play in ensuring that prevention interventions move from the realm of proven efficacy to real-world effectiveness.

A range of new HIV prevention technologies, such as treatment and prevention, including the oral Pre-exposure Prophylaxis (PrEP) and voluntary medical male circumcision, are now available. Yet global HIV incidence has declined by less than 2% per year since 2010.

Research shows that these new HIV prevention modalities – such as PrEP – are underutilised. In addition, 38.5% of those infected are not receiving treatment. Retention in care remains suboptimal.

The big question is how to get people to use what is available.

Engagement is an important part of the answer as communities create the social context that not only supports, but facilitates the linkage of those who need HIV prevention and treatment services.

For adolescent girls and young women in particular, communities could support comprehensive sexual health education, leading the way in respecting their rights to independently access sexual and reproductive health services. Communities can help target negative social and gender norms that increase the vulnerability of young women. Examples include ensuring young women who seek prevention or treatment aren’t stigmatised or discriminated against.

Communities can also play a role in holding governments accountable for ensuring that services are accessible to all those who need it.

Next steps

UNAIDS affirms the importance of communities in the fight against HIV through “communities making a difference”.

But communities need more. They need greater recognition as equal partners in the fight against HIV as well as resources to continue doing the critically important work they are doing.The Conversation

Hilton Humphries, Behavioural Scientist, Centre for the AIDS Program of Research in South Africa (CAPRISA)

This article is republished from The Conversation under a Creative Commons license. Read the original article.



Little Elves spend weekend wrapping 5,000 gifts for people living with AIDS

“Every gift has a card and someone signs every one and includes a Joyeux Noël or Merry Christmas. So they don’t feel alone. Even though they don’t know us, they know that someone thought of them.”

Sylvain Duhamel, Chief Elf Officer (CEO) of the Little Elves Foundation, and helpers wrap gifts for isolated or underprivileged people on Saturday, Dec. 7, 2019. DAVE SIDAWAY / MONTREAL GAZETTE

Wearing wide yellow suspenders under a red apron, white-bearded chief elf Sylvain Duhamel is standing in a corner overseeing his workshop: a classroom at Collège Jean-de-Brébeuf.

Gifts are piled on tables along the walls. For adults, they include blankets, socks, puzzles, notebooks, reusable cups and tins of cookies; for children, games, dolls, dominoes, candy and colouring books.

It’s Saturday morning and, as an assistant wearing a pointy green hat plays White Christmas on a piano, Duhamel and dozens of volunteers are scrambling. They have only two days to wrap 5,000 presents.

The brightly colored boxes must be ready by early Monday when trucks will carry them to 55 hospices and community organizations across Canada that help isolated and underprivileged people living with HIV-AIDS.

Duhamel, founder of the Little Elves Foundation, started the annual tradition anonymously and on a much smaller scale during the Christmas of 1991, soon after his brother Alain died of AIDS at age 31.

“I had been there for him for the two years he was sick,” Duhamel said during a break in the gift-wrapping frenzy. “I missed my brother and I knew some people were alone, so I decided to do something for those who didn’t have anyone.”

So he bought gifts and showed up at the door of a few Montreal hospices.

“At the first house I visited, the guy who answered the door, a resident, asked me: ‘Who are the gifts from?’ And I wanted to be anonymous and add to the magic of Christmas, so I said: ‘A little elf,’ ” Duhamel recalled.

He kept his acts of kindness secret until six years later when he told his now-husband. They decided to tell others and the project has grown steadily since. In 2002, the foundation, a non-profit charitable organization, was created so tax receipts could be given to donors.

In the early years, the gifts were wrapped at Duhamel’s house. But by 2004, more than 1,000 were to be given out and new digs were found at Collège Jean-de-Brébeuf in Côte-des-Neiges.

Over the past 28 years, more than 57,000 gifts have been handed out, not including those about to be distributed.

The presents — average price: $8 — are given to “people affected by HIV-AIDS who are in need,” he said. “We define ‘in need’ as lonely or poor.”

This year, 963 children will benefit. Presents will also go to several homeless shelters because some people living on the street have AIDS, Duhamel said.

“Every gift has a card and someone signs every one and includes a Joyeux Noël or Merry Christmas. So they don’t feel alone. Even though they don’t know us, they know that someone thought of them.”

Businesses lend a hand. Two trucking companies, Transport Robert and Kindersley Transport, help with shipping. Jouets Choo Choo, a toy store, co-ordinates the purchase of discounted children’s gifts.

Little Elves raised $40,000 this year to buy the presents. Half came from the sale of sweet and spicy nuts at a kiosk at Jean Talon Market’s Marché des Saveurs du Québec. The rest comes from donations.

