Liên quan giữa Sự kỳ thị và phân biệt đối xử bệnh AIDS với sức khỏe tâm thần ở những người sống chung với HIV ở Campuchia_Association of AIDS stigma and discrimination with mental disorders among people living with HIV in cambodia AIDSrelated stigma and discrimination impede millions of PLHIV from accessing and benefiting from effective prevention and treatment services Approximately 50–60% of HIVinfected people are unaware of their serostatus, and many choose to hide it (Grossman Stangl, 2013 and Sidibé Goosby, 2013)AIDSrelated stigma and discrimination have been found to be associated with delays in seeking care potential barriers to HIV counselling and testingdisclosure of HIV serostatusretention in care and treatmentuptake of and adherence to antiretroviral therapy (ART)Point prevalence rates of major depressive disorder among PLHIV: 3% 54% (Adewaya et al., 2007; Akena et al., 2012)Mental disorders are also associated with several health and healthcare seeking behaviors such as:poor adherence to medicationslow rates of retention in ART carepoor ARTrelated clinical outcomesRationale: Limited attention to AIDSrelated stigma and discrimination as well as mental disordersThe linkage between these two problems has not been well addressedThere is no study on this issue in CambodiaObjective: to examine the association of AIDSrelated stigma and discrimination with mental disorders among PLHIV in Cambodia
Association of AIDS Stigma and Discrimination with Mental Disorders among People Living with HIV in Cambodia Presented by: Pheak Chhoun, MPH Research Fellow, Center for Population Health Research Investigators: KHANA (Cambodia): Siyan Yi, Pheak Chhoun, Samedy Suong1, Kouland Thin, Sovannary Tuot Touro University California (USA): Siyan Yi, Carinne Brody 7th ICPH, Hue City, Vietnam | 26-27 September 2015 AIDS-related stigma among PLHIV • AIDS-related stigma and discrimination impede millions of PLHIV from accessing and benefiting from effective prevention and treatment services – Approximately 50–60% of HIV-infected people are unaware of their sero-status, and many choose to hide it (Grossman & Stangl, 2013 and Sidibé & Goosby, 2013) • AIDS-related stigma and discrimination have been found to be associated with – – – – – delays in seeking care potential barriers to HIV counselling and testing disclosure of HIV sero-status retention in care and treatment uptake of and adherence to antiretroviral therapy (ART) Mental health among PLHIV • Point prevalence rates of major depressive disorder among PLHIV: 3% - 54% (Adewaya et al., 2007; Akena et al., 2012) • Mental disorders are also associated with several health and healthcare seeking behaviors such as: – poor adherence to medications – low rates of retention in ART care – poor ART-related clinical outcomes (Springer et al., 2012) Rationale and Objective • Rationale: – Limited attention to AIDS-related stigma and discrimination as well as mental disorders – The linkage between these two problems has not been well addressed – There is no study on this issue in Cambodia • Objective: to examine the association of AIDS-related stigma and discrimination with mental disorders among PLHIV in Cambodia Map of Study Site Study sites and sampling: • Sample size: 1,003 adult PLHIV • Data collection period: May 2014 • Sampling: Two-stage cluster sampling (probability proportional-to-size wasused to select the required number of PLHIV from each province) • Inclusion