JAIDS Journal of Acquired Immune Deficiency Syndromes:
Role of Community-Level Factors Across the Treatment Cascade: A Critical Review
Underwood, Carol PhD*; Hendrickson, Zoé BA*; Van Lith, Lynn M. MPA†; Lengwe Kunda, John Eudes PhD‡; Mallalieu, Elizabeth C. MPH†
*Department of Health, Behavior & Society, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD;
†Center for Communication Programs, Department of Health, Behavior & Society, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD; and
‡Department of Public Health & Policy, London School of Hygiene and Tropical Medicine, Lusaka, Zambia.
Correspondence to: Carol Underwood, PhD, Department of Health, Behavior & Society, Bloomberg School of Public Health, Johns Hopkins University, 111 Market Place, Suite 310, Baltimore, MD 21202 (e-mail: firstname.lastname@example.org).
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.jaids.com).
Supported by United States Agency for International Development (USAID), Cooperative Agreement #AID-OAA-A-12-00,058.
The authors have no conflicts of interest to disclose.
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Abstract: Addressing community-level factors (CLFs) is integral to the ongoing effort to design multilevel, effective, and sustainable interventions to address each element of the HIV/AIDS treatment cascade. This review, the first critical review of this topic, identified 100 articles that (1) assessed CLFs in relation to the HIV/AIDS treatment cascade, (2) had been peer-reviewed, and (3) were based on studies conducted in low- or middle-income countries. Social support and social networks, cultural norms, gender norms, and stigma were the key CLFs associated with treatment and care. This extensive review found only 5 evaluations of interventions designed to affect CLFs, reflecting a major gap in the literature. All were communication interventions designed to create a more positive environment for HIV testing and access to treatment and care, thus pointing to some of the potential extraindividual effects of communication interventions. The qualitative data are rich and vital for understanding the context; yet, more quantitative analysis to provide evidence regarding the distribution of these factors is essential, as only 19 of the studies were quantitative. There is a pressing need to (1) collect community-level data, (2) validate social and gender norm scales, and (3) better use available data regarding social norms, gender norms, and other CLFs. These data could be aggregated at the cluster, neighborhood, or community levels and incorporated into multilevel analysis to help clarify the pathways to enhanced outcomes across the treatment cascade and thereby mitigate HIV sequelae.
Studies regarding factors associated with the HIV treatment cascade, including access to testing and loss to follow-up during adherence to pre–antiretroviral therapy (pre-ART), ART initiation, and ART treatment, often focus at the individual or clinic levels.1–4 Importantly, the role of structural determinants has been acknowledged increasingly over the past decade.5–8 Yet, the arena where social relations are constructed and reconstructed and where social change occurs—namely, the community—is still relatively ignored.9 Recent highlighting by the Joint United Nations Program on HIV/AIDS10,11 of the importance of community across the treatment cascade underscores how essential community-wide systems are for motivating use of HIV diagnosis and treatment services and argues for expanded research in this direction.12 Coates12 points to the potential role of community-level interventions in creating an enabling environment for prevention as well as for testing, treatment, and care.
To date, no review of the literature on community-level factors (CLFs) and the treatment cascade has been published. A better understanding of CLFs in HIV treatment and care would contribute to the larger effort to design multilevel, effective, and sustainable programs and interventions. This review, which seeks to address that gap, was guided by the understanding that CLFs could be assessed from both a contextual and a compositional perspective.13 Contextual factors, such as the number of community groups providing care and support, are integral to the community and measurable only at that level. Compositional factors, such as the proportion of the population that has been tested, are aggregated from individual-level variables and consequently are much more readily available. This reviews covers articles addressing both compositional and contextual CLFs The articles included in this review use the term “community” to refer to people living in the same geographic area.
This critical review of the literature sought to answer the following research questions:
* What CLFs promote/inhibit HIV testing, encourage/discourage uptake of appropriate treatment, or support/undermine adherence and care in low- and middle-income countries?
* What CLFs have HIV-related interventions addressed? How and with what effect?
Informed by the literature, the research team developed complex search strings to search for CLFs “AND” for each phase of the HIV/AIDS treatment cascade. The detailed search protocol is available as Supplemental Digital Content (see Appendix A, http://links.lww.com/QAI/A539). A search hedge developed by research librarians at the Johns Hopkins Welch Medical Library limited the search to low- and middle-income countries. This search strategy was adapted for and executed in PubMed, Embase, Scopus, CINAHL, and Global Health. The only citations included were those regarding low- and middle-income countries, published before January 8, 2014 in English, Spanish, or French, and with abstracts available.