“We buy as many gifts as we can with what we raise,” Duhamel said.

“The demand this year is for 5,800 at the organizations who have signed up, but we will only reach 5,000. There are 800 people who won’t get gifts, but all the kids are covered.”

The presents are stored at Duhamel’s home and were delivered to the school on Friday evening. Then, about 180 elves were to work from 8:30 a.m. to 6 p.m. on Saturday and Sunday to prepare the gifts to be ready for shipping on Monday.

Once they’re on their way, the elves rest until next fall, though the organization accepts donations year-round.

Duhamel, a landscaper by day, said the situation has improved for people living with AIDS over the past three decades.

“It was very difficult when my brother died. He spent seven months in the hospital. It was a time when the doctors and nurses didn’t know what to do. Everything was experimental.

“There are treatments now. But people are still living with the loneliness of it because many are still rejected by their families. Christmas is a very difficult time.”



Little Elves spend weekend wrapping 5,000 gifts for people living with AIDS

The Black Women’s Health Imperative Unveils First-Of-Its-Kind Policy Agenda Addressing HIV/AIDS Epidemic Among Black Women

Washington, DC, December 06, 2019 –(– Today, the Black Women’s Health Imperative (BWHI) released its national HIV/AIDS policy agenda on Black Women’s Health titled The HIV/AIDS Policy Agenda for Black Women. The agenda also features contributions from other leading women’s health organizations, which include the Positive Women’s Network, AIDS United, SisterLove, Inc., and Women Organized to Respond to Life-Threatening Diseases (WORLD).

Black Americans have been disproportionately impacted by HIV and AIDS since the epidemic’s beginning, and that disparity has deepened over time. While representing only 12 percent of the United States population, Black Americans accounted for almost half (42 percent, or 476,100) of the estimated 1.1 million people living with HIV (PLHIV), both diagnosed and undiagnosed, and almost half (44 percent) of those diagnosed with HIV in 2016.

“We must continue to raise the health profile of Black women and the specific health-related needs and interests of Black women if we are to ever have a chance of ending the HIV epidemic by 2030,” said Valerie Rochester, Vice President for Program Strategy at AIDS United. “This policy agenda offers unique guidance on how legislators and policy makers can best ensure the needs of Black women are elevated.”

The HIV/AIDS Policy Agenda for Black Women covers several vital issues, which include prevention of future HIV infections and identifying research priorities, access to comprehensive treatment for all Black women living with HIV, and the provision of essential supports, beyond medical treatment, that improve the emotional and physical wellbeing of Black women who are living with HIV. Under each key area, BWHI includes a thorough discussion regarding important policy issues facing Black women today.

“Black women must finally be a priority in policy directed towards the prevention of HIV and other sexually transmitted infections, and one of our goals is to ensure that a spotlight is placed on how to end the epidemic among cis and transgender Black women,” said Linda Goler Blount, President & CEO of the Black Women’s Health Imperative. “We are excited to release this first-of-its-kind policy agenda, which offers our nation a framework for addressing some of the health inequities of HIV/AIDS for Black women and girls.”

The policy agenda was unveiled and discussed today during the National Organization of Black Elected Legislators (NOBEL Women) Annual Legislative Breakfast at the National Black Caucus of State Legislators (NBCSL) annual legislative conference in Fort Lauderdale, Florida.

“The release of the HIV/AIDS Policy Agenda for Black Women today at our annual breakfast was monumental because our organization aims to remain at the forefront of evaluating, recommending and championing policy and programming solutions that will alleviate economic and health disparities in our communities,” said State Representative Karen Camper (D-TN) and National President of NOBEL Women. “We commend the Black Women’s Health Imperative for this important work and look forward to collaborating to combat this epidemic in our nation.”

The Black Women’s Health Imperative is a national non-profit organization dedicated to advancing health equity and social justice for Black women, across the lifespan, through policy, advocacy, education, research and leadership development. The organization identifies the most pressing health issues that affect the nation’s 22 million Black women and girls, like HIV/AIDS, and invests in the best of the best strategies and organizations that accomplish its goals.

The policy agenda is available for download here: For more information about the Black Women’s Health Imperative, please visit

Contact Information:
Black Women’s Health Imperative
Monica Coleman
Contact via Email

Read the full story here:



Why This New Strawberry-Flavored HIV Med Is a Game Changer

“This is excellent news for all children living with HIV.”

Until last month, HIV drugs for babies and toddlers came in hard-to-swallow pills or yucky-tasting syrups. But now, Cipla, a manufacturer of generic drugs in India, has created Quadrimune. Its pediatric formulation comes in strawberry-flavored granules that allow it to be sprinkled on food or mixed in milk, reports The New York Times.