Criteria: – Men or women aged 18 years or older – Having been registered as a PLHIV within the network of the community based implementing partner – Being able to provide consent to participate in the study – Being able to present themselves on the day of the data collection • Exclusion Criteria: – PLHIV who were mentally and/or physically too sick to participate in the study Variables and measurement • • • • • Socio-economic characteristics Social support Pre-ART/ART services Mental disorders (GHQ-12) Perceived AIDS-related stigma and discrimination (People Living with HIV Stigma Index) Data Analyses • Double data entry: EpiData • Bivariate analyses: – Chi-square or Fisher’s Exact test for categorical variables comparison – Student’s t-test or ANOVA for continuous variables • Multivariable logistic regression model – Control the effects of potential confounders – Including all variables associated with level of mental disorders in bivariate analyses at the level of p< 0.10 – Soft wares: SPSS version 22 Ethical Considerations • Ethical approval: – National Ethics Committee for Health Research (NECHR) • Written informed consent: All participants • Confidentiality & privacy protection: – No personal identifier collected – Interviews at private places Comparisons of socio-demographic characteristic with level of mental disorders Total score of GHQ-12 Socio-demographic characteristics Total ≤3 ≥4 n (%) n (%) n (%) OR (95% CI) Gender Male 329 (32.8) 242 (38.8) 85 (22.5) Ref Female 674 (67.2) 381 (61.2) 292 (77.5) 2.2 (1.6-2.9) ≤ 43 years 510 (50.7) 320 (51.3) 190 (50.3) Ref > 43 years 495 (49.3) 304 (48.7) 188 (49.7) 1.1 (0.8-1.3) ≥ years 567 (56.4) 293 (47.0) 144 (38.1) Ref < years 438 (43.6) 331 (53.0) 234 (61.9) 1.4 (1.1-1.9) Age group Formal education completed Comparisons of socio-demographic characteristic with level of metal disorder (cont) Total score of GHQ-12 Socio-demographic characteristics Total ≤3 ≥4 n (%) n (%) n (%) OR (95% CI) Marital status Married 630 (62.8) 405 (65.1) 223 (59.0) Ref Unmarried 373 (37.2) 217 (34.9) 155 (41.0) 1.4 (1.1-1.7) Employed 880 (87.6) 563 (90.2) 314 (83.3) Ref Unemployed 124 (12.4) 61 (9.8) 63 (16.7) > US$75 565 (56.8) 277 (44.8) 152 (40.6) Ref ≤ US$75 430 (43.2) 341 (55.2) 222 (59.4) 1.5 (1.1-1.5) Current employment status 1.9 (1.3-2.7) Average monthly income Comparisons of socio-demographic characteristic with level of metal disorder (cont) Total score of GHQ-12 Socio-demographic characteristics Total ≤3 ≥4 n (%) n (%) n (%) OR (95% CI) Duration of living with HIV ≤ years 520 (51.7) 328 (52.6) 891 (50.5) Ref > years 485 (48.3) 296 (47.4) 187 (49.5) 1.1 (0.8-1.4) Spouse/partner’s HIV status (for married PLHIV) Negative 197 (22.9) 141 (25.9) 56 (15.9) Ref Positive 663 (77.1) 404 (74.1) 256 (82.1) 1.6 (1.1-2.3) 77 (8.8) 54 (9.9) 22 (6.9) Ref 794 (91.2) 494 (90.1) 298 (93.1) 1.5 (1.1-2.5) Spouse/partner knows your HIV status No Yes Comparisons of socio-demographic characteristic with level of metal disorder (cont) Total score of GHQ-12 Socio-demographic characteristics Total ≤3 ≥4 n (%) n (%) n (%) OR (95% CI) Currently on ART treatment No 36 (3.6) 26 (4.2) 10 (2.7) Ref Yes 958 (96.4) 589 (95.8) 366 (97.3) 1.6 (0.8-3.4) > 500 512 (51.8) 304 (49.4) 170 (45.9) Ref ≤ 500 477 (48.2) 312 (50.6) 200 (54.1) 1.1 (0.9-1.5) CD4 count at the most recent blood test Received social support in the past 12 months Yes 956 (95.2) 599 (96.1) 354 (93.7) Ref No 48 (4.8) 