These search terms located a total of 5279 articles. After the removal of duplicates, conference papers, and dissertations, 2809 articles remained for initial review. Two reviewers independently reviewed all titles and abstracts and chose 324 articles that explicitly or implicitly referred to CLFs. A third reviewer reread the 324 abstracts and, if needed, the relevant article, to determine whether CLFs were actually addressed; 197 articles were deemed relevant. An additional 11 articles were added from a previous literature review because of their relevance. Overall, 208 articles were assessed for inclusion in this document (Fig. 1).
A team of 5 reviewers read the articles. Each article was read by 2 randomly selected reviewers who independently made a further selection based on the following inclusion criteria: (1) CLFs had been assessed in relation to the HIV/AIDS treatment cascade, (2) the articles had been peer-reviewed, and (3) the study was conducted in a low- or middle-income countries. On completion of that step, all readers discussed articles with discordant assessments. These discussions led to consensus on 100 articles that would be included in this literature review.
Following a brief discussion of health system factors, findings are presented according to the individual elements of the treatment cascade: testing, pre-ART, ART adherence, and care.3 Within each element, the associated CLFs and whether their effects are negative or positive effects are discussed (Fig. 2).3
Health care system factors that aid or impede access throughout the treatment cascade are typically structural in that decisions are generally made at the national or provincial level rather than in communities. Nonetheless, both human and material resource allocation can manifest differently in different communities. Health care systems factors that were identified in this review as potentially subject to community-level intervention included distance, cost, lack of confidentiality, and inconvenient hours associated with testing,14–17 pre-ART18,19 timely initiation of ART,20 adherence,21–24 and care.15 This search, however, found no articles that explored community-specific aspects of health systems on treatment or care.
HIV Counseling and Testing
An analysis of community factors in 8 African countries found that living in communities with relatively high community levels of HIV knowledge, male employment, and primary school completion by both men and women were all positively associated with men's uptake of HIV counseling and testing (HCT). In communities where more women were employed, and there were a higher number of sexual partners in the community, men were less likely to be tested for HIV.25
Social Support and Social Networks
Social influence and support are important to people's health decisions, including whether one should test for HIV. Living in communities that have low testing rates are unsupportive, place blame, or associate HCT with immorality is associated with low HCT uptake.26,27 The fear of social exclusion, stigma, and loss of social support caused many to avoid HCT.16,27–30
In many countries, membership in community organizations (eg, women's groups, people living with HIV [PLHIV] groups, burial societies, sports clubs, political groups) is positively associated with uptake of HCT.28,31,32 Organizational membership increases social capital and support and can give members a feeling of belonging. In Malawi, male and female members of community groups (16.2% and 10.5%, respectively) were twice (P < 0.05) as likely as nonmembers (8.5% and 4.6%, respectively) to have had an HIV test.32 In Zimbabwe, rates of uptake by both men and women were higher among community organization members (15% and 35.6%, respectively) than among nonmembers (9.2% and 29.6%, respectively).31 Group membership aggregated at the village level was also positively associated with higher HCT rates over 3 years.31
The Health Communication Partnership Zambia sought to strengthen community-based systems as part of a larger effort to encourage positive health behaviors. The project evaluation found that the intervention was able to build community capacity, which was associated with community action to improve health behaviors. Respondents from communities with high levels, rather than low levels, of community action were twice as likely to have undergone HCT and know the results (odds ratio = 2.00, P < 0.001).33
Cultural and Gender Norms
Gender, social, and cultural norms in a community can influence HCT uptake. Multiple studies have found that men associate HCT with diminished masculinity.16,25,34 South African men reported fear of becoming a burden and no longer being able to fulfill their provider role as reasons for not seek testing.34 A study in Zambia found that men felt their position in intimate relationships would be undermined if they agreed to HCT at the urging of a wife or other partner.27
Some communities and cultures require the wife to obtain her husband's permission to be tested, possibly placing the woman in a dangerous situation if her partner suspects her request for testing arises from either her infidelity or suspicion of his.16,26 Gender norms that restrict women's access to financial resources also make it difficult for them to receive HCT.16
Although often measured at the individual level, stigma is a social construct that frequently manifests itself at the community level.35 Therefore, accounts of stigma are intrinsically linked to CLFs across the treatment cascade. Both perceived and actual stigma in communities leads to lower levels of HIV testing.15,16,26,29,30,36–54 A study in Nigeria found that men from communities that reported a medium level of stigma (on a tripartite scale of low, medium, and high stigma) were 43% less likely to report readiness for HCT than men living in communities with low levels of stigma (odds ratio = 0.57, P < 0.001).36
The period between testing and treatment is often perilous, with loss of patients at each step of the cascade, beginning with patients who never collect their CD4 count results and ending with those who, although eligible, do not initiate ART.2 A systematic review and meta-analysis of 12 countries in sub-Saharan Africa demonstrated high pre-ART attrition and losses twice as high among those not yet eligible for ART.1 According to another systematic review, among clients testing positive for HIV who are not ART-eligible at diagnosis, less than one-third are retained continuously in care.2 Poor rates of referrals following diagnosis are reported in Ethiopia, indicating a need to strengthen linkages and retention in care and address patient-identified barriers, including fear of stigma and lack of community support.55
The care pathway is not a simple linear process, as clients enter and leave, and losses occurring throughout, particularly before ART initiation.3 Although much of the literature focuses on addressing these losses through clinical improvements, such as point-of-care CD4 count testing or improved referral systems, far less attention has focused on CLFs that may also influence the pre-ART period.