What’s more, the drug will likely be priced at $1 a day.

The med could save thousands of lives each year, notably in Africa, where nearly 80,000 babies die annually because of HIV.

“This is excellent news for all children living with HIV,” Winnie Byanyima, the executive director of United Nations AIDS agency UNAIDS, told the Times. “We have been eagerly waiting for child-friendly medicines that are easy to use and good to taste.”

A research arm of Doctors Without Borders is conducting a clinical trial of the med on HIV-positive infants (it has been tested in adults). And the Food and Drug Administration (FDA), which approves meds for use in the United States, is currently reviewing Quadrimune. FDA approval means that the World Health Organization would likely certify it as well—possibly as soon as spring 2020.

Check out the Times article for more about Cipla and pediatric HIV meds.

In related POZ news, see “Rapidly Treating Infants Born With HIV Shrinks the Viral Reservoir.” And to learn more about Byanyima, see the August article “Meet the New Leader of the United Nations AIDS Program.”


Author: Trenton Straube


WHO recommends rapid dual HIV/syphilis tests for pregnant women

New policy brief recommends screening for HIV and syphilis using a single test to reduce mother-to-child transmission of syphilis, which is linked to 200,000 stillbirths annually.

Thai baby

Syphilis is the second most common cause of stillbirth in the world but testing and treatment for this sexually transmitted infection (STI) among pregnant women is poor in many countries, and much less common in antenatal care than HIV testing and treatment.

Globally, there has been marked progress towards eliminating mother-to-child transmitted HIV but progress is much slower for preventing congenital syphilis, with around 660,000 cases reported in 2016. More than 350,000 of these led to birth complications, including 200,000 stillbirths and neonatal deaths.

To close the gap, the WHO has released a new policy brief recommending countries offer a single finger-prick rapid diagnostic test that screens for HIV and syphilis simultaneously.

These simple tests can detect antibodies to both Treponemal pallidum (the cause of syphilis infection) and HIV, and can be carried out in health facilities rather than being sent for laboratory analysis. This means results are available quickly, enabling those who test positive for either infection to start treatment. They are also cheaper compared to standard, separate testing.

However, because the dual test does not differentiate between active or past syphilis infection, a past syphilis infection may still produce a positive result. For this reason, the WHO recommends that any woman testing positive for syphilis be prescribed benzathine penicillin then referred for further testing for a final, confirmatory diagnosis.

Countries introducing the dual HIV/syphilis test into antenatal care will need to revise their HIV testing strategy for pregnant women. This is because the testing strategy needed for dual detection of HIV and syphilis differs from the recommended strategies for separately testing for HIV or syphilis. In particular, it is important not to offer the dual test to women living with HIV who are taking antiretroviral treatment, those with an existing syphilis infection which is being treated, and for retesting for HIV.

In addition to increasing syphilis testing and treatment, use of the dual-purpose test will save costs in several ways. It has the potential to simplify the training of testers because it requires staff to learn one testing method rather than two. It will also reduce storage and transportation costs because rapid diagnostic tests do not require refrigeration and will reduce waste disposal.

The policy brief includes a checklist of issues to consider when implementing dual testing in order to maximise its benefits, such as the need to provide the service in community settings to reach pregnant women from key populations who are at heightened risk for both HIV and syphilis.



Faculty Attitudes About Caring for People Living With HIV/AIDS: A Comparative Study

Juan M. Leyva-Moral, PhD, MSc, RN; Karen A. Dominguez-Cancino, MPH, BSN, RN; Genesis M. Guevara-Vasquez, MSc, Lic(Est); Joan E. Edwards, PhD, RN, CNS, FAAN; Patrick A. Palmieri, DHSc, EdS, MBA, MSN, RN, FAAN


BACKGROUND:People living with HIV/AIDS (PLHIV) experience stigma and discrimination. Negative attitudes of nursing faculty about caring for PLHIV can adversely affect student perceptions and their nursing care. The study purpose was to describe nursing faculty attitudes and beliefs about caring for PLHIV.

METHOD:The HPASS (Healthcare Provider HIV/AIDS Stigma Scale), Spanish version, was delivered to nursing faculty in Colombia and Peru.

RESULTS:The HPASS was completed by 98 nursing faculty. The overall mean score was 2.41 (SD = 0.69), with subscale scores: stereotypes, 2.55 (SD = 0.84); discrimination, 2.28 (SD = 0.74); and prejudices, 2.41 (SD = 0.63). Peruvian faculty had the highest scores, statistically correlated with the importance of religion, whereas Colombia had the lowest.