24 (3.9) 24 (6.3) 1.7 (1.1-3.0) Prevalence of Stigma and discrimination experiences in family and community in the past 12 months 2.3 20.7 13 12.1 13 11.3 8.2 2.3 13 2.1 0.8 t t e s d b n n n n er ed ed ed IV on ac jo en io io ou lte ice ss tn tio ss at sio pl cti m ot at ab ec of rv LH au ra ar c in lu u j e y e s r r P m c p e d s u d g o s s e e x r as ro pl ed lr r im m an th he Lo sip se ro rp ua or m al isc om lly ch em ot lly f o os e r o tie d a x a r f i i i d f g o r h t f g re by sic Se g fo lte sic ed tiv tiv tiv ed ed in su ed su ted hy ac ac ed nt ac us ein hy ni ted be re rc s e P f n n l b e P s a P i o e e y r u v d f f r u l f e il in cia be ev g g g io re pr ba m eo pr So g g em er ein lig r im ein ein ar Fa n g e c n V i B s i m B B R e di Aw ein be B ily g B ild m ein a h F C B lu xc e s tie n sio lu xc e s tie n sio 14 Comparisons of stigma and discrimination experienced in communities in the past 12 months Total score of GHQ-12 Stigma and discrimination experiences Total n (%) ≤3 n (%) ≥4 n (%) OR (95% CI) Physically harassed and/or threatened No 925 (92.0) 595 (95.4) 327 (86.5) Ref Yes 80 (8.0) 29 (4.6) 51 (13.5) 3.2 (2.0-5.1) Subjected to psychological pressure by your husband/wife or partner No 883 (87.9) 578 (92.6) 302 (79.9) Ref Yes 122 (12.1) 46 (7.4) 76 (20.1) 3.2 (2.1-4.7) Forced to change your place of residence or unable to rent accommodation No 973 (96.8) 610 (97.8) 360 (95.2) Ref Yes 32 (3.2) 14 (2.2) 18 (4.8) 2.2 (1.1-4.4) Comparisons of stigma and discrimination experienced in communities in the past 12 months Total score of GHQ-12 Stigma and discrimination experiences Total n (%) ≤3 n (%) ≥4 n (%) OR (95% CI) Refused employment or a work opportunity because of HIV status No 872 (87.0) 569 (91.2) 300 (79.4) Ref Yes 133 (13.2) 55 (8.8) 78 (20.6) 2.7 (1.9-3.9) Nature of work been changed, or been refused promotion as a result of HIV status No 872 (86.8) 564 (90.4) 305 (80.7) Ref Yes 133 (13.2) 60 (9.6) 73 (19.3) 2.3 (1.6-3.3) Your child had been prevented from attending school because of your HIV status No 954 (95.0) 603 (96.6) 348 (92.3) Ref Yes 50 (5.0) 21 (3.4) 29 (7.7) 2.4 (1.3-4.3) Prevalence of self-reported internal stigma experienced in the past 12 months 70 59.6 60 53.1 50 46 45.9 42.9 40 35.5 31.1 30 22.3 20 16 10 10 4.9 e Fe l in s ga m ed e Fe lin ui gg l ty Se am Bl l f- e B m la in th go s er vi Ha l ng e Fe ow g li n se th at e te es l fs ey th m ul ho d be pu s ni he d Fe i os Ch in el ng gs ci d ui e att to t no al nd s at lg ic a o I r he in g ng lo ati s fam i ly / e fri De D nd ci d i ec s in p to os t g n di g W 4.9 rk wo pp oa t t no i th al aw r d in l g or yf m fro m ro /p b jo ed 4.4 on oti in /t n o ati uc in p go D u rt po id ec ni in g 2.8 ty m et og t t no r ar De ci ie d n di g ci d De o tt no in g ve oh tt o n x se e av (m d oi Av in e) or g ch in go ild n re oa gt n cl i al c lo sp ho / ic l i ta Comparisons of internal stigma experiences in the past 12 months among PLHIV Total score of GHQ-12 Internal Stigma Total ≤3 ≥4 experiences n (%) n (%) n (%) OR (95% CI) I feel ashamed No 543 (51.4) 381 (61.1) 160 (42.4) Ref Yes 461 (45.9) 243 (38.9) 217 (57.6) 2.1 (1.6-2.8) No 779 (77.7) 520 (83.5) 256 (67.9) Ref Yes 224 (22.3) 103 (16.5) 121 (32.1) 2.4 (1.8-3.2) No 955 (95.1) 610 (97.8) 342 (90.7) Ref Yes 49 (4.9) 14 (2.2) 35 (9.3) 4.5 (2.4-8.4) I have low self-esteem I feel suicidal Comparisons of internal stigma experiences in the