Social Support and Social Networks
Following HCT, a largely private and individual decision, many PLHIV depend on social support networks to help them navigate the pre-ART period.56 Those without reliable or trusted networks are at high risk of dropping out. Social support, including physical, spiritual, or financial support, is vital for promoting pre-ART care and timely ART initiation.18,57 Support from community-based organizations and networks of PLHIV also has the potential to increase utilization of HIV-related services.17,58,59 Likewise, a review of community-based support services points to a positive associate between the availability of such services and expanded access to, and increased coverage of, ART programs in resource-limited settings, whereas acknowledging that most studies included in the review did not quantify the mean effect of community-support initiatives.60
Social support may hinder or reinforce care-seeking behavior and ART uptake among sex workers and men who have sex with men (MSM). Fear of losing fellow sex workers' social support and client referrals hindered care-seeking behavior in India; the feared repercussions of rejection and social isolation led women to postpone ART initiation until they were symptomatic.61 This has been found true also for MSM and transgender women, who feared social rejection if seen taking ART.62 However, when collective efficacy, agency, and social support are high, both service utilization and consistent condom use improve among both sex workers and MSM.63
Cultural and Gender Norms
Prevalent gendered attitudes and norms can lead to delay in seeking pre-ART care and in loss to care. A study in Malawi found that widely held concepts of masculinity and femininity strongly inhibit willingness to seek care.56 In Burkina Faso, gendered values attached to femininity motivate women to seek care, whereas gender norms inhibit men from seeking care early,64 which also places their partners at risk of HIV infection. Likewise, in Thailand, more women initiate treatment than men, although men are more likely to be infected with HIV.65
Stigma remains a formidable challenge throughout the pre-ART period. Fear of the stigma attached to being seen at an ART facility is prominent in several countries including Uganda, South Africa, Ghana, and Swaziland.66–69 Key populations, including sex workers, MSM, and people who inject drugs, often face formidable barriers when entering treatment. Stigmatizing attitudes and behaviors of health workers remain pervasive, discouraging linkage and retention in HIV care.15,70,71 These negative provider attitudes could be addressed through training programs that address stigma-related barriers.72
Stigma can vary between urban and rural setting. As the effect of antiretrovirals became visible and the health status of PLHIV began to improve in Zimbabwe, broader acceptance and greater social cohesion were evident in rural areas, whereas in urban areas, less cohesion and delayed care seeking emerged.73 In South Africa, a higher proportion of PLHIV from rural than from urban communities sought services, with the largest percentages seen in rural communities with active HIV support groups.74
Adherence to ART is essential for viral load suppression, which is correlated with a steep reduction in HIV transmission at the population level.75 Several studies have found that community-level HIV/AIDS knowledge, which can decrease misconceptions and enhance support for PLHIV, is positively associated with adherence.76,77
Social Support and Social Networks
Social support is critical in encouraging PLHIV to normalize their lives and adhere to treatment.27,76–80 A study in Zimbabwe found that social networks can enhance adherence among children through increased support for PLHIV, mitigation of stigma, improved access to health services, and disclosure.76 Networks of family members, friends, teachers, community-based organizations, and employers are important in supporting adherence and retention in care.17,56,59,76,77,79,81–88 A systematic review found that patients with community support had better virological and immunological outcomes as well as increased levels of retention and rates of survival.60
Although social networks often play a positive role in adherence, they can prevent adherence if PLHIV avoid disclosure for fear of rejection. Conversely, in other cases, PLHIV adhere because they fear that nonadherence could jeopardize support from significant others and family.79,81,85,89
Cultural and Gender Norms
In Zimbabwe, a study found that many men struggle to adhere because they avoid clinics identified as “AIDS clinics” by their community.79 Women also struggle to adhere, particularly when their husbands refuse to provide money for transport or clinic fees.79 Women who are financially dependent on their husbands may choose to remain sick when adherence is associated with the possibility of divorce.79,85