CONCLUSION:Nursing faculty attitudes toward PLHIV were slightly positive in Colombia to slightly negative in Peru; however, both countries had negative stereotypes. Knowledge deficiencies about HIV persist and attitudes appear to be influenced by culture and religion. [J Nurs Educ. 2019;58(12):712–717.]

Despite advancements in scientific knowledge and clinical management strategies since the first reported case of AIDS (Centers for Disease Control and Prevention, 1982), people living with HIV/AIDS (PLHIV) continue to experience stigmatization and discrimination throughout the world (Munro et al., 2017Wagner, Girard, McShane, Margolese, & Hart, 2017). Discriminatory behaviors and fears about contracting the virus persist in nursing (Stringer et al., 2016Vorasane et al., 2017Waluyo, Culbert, Levy, & Norr, 2015) with positive correlations between negative attitudes toward caring for PLHIV and advanced age, homophobia, having children, race, and religion (Peate, Suominen, Välimäki, Lohrmann, & Muinonen, 2002Stringer et al., 2016). With more caring nursing attitudes and increased understanding about the virus and the disease, PLHIV can be respected, nurtured, and understood (Watson, 2002).

Nursing faculty attitudes and beliefs are important to understand as they can become part of the informal, or occult, curriculum (Sirota, 2013Tanner, 1992, 2004)—that is, there can be implicit learning impregnated with values (Chuang et al., 2010Thompson, Emrich, & Moore, 2003). Since the earliest study examining student and faculty attitudes about caring for PLHIV (Mueller, Cerny, Amundson, & Waldron, 1992), there have been fewer than 20 additional studies reported in the literature (PubMed® and SciELO searches). However, the results of the few studies often report only students in small local samples using a validated, although outdated, instrument (Bektas & Kulakaç, 2007Earl, 2010Li, Scott, & Li, 2008Lohrmann et al., 2000Röndahl, Innala, & Carlsson, 2003Suominen, Laakkonen, & Lioznov, 2015).

In the context of PLHIV in South America, Colombia (Red Colombiana de Personas que Viven con VIH, 2015) and Peru (Consorcio de Organizaciones de Personas con VIH en el Peru, 2018) report higher than average stigma indexes, which results in widespread discrimination. Furthermore, the health system contributes to the stigmatization of PLHIV in Colombia (Djellouli & Quevedo-Gómez, 2015Ritterbusch, Correa-Salazar, & Correa, 2018) and Peru (Perez-Brumer et al., 2017Valenzuela et al., 2015) through discriminatory and prejudicial conduct of health care professionals (Avert, 2019Cianelli, Ferrer, & McElmurry, 2008), which negatively influences their quality of care (Piñeirúa et al., 2015). Despite being recognized, the stigma and discrimination within the health systems have largely been ignored (Cáceres & Mendoza, 2009) as an institutionalized reality (Valencia-Garcia, Rao, Strick, & Simoni, 2017). As potential change agents within the context of health systems, the objective of this study was to understand Colombian and Peruvian nursing faculty attitudes and beliefs about caring for PLHIV.


Study Design and Population

This pilot study represents the South America data from an ongoing multicenter observational study with nonrandomized electronic sampling. Data were collected from four schools of nursing in Colombia and Peru using an online version of the Healthcare Provider HIV/AIDS Stigma Scale, or HPASS (Wagner, Hart, McShane, Margolese, & Girard, 2014), from January to July 2017. The HPASS was sent to university faculty e-mails on record (estimated response rate = 52%). The inclusion criteria were all nursing faculty with an e-mail on record, whereas all others were excluded. The study was approved by the university institutional review board.

Instruments and Measures

The validated 30-item HPASS (Wagner et al., 2014) measures stigma with three dimensions: discrimination (six items), prejudice (13 items), and stereotype (11 items). The internal consistency and test–retest reliability for the scale (Cronbach’s alpha between .88 and .94) and the three individual subscales (Cronbach’s alpha between .80 and .93) are excellent (Wagner et al., 2014Xie et al., 2019). The 6-point Likert scale, ranging from complete disagreement (1) to complete agreement (6), in response to statements about PLHIV-eliminated ambiguous midline responses to provide an “accurate picture of the attitudes and beliefs” held by participants (Wagner et al., 2014, p. 2405). The scale midpoint score is 105, ranging between 30 and 180. Similarly, the subscale midpoints are 21 for discrimination (range = 6 to 36), 45.5 for prejudice (range = 13 to 78), and 39 for stereotype (range = 11 to 66). Higher scale scores from the midpoint are associated with more stigma (similar for subscales) and lower scores with less stigma.


A Spanish version of the scale (HPASS-ESP), for cross-cultural research in South America, was produced through a rigorous process including forward and reverse translations, expert item evaluations, subscale analysis, and adaptation for equivalence in content, context, and culture (Guillemin, Bombardier, & Beaton, 1993Sousa & Rojjanasrirat, 2011). The experts included 12 bilingual nursing faculty from Chile, Colombia, and Peru.

