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      Factors contributing to food insecurity among women living with HIV in the Dominican Republic: A qualitative study

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          Abstract

          Background

          Food insecurity contributes to poor health outcomes among people living with HIV. In Latin America and the Caribbean, structural factors such as poverty, stigma, and inequality disproportionately affect women and may fuel both the HIV epidemic and food insecurity.

          Methods

          We examined factors contributing to food insecurity among women living with HIV (WLHIV) in the Dominican Republic (DR). Data collection included in-depth, semi-structured interviews in 2013 with 30 WLHIV with indications of food insecurity who resided in urban or peri-urban areas and were recruited from local HIV clinics. In-person interviews were conducted in Spanish. Transcripts were coded using content analysis methods and an inductive approach to identify principal and emergent themes.

          Results

          Respondents identified economic instability as the primary driver of food insecurity, precipitated by enacted stigma in the labor and social domains. Women described experiences of HIV-related labor discrimination in formal and informal sectors. Women commonly reported illegal HIV testing by employers, and subsequent dismissal if HIV-positive, especially in tourism and free trade zones. Enacted stigma in the social domain manifested as gossip and rejection by family, friends, and neighbors and physical, verbal, and sexual abuse by intimate partners, distancing women from sources of economic and food support. These experiences with discrimination and abuse contributed to internalized stigma among respondents who, as a result, were fearful and hesitant to disclose their HIV status; some participants reported leaving spouses and/or families, resulting in further isolation from economic resources, food and other support. A minority of participants described social support by friends, spouses, families and support groups, which helped to ameliorate food insecurity and emotional distress.

          Conclusions

          Addressing food insecurity among WLHIV requires policy and programmatic interventions to enforce existing laws designed to protect the rights of people living with HIV, reduce HIV-related stigma, and improve gender equality.

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          Most cited references62

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          HIV and AIDS-related stigma and discrimination: a conceptual framework and implications for action.

          Internationally, there has been a recent resurgence of interest in HIV and AIDS-related stigma and discrimination, triggered at least in part by growing recognition that negative social responses to the epidemic remain pervasive even in seriously affected communities. Yet, rarely are existing notions of stigma and discrimination interrogated for their conceptual adequacy and their usefulness in leading to the design of effective programmes and interventions. Taking as its starting point, the classic formulation of stigma as a 'significantly discrediting' attribute, but moving beyond this to conceptualize stigma and stigmatization as intimately linked to the reproduction of social difference, this paper offers a new framework by which to understand HIV and AIDS-related stigma and its effects. It so doing, it highlights the manner in which stigma feeds upon, strengthens and reproduces existing inequalities of class, race, gender and sexuality. It highlights the limitations of individualistic modes of stigma alleviation and calls instead for new programmatic approaches in which the resistance of stigmatized individuals and communities is utilized as a resource for social change.
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            Conceptual framework for understanding the bidirectional links between food insecurity and HIV/AIDS.

            Food insecurity, which affects >1 billion people worldwide, is inextricably linked to the HIV epidemic. We present a conceptual framework of the multiple pathways through which food insecurity and HIV/AIDS may be linked at the community, household, and individual levels. Whereas the mechanisms through which HIV/AIDS can cause food insecurity have been fairly well elucidated, the ways in which food insecurity can lead to HIV are less well understood. We argue that there are nutritional, mental health, and behavioral pathways through which food insecurity leads to HIV acquisition and disease progression. Specifically, food insecurity can lead to macronutrient and micronutrient deficiencies, which can affect both vertical and horizontal transmission of HIV, and can also contribute to immunologic decline and increased morbidity and mortality among those already infected. Food insecurity can have mental health consequences, such as depression and increased drug abuse, which, in turn, contribute to HIV transmission risk and incomplete HIV viral load suppression, increased probability of AIDS-defining illness, and AIDS-related mortality among HIV-infected individuals. As a result of the inability to procure food in socially or personally acceptable ways, food insecurity also contributes to risky sexual practices and enhanced HIV transmission, as well as to antiretroviral therapy nonadherence, treatment interruptions, and missed clinic visits, which are strong determinants of worse HIV health outcomes. More research on the relative importance of each of these pathways is warranted because effective interventions to reduce food insecurity and HIV depend on a rigorous understanding of these multifaceted relationships.
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              Stigma and racial/ethnic HIV disparities: moving toward resilience.

