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
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
1


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)
2


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)

3


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

4


Map of Study Site

5


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
6

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)

7


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
8

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

9


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)

≥ 5 years

567 (56.4)

293 (47.0)

144 (38.1)

Ref

< 5 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
≤ 8 years

520 (51.7)

328 (52.6)

891 (50.5)

Ref

> 8 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
4 2.3

20.7

13

12.1
8

6 .9

13 .2
11.3

7 .4

8.2

9 .4
5

4 .8
2.3

13 .2

2.1

3 .2
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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 .3

45.9

42.9

40

35.5
31.1

30

22.3

20

16 .8
10 .1

10

6 .9

4.9

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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