Data Analysis

Descriptive statistics were performed for all variables in the two-country sample, as well as for each individual country. Bivariate inferential statistics were performed to compare the total scale score, each subscale, and the sociodemographic variables by country. As a pilot study, the threshold for significance was set at 0.09 (Conn, Algase, Rawl, Zerwic, & Wyman, 2010Hertzog, 2008). An analysis was also performed to examine the correlation between sociodemographic variables and the HPASS-ESP scores (scale and subscales). Parametric and non-parametric statistics were used (McCullagh & Nelder, 1989Polit & Beck, 2017Siegel & Castellan, 1988) with a correlation analysis to measure the direction and strength of potential associations across the three considered subscales (Altman, 1991). The data were organized in an Excel® spreadsheet and analyzed with Stata® 14.0. The study is reported according to the STROBE (Strengthening The Reporting of OBservational Studies in Epidemiology), following the minimum reporting requirements for cross-sectional studies (von Elm et al., 2014).


The total of 98 nursing faculty from Peru (N = 57) and Colombia (N = 41) responded to the HPASS-ESP. The participant median age was 44 years (interquartile range [IQR] = 37 to 53), the majority identified as female (n = 80, 81.6%), with a median teaching experience of 9.5 years (IQR = 5.0 to 15), and 93.9% completed postgraduate studies. Participants primarily taught in an undergraduate program (n = 85, 86.7%), most self-identified as Catholic (n = 87, 88.8%), and most indicated religion as important to very important in their lives (n = 79, 80.6%).

Overall, the mean scale score was 80.0 (SD = 22.9); the subscale mean scores were 12 (IQR = 9.0 to 16) for discrimination, 31 (IQR = 21 to 40) for prejudices, and 35.2 (SD = 10.3) for stereotypes. The mean scale score was 68.6 (SD = 20.6) for Colombia and 88.2 (SD = 21.1) for Peru. The country subscale scores included the following: discrimination of 11 (IQR = 8 to 15) for Colombia and 14 (IQR = 10 to 18) for Peru; prejudices of 24 (IQR = 19 to 35) for Colombia and 36 (IQR = 28 to 41) for Peru; and stereotypes of 29.9 (SD = 9.7) for Colombia and 39.1 (SD = 9.0) for Peru. When comparing the countries, the scores were statistically significant for the sigma scale (p < .001) and each of the three subscales, discrimination (p = .030), prejudices (p = .006), and stereotypes (p < .001).

In the analysis of the sociodemographic variables, total scale score, and subscale scores, statistically significant associations were found between the level of education and the scale (p = .037) and the discrimination subscale (p = .019). For education level and the scale score, participants with undergraduate education (80.5, SD = 22.6) scored higher than those with postgraduate education (56.3, SD = 16.8). In the case of the discrimination subscale, participants with undergraduate education (12, IQR = 9.0 to 16) also scored higher than participants with postgraduate education (6.5, IQR = 6.0 to 9.5). In the analyses by country, the significance remained for the discrimination subscale for Peruvian participants (p = .0316), and the scores for participants with undergraduate education (2, IQR = 1.5 to 2.7) were higher than those with postgraduate education (1, IQR = 1.1 to 1.6).

As the years of teaching experience had different distributions (normal for Colombia and not normal for Peru), the analysis was performed separately. A significant statistical difference was found with years of experience in the case of Peru for total scale score (Spearman’s rho = 0.32; p = .014), and the prejudice (Spearman’s rho = 0.39; p = .003), stereotype (Spearman’s rho = 0.24; p = .07), and discrimination subscales (Spearman’s rho = 0.23; p = .09). However, none of these associations were significant for Colombia. In the analysis of religious importance for the two countries, a significant difference was found in the scale score and stereotype subscale (Peru = 2.91, SD = 0.10; Colombia = 2.25, SD = 0.11; p < .0001); no relationship was found with the other subscales.

There were also significant correlations between the total scale score and each of the three subscales (discrimination: r = .73, < .001; prejudice: r = .91, <0.001; and stereotype: r = .83, p < .001). Additionally, there were correlations observed between all the subscales (stereotype and prejudice: r = .57, p < .001; stereotype and discrimination: r = .38, p < .001; and discrimination and prejudice: r = .68, p < .001). Finally, in terms of stereotypes and false beliefs, four item responses scored greater than 4 of 5, indicating participants from both countries generally believe “if people act responsibly, they will not contract HIV” and HIV positive patients “have engaged in risky activities despite knowing these risks” and “should accept responsibility for acquiring the virus.” They were also “worried about contracting HIV from HIV+ patients.”