past 12 months among PLHIV Total score of GHQ-12 Internal Stigma experiences Total n (%) ≤3 n (%) ≥4 n (%) OR (95% CI) I isolated myself from my family and/or friends No 936 (93.1) 599 (96.0) 334 (88.4) Ref Yes 69 (6.9) 25 (4.0) 44 (11.6) 3.2 (1.9-5.3) No 956 (95.1) 607 (97.3) 347 (91.8) Ref Yes 49 (4.9) 17 (2.7) 31 (8.2) 3.2 (1.7-5.8) I made the decision to stop working Comparisons of fear of stigma and discrimination experienced in the past 12 months Fears of stigma and discrimination Total score of GHQ-12 Total ≤3 ≥4 n (%) n (%) n (%) OR (95% CI) Having been fearful of the following things happening to you: Being gossiped about No 658 (65.5) 451 (72.3) 204 (54.0) Ref Yes 347 (34.5) 173 (27.7) 174 (46.0) 2.2 (1.7-2.9) Being verbally insulted, harassed, or threatened No 758 (75.4) 511 (81.9) 244 (64.6) Ref Yes 247 (24.6) 113 (18.1) 134 (35.4) 2.5 (1.9-3.3) Being physically harassed and/or threatened No 849 (84.5) 557 (89.3) 289 (76.5) Ref Yes 156 (15.5) 67 (10.7) 89 (23.5) 2.6 (1.8-3.6) Comparisons of fear of stigma and discrimination experienced in the past 12 months Total score of GHQ-12 Fears of stigma and discrimination Total n (%) ≤3 n (%) ≥4 n (%) OR (95% CI) Being physically assaulted No Yes 865 (86.1) 140 (13.9) 565 (90.5) 297 (78.6) Ref 59 (9.5) 81 (21.4) 2.6 (1.8-3.8) 527 (84.7) 307 (82.1) Ref 95 (15.3) 67 (17.9) 1.2 (0.9-1.7) Being rejected to have sexually intimate with No Yes 837 (83.8) 162 (16.2) Results of univariate and multivariate logistic regression analyses of the association between stigma and discrimination with levels of mental disorders among PLHIV Stigma and discrimination scales Total score of GHQ-12 ≤3 ≥4 n (%) n (%) OR (95% CI) AOR (95% CI)† Total score of stigma and discrimination experience ≤2 468 (75.2) 210 (56.1) Ref Ref ≥3 154 (24.8) 164 (43.9) 2.4 (1.8-3.1)*** 1.9 (1.4-2.6) *** ≤4 434 (70.1) 196 (52.1) Ref Ref ≥5 185 (29.9) 180 (47.9) 2.2 (1.7-2.8) *** 1.7 (1.2-2.3) ** Total score of internal stigma Total score of fear of stigma and discrimination ≤1 492 (79.1) 237 (63.4) Ref Ref ≥2 130 (20.9) 137 (36.6) 2.2 (1.6-2.9) *** 1.5 (1.1-2.2)* Limitation of the study • Representativeness of the study population • GHQ-12 was not a diagnostic instrument • Cross-sectional design precludes interpretation of the findings • Unknown validity of the tools • Self-reported measures: Underreporting and over-reporting • Possibility of recall bias Conclusions • AIDS-related stigma and discrimination among PLHIV in Cambodia may have potential impacts on their mental health conditions • Community-based interventions to reduce the stigma and discrimination in the general public and to help PLHIV to cope with this situation are needed Acknowledgement • • • • NCHADS PHDs, ODs USAID Implementing partners and their staff members • Study participants, local authorities • Research team members ... to examine the association of AIDS- related stigma and discrimination with mental disorders among PLHIV in Cambodia Map of Study Site Study sites and sampling: • Sample size: 1,003 adult PLHIV •... discrimination with levels of mental disorders among PLHIV Stigma and discrimination scales Total score of GHQ-12 ≤3 ≥4 n (%) n (%) OR (95% CI) AOR (95% CI)† Total score of stigma and discrimination. .. working Comparisons of fear of stigma and discrimination experienced in the past 12 months Fears of stigma and discrimination Total score of GHQ-12 Total ≤3 ≥4 n (%) n (%) n (%) OR (95% CI) Having