              Prior research suggests that stigma plays a role in racial/ethnic health disparities. However, there is limited understanding about the mechanisms by which stigma contributes to HIV-related disparities in risk, incidence and screening, treatment, and survival and what can be done to reduce the impact of stigma on these disparities. We introduce the Stigma and HIV Disparities Model to describe how societal stigma related to race and ethnicity is associated with racial/ethnic HIV disparities via its manifestations at the structural level (e.g., residential segregation) as well as the individual level among perceivers (e.g., discrimination) and targets (e.g., internalized stigma). We then review evidence of these associations. Because racial/ethnic minorities at risk of and living with HIV often possess multiple stigmas (e.g., HIV-positive, substance use), we adopt an intersectionality framework and conceptualize interdependence among co-occurring stigmas. We further propose a resilience agenda and suggest that intervening on modifiable strength-based moderators of the association between societal stigma and disparities can reduce disparities. Strengthening economic and community empowerment and trust at the structural level, creating common ingroup identities and promoting contact with people living with HIV among perceivers at the individual level, and enhancing social support and adaptive coping among targets at the individual level can improve resilience to societal stigma and ultimately reduce racial/ethnic HIV disparities.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Formal analysisRole: Funding acquisitionRole: MethodologyRole: SupervisionRole: VisualizationRole: Writing – original draft
                Role: ConceptualizationRole: Formal analysisRole: VisualizationRole: Writing – original draft
                Role: InvestigationRole: MethodologyRole: Project administrationRole: ResourcesRole: SupervisionRole: Writing – review & editing
                Role: Data curationRole: Formal analysisRole: ValidationRole: Writing – review & editing
                Role: Writing – review & editing
                Role: Funding acquisitionRole: MethodologyRole: Project administrationRole: ResourcesRole: SupervisionRole: Writing – review & editing
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: Funding acquisitionRole: InvestigationRole: MethodologyRole: SupervisionRole: ValidationRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                25 July 2017
                2017
                : 12
                : 7
                : e0181568
                Affiliations
                [1 ] Department of Behavioral and Policy Sciences, RAND Corporation, Santa Monica, California, United States of America
                [2 ] Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, California, United States of America
                [3 ] United Nations World Food Programme, Dominican Republic Country Office, Santo Domingo, Dominican Republic
                [4 ] Consejo Nacional de VIH/SIDA (CONAVIHSIDA), Santo Domingo, Dominican Republic
                [5 ] United Nations World Food Programme - Regional Bureau for Latin American and the Caribbean, Panamá, Rep. de Panama
                [6 ] Division of HIV, ID and Global Medicine, School of Medicine, University of California - San Francisco, San Francisco, California, United States of America
                Western Sydney University, AUSTRALIA
                Author notes

                Competing Interests: The authors declare that no competing interests exist.

                Author information
                http://orcid.org/0000-0001-7742-6024
                Article
                PONE-D-16-49382
                10.1371/journal.pone.0181568
                5526502
                28742870
                752e9805-dbc1-4ae2-ba4f-26890e060751
                © 2017 Derose et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 14 December 2016
                : 24 June 2017
                Page count
                Figures: 0, Tables: 1, Pages: 19
                Funding
                Funded by: World Food Programme
                Award Recipient :
                Funded by: World Food Programme
                Award Recipient :
                Funded by: funder-id http://dx.doi.org/10.13039/100000025, National Institute of Mental Health;
                Award ID: R34MH110325
                Award Recipient :
                Funded by: funder-id http://dx.doi.org/10.13039/100000133, Agency for Healthcare Research and Quality;
                Award ID: T32HS00046
                Award Recipient :
                Funded by: funder-id http://dx.doi.org/10.13039/100000133, Agency for Healthcare Research and Quality;
                Award ID: T32HS00046
                Award Recipient :
                Funded by: funder-id http://dx.doi.org/10.13039/100000062, National Institute of Diabetes and Digestive and Kidney Diseases;
                Award ID: K01DK107335
                Award Recipient :
                We acknowledge financial support from the World Food Programme (WFP) for local data collection. For analysis and manuscript preparation, we acknowledge the following institutions for partial or full salary support of various co-authors: the National Institute of Mental Health or NIMH (grant number R34MH110325, Dr. Derose); the Agency for Healthcare Research and Quality or AHRQ (grant number T32HS00046, Dr. Palar, Dr. Payán); the National Institute of Diabetes and Digestive and Kidney Diseases or NIDDK (grant number K01 DK107335, Dr. Palar). The contents of the manuscript are solely the responsibility of the authors and do not represent the official views of WFP, NIMH, AHRQ, or NIDDK. The funders provided support in the form of salaries for authors [NIMH: KPD; AHRQ: DDP, KP; NIDDK: KP; WFP: MAF, ST, HF], but did not have any additional role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. The specific roles of these authors are articulated in the ‘author contributions’ section.
                Categories
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                Custom metadata
                The data upon which this manuscript is based are in-depth interview transcripts from a small sample of marginalized and stigmatized HIV+ women and contain highly sensitive data, including personal information on sexual behavior and intimate partner violence. As whole transcripts, these data are identifiable via inference, and thus, sharing them would violate the promise of confidentiality made to participants during informed consent. Excerpts of the transcripts relevant to the study, beyond what is already provided in the article as illustrative quotations, are available to qualified researchers upon request to the first author: Dr. Kathryn Derose ( derose@ 123456rand.org ). Queries regarding data access can be addressed by the RAND Human Subjects Protection Committee (HSPC) by contacting Sandy Berry, HSPC Chair ( berry@ 123456rand.org ).

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