The findings from this study indicate nursing faculty attitudes about caring for PLHIV are neutral to slightly positive; however, there are notable differences between Colombia and Peru, as well as some common areas for improvement. The item analysis indicates a persistent presence of false myths and lack of knowledge about HIV/AIDS, also reported in other studies (Leyva et al., 2017). The analysis indicates both countries demonstrate stereotypical attitudes and beliefs that can adversely impact patient care. However, despite concerns about contracting the virus, the participants were not hesitant to “come into physical contact with HIV+ patients” and believe there is no “right to refuse to treat HIV+ patients to protect” themselves.

Overall, the faculty results observed in the two countries are slightly higher than the scores from other countries (e.g., Spain and Germany) in terms of the overall stigma score and stereotype score. This finding might be attributed to the high HIV-related stigma reported in Latin America (Johnson et al., 2015), including overt discrimination experienced by lesbian, gay, transgender, and bisexual people (i.e., the LGBTQ community) (Barrientos, 2016). In Latin America, there is a close relationship between machismo and the meanings associated with sexuality (Marín, 2003), and therefore attributed to sexually transmitted infections such as HIV (Cianelli et al., 2008Quevedo-Gómez, Krumeich, Abadía-Barrero, Pastrana-Salcedo, & van den Borne, 2012). In the Latino community, ideas about machismo seem to contribute to discrimination against women and gay men, resulting in enhanced homophobia and increased sexual coercion (Marín, 2003).

In addition, the higher scale score in Peru might be associated with the machismo prevailing in the Peruvian health sector (Palmieri, 2017) and therefore the discrimination experienced by the collective LGBTQ community. Other investigations have found correlations associated with stigma and discrimination with religion (Kinyanda et al., 2012Leyva-Moral et al., 2017Stringer et al., 2016), noted to be a significant difference between Peru and Colombia in this study. In particular, the higher scores in Peru might be explained by conservative Catholic traditions. However, these differences could also result from the sampling strategy and variability of sociocultural contexts in which participants share cultural meanings associated with sexuality and HIV but not with religious affiliation.

Positive attitudes are related to increased caring behaviors (Dyson, 1996Watson, 2008). Nursing education has long played an important role in the development of caring attitudes (Eron, 1955), the acquisition of knowledge (Benner, 1982), and the advancement of caring behaviors (Bevis & Watson, 1989). For nurses, caring is “the moral ideal of nursing whereby the end is protection, enhancement, and preservation of human dignity” (Watson, 1985, p. 29). However, negative faculty attitudes and incorrect beliefs about caring for PLHIV can adversely influence the attitudes of students and the care they provide. This can be partly explained in relationship to their comfort teaching specialized content about populations. For example, Sirota (2013) described “a long skew toward negative attitudes” (p. 222) for more than half of the nursing faculty (n = 733) in a study regarding homosexuality. As less than 30% of faculty were prepared to teach students about homosexuality, almost 90% indicated a “sense of ignorance about what content to teach and how to teach it” (p. 225). The implication is that faculty are not comfortable teaching what they do not understand.

Faculty caring behaviors can positively influence the caring behaviors of their students (Labrague, McEnroe-Petitte, Papathanasiou, Edet, & Arulappan, 2015). As such, developing faculty education about caring for PLHIV is a viable strategy to advance positive caring attitudes in students. In general, university faculty need to develop critical and constructive approaches to teaching students about HIV/AIDS (Camillo, Maiorino, & Chaves, 2013), including sharing personal experiences from PLHIV in the classroom. In this regard, expert patient illness narratives have been reported to be an effective teaching method for nursing students (Feijoo-Cid, Moriña, Gómez-Ibáñez, & Leyva-Moral, 2017) to develop cultural sensitivity, respect, and trust in others (Davidson, 2005). Similarly, when PLHIV are included as simulated patients, HIV-related stigma decreases and comfort in providing care increases (Jaworsky et al., 2017). More favorable attitudes about caring for HIV-infected pregnant women among certified nurse practitioners compared with RNs (Farley et al., 2014). Finally, positive empathetic attitudes (r = .36, p < .001) were negatively correlated with avoidant attitudes (r = −.34, p < .001) in nurses working in HIV clinics compared with those working in general clinics (Hamama et al., 2014). Education and daily interactions between the providers and PLHIV result in more positive caring attitudes.


This study has three important limitations. First, this study used a self-administered instrument. According to Parahoo (1997), participants might have tried to present what they believe is a desirable image resulting in more favorable scores. Second, the nonrepresentative convenience samples in metropolitan areas of each country might not be representative of the entire country. Third, the small sample size resulting from the intentional sampling strategy could have similarly influenced the results. Even so, this study is the largest sample size reported in the literature for Latin America and the only study comparing the context of different countries.


In general, nursing faculty attitudes toward caring for PLHIV were slightly negative in Peru to slightly positive in Colombia, with the stereotype subscale requiring improvement in both countries. Myths and lack of knowledge about HIV/AIDS remain problematic and attitudes appear to be influenced by nationality, education, and religion. Nursing faculty need to take a critical and constructive approach to improving HIV/AIDS education, including the incorporation of real-world experiences of PLHIV in the classroom.

Importantly, previous research has not established the correlation between the three dimensions (discrimination, prejudices, and stereotypes) among nursing faculty. In addition, this study found a correlation between the three subscales and the overall scale. This finding is important to justify continued research with the HPASS with the goal of developing interventions to decrease stigma. As all the factors are related, an educational activity designed to improve attitudes will impact the three dimensions.

Additional research is necessary for three reasons. First, the inclusion of more participants from additional universities in the represented countries can improve the fidelity of the findings. Also, participants from similar countries in the Andean Region of South America (e.g., Argentina, Bolivia, Chile, and Ecuador) can provide more information about the effects of nationality, as well as culture, on the HPASS scores. Second, qualitative research is necessary to explain the HPASS subscale scores. For example, a qualitative study can directly explore the influence of faculty attitudes on the behavior of students and, more importantly, their behaviors in providing care. Finally, theory-derived and evidence-informed interventions need to be developed to advance the knowledge and attitudes of nursing faculty about caring for PLHIV.



Catholic group in Iloilo City renews call for compassion for HIV, AIDS people

Iloilo City — A Roman Catholic organization has renewed the call for people to have compassion for people living with Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS).

A Roman Catholic priest counsels a man with Human Immunodeficiency Virus (HIV) at Saint Vincent Ferrer Seminary in Iloilo City.  (Carlos Garica/Photographic Society of Iloilo)

A Roman Catholic priest counsels a man with Human Immunodeficiency Virus (HIV) at Saint Vincent Ferrer Seminary in Iloilo City. (Carlos Garica/Photographic Society of Iloilo)


“We look at them just like how Jesus looks at the sick. We need to treat them with compassion and love,” said Sr. Mila Grace Silab of the Philippine Catholic HIV-AIDS Network (PhilCHAN) on Monday.

“Unfortunately, the stigma persists,” Silab said as PhilCHAN Iloilo chapter and Photographic Society of Iloilo (PSI) mounted a weeklong photo exhibit to mark World AIDS Day.

Silab, who is president of St. Paul University-Iloilo, said there must be a paradigm shift in how society treats people living with HIV and AIDS.

“We should not be afraid of them. They are our brothers and sisters,” she told Manila Bulletin.

PhilCHAN is strengthening its own faith-based services after the United Nations Programme on HIV and AIDS (UNAIDS) ranked the Philippines as the area where the fastest-growing number of HIV cases in the world is recorded.

As of this year, the Department of Health (DOH) estimates there are 36 HIV cases recorded daily. From 1984 to April 2019, there are now more than 66,000 cases of HIV and AIDS.

PhilCHAN works under the Catholic Bishops’ Conference of the Philippines (CBCP). Priests, nuns, and the laity volunteer to counsel persons with HIV and AIDS.

“We want to give them hope and steer them away from depression or suicide,” Silab said.

PhilCHAN also wants to address value systems and help change behaviors, particularly of those who engage in risky sexual activities.

While PhilCHAN has a chapter in Iloilo, Silab said the group works across the entire Western Visayas region and serves in Aklan, Antique, Capiz, Guimaras, and Negros Occidental.

There are over 3,175 HIV cases in the Western Visayas region and more than 300 have died from AIDS there.

Author: Tara Yap


Catholic group renews call for compassion for HIV, AIDS people

Mercredi leading fight against HIV, AIDS in Sask.


The HIV And AIDS epidemic in Saskatchewan remain one of the province’s most critical issues. Saskatchewan has the highest HIV diagnosis rate in the country, and it’s estimated that 30 percent of people with HIV in the province are unaware they’ve contracted the virus.

Invaluable are those in the province, therefore, who have dedicated their lives to help educate and support those with HIV and AIDS. Jason Mercredi, Executive Director of AIDS Saskatoon, is one of those people working to make a difference.

Mercredi, who is from La Ronge, worked in youth outreach before being recruited by AIDS Saskatoon seven years ago. His desire to work in this particular field came from a personal encounter while growing up.

“I had someone who I grew up with living with HIV, and I thought it was pretty messed up that [it] had happened to someone our age. In a first world country, that really shouldn’t be happening,” said Mercredi.

“We see so much injustice, and the discrimination is quite heavy with folks who have HIV and addictions. That’s really what propelled me,” he said.

Mercredi has served as executive director for the past two years, in which he said he’s starting to see some positive shifts in the attitudes towards AIDS and addictions.

“Harm education is becoming much more accepted. I don’t know if it’s being implemented correctly in every place, but we’re seeing places like the Health Authority really try to embrace harm reduction, which is great,” he said.

One of the most important upcoming developments in Saskatoon, of which Mercredi has been a leader, is the soon-to-be opened safe consumption site in west-side of Saskatoon, approved by Health Canada in July 2019. AIDS Saskatoon will offer their current services when they move into the facility this November, and will open the safe consumption site in the new year, which will be the first of its kind in the province.

“We think we’re going to have one of the best sites and models in Canada. We’re really going to make sure we’re doing our best to get people connected with care,” he said. “This is a public health issue; we have people dying. The time to act like (safe consumption sites) are a matter of opinion is over. They are a scientific fact, they work.”

While Mercredi objects to personally taking credit for these decidedly significant developments in Saskatoon, he recognizes that progress occurs when putting Indigenous people in positions to succeed.

“I think our success as an agency shows the need to make sure we have Indigenous people in positions of leadership,” he said. “Indigenous leadership is going to be key in moving the need forward in any societal issues. When you have Indigenous leaders, things seem to happen in a good way.”



The struggle is real for gay men who don’t enjoy anal sex

You have a deep, dark secret. You’re carrying around something shameful, something you feel like you can’t even tell your best gay friend. No, it’s not some vintage STD like crabs, or a sweaty armpit fetish… you’re simply a gay man… who doesn’t like anal sex. Gasp!

Believe it or not, many gay guys struggle with how to navigate this, feeling like it’s somehow not acceptable in a community that often demands we label ourselves “top,” “bottom,” or “vers.” So let’s explore what if means if you’re a “side”–meaning, you don’t like/partake in anal sex–because it’s way more common among gay men than people think…

The first question to ask yourself is why don’t you like anal sex?

For some guys, it has to do with the idea of not being “clean.” Let’s face it, we’re talking about insertion in the same place where our body eliminates things it doesn’t need. It takes some concerted effort and work to manage feeling, smelling, and looking clean, from certain diet choices to hygiene regimens. For some, this is just an immediate turn off, and isn’t something they want to work through, and that’s OK!

For other guys, it has to do with the penetration or insertion into another body, which can be a very vulnerable thing. If you’re the bottom, you literally have to accept someone else inside you. You can’t feel much more defenseless than that. For the top, it involves taking on that responsibility, and might just seem like too much for some.

There’s also the risk of sexual transmitted diseases. Those who have anal sex are at higher risk for transmitting HIV or other STDs, and the risk is even greater for the person being penetrated. Of course, there several effective ways to prevent HIV and STD transmission–from condoms to PREP or being undetectable–but for some it can simply create an anxiety that’s not worth the payoff.

If any of these are the case, there’s the possibility of working through your fears with a therapist or another supportive person, including a comfortable and patient sex partner with whom you can experiment. Many times, our fears are unfounded or based in something irrational, in which case we can get past them.

But it’s also possible that you simply aren’t that into it. Some guys just aren’t. And there is absolutely nothing wrong with that either!

Unfortunately, in the world of Grindr, where people literally identify themselves by their preferred positions, it can seem like not having anal sex isn’t an option. It’s such a part of the cultural norm or conversation in the gay world, that it feels wrong to not be into it. Many guys don’t even refer to it as being “sex” unless it involves anal penetration.

I’d like to begin perpetuating a new belief about this. Sex is sex, no matter what “kind” of sex it is. From oral, to hands, to toys, any kind of sex act is still sex. It doesn’t have to involve anal penetration to be a fulfilling, intimate, and hot. So instead of seeing anything other than anal as “less than,” begin to see it as “equal to.”

When a guy asks you what kind of sex you’re into, you don’t even need to point out that you aren’t into anal sex. You can simply refer to the things you like to do besides anal, as they are just as valid. And if your potential partner rejects you when he finds out you’re not into anal, then it’s his loss, and he is truly limiting himself.

Whatever your reasons for not being into anal sex, it’s OK. Just remember that communication is key. The important thing is to share your feelings, desires, and concerns with your partner(s). And don’t forget these four words: anal sex isn’t everything!


Jake Myers is a Licensed Marriage and Family Therapist in Los Angeles. He has a Bachelor’s degree in Psychology and a Master’s degree in Clinical Psychology, with a specialization in LGBT Affirmative Psychotherapy.