A qualitative study conducted in Mexico found that discrimination in access to public services hindered adherence.90 A qualitative study of children on ART and their caregivers highlighted stigma at school as an impediment to adherence.91 Similarly, a study in western Kenya found that 16% of children living with HIV were lost to follow-up because of discrimination by the family or community, and 30% were lost to follow-up because of caregivers' fears of stigmatizing by family or community.92 Several studies have found that participants' fear of stigma and discrimination constituted a common barrier to adherence.3,8,12,13,22,93–98 Stigma was also cited as a reason not to accept home-based DOT (Directly Observed Therapy) with antiretroviral medication in Vietnam.99
Yet, at least 1 study found that anticipated stigma was an inadvertent motivator of adherence, as PLHIV took their medications to avoid a sickly appearance and the anticipated negative community reaction.100 Similarly, a study in South Africa found that, despite the negative climate occasioned by stigma, study participants noted the positive effects of ART and their ability to improve their health and accommodate their HIV status.101
HIV/AIDS care is the final step of the HIV/AIDS treatment cascade. Care includes engagement in, and outcomes of, treatment and services for PLHIV, with the ultimate goal of viral suppression.102 An extensive search of the literature found only 10 articles that addressed CLFs and HIV/AIDS care.15,35,58,103–109
Social Support and Social Networks
In Malawi, individuals living in areas with community support had decreased risk of death, decreased loss to follow-up, and increased adherence to ART compared with those in areas lacking community support.105 A qualitative study in Uganda found that community support, community groups, and networks were vital to palliative care delivery, treatment support, and bereavement support. Leadership, capacity building, partnerships with community members, and supportive policies facilitated community participation in the provision of palliative care.103
A home-based care intervention in Ethiopia worked with community-based organizations (CBOs) and nongovernmental organizations through community mobilization to train community members to provide basic palliative care.104 The study found a reduction in opportunistic infections and mortality and concluded that the intervention improved the health and well-being of PLHIV while reducing HIV-related stigma.
Finally, a cross-sectional survey in Nigeria found that CBO engagement in the community, as measured contextually by the number of CBOs per 100,000 people, was associated with better odds of both the availability and the utilization of prevention or care services.58
Stigma has been found to impede HIV/AIDS care delivery in multiple countries.35,110 A study in Serbia exploring PLHIV perspectives found that the limited availability of state-funded HIV treatment has interacted with structural forces to create new forms of stigmatization that limit empowerment and employment opportunities.106 Prisoners reentering mainstream society in Malaysia who perceived that public attitudes were highly stigmatizing toward PLHIV faced more challenges, including difficulty in obtaining HIV care, compared with those reporting low HIV stigma.107 Female sex workers, MSM, transgender, and peer educators in southern India reported fear of and experiences of discrimination from family and community members (eg, neighbors, school, and government), as well as perceived and actual discrimination from health care providers, as barriers to care and support services, particularly at government-run facilities.15 Both a qualitative study in Grenada and Trinidad and Tobago108 and a cross-sectional study Nigeria109 found that providers' stigmatizing acts of neglect and refusal of services were barriers to care for PLHIV.45,46
As this was a critical and not a systematic review, articles that might have been included may have been overlooked. For example, studies from the gray literature were not included because the type of review process to which they were subject, if any, is unknowable. Studies from high-income countries were also excluded given the dominant role that economics play in reducing obstacles to, and creating opportunities for, treatment and care. Finally, this review did not assess the quality or strength of the evidence presented in the articles. This is clearly an aspect that requires further attention and should be undertaken in future research.
This review has sought to highlight CLFs identified in the literature as associated, whether positively or negatively, with the stages in the HIV treatment cascade in low- and middle-income countries. Positive social norms and social support organized around HIV treatment and care were widely discussed in the literature and are areas where programmatic interventions might have high impact. In particular, equitable gender norms, cultural norms to enable appropriate treatment of key populations, and stigma reduction were identified as areas that should be addressed with communities to reduce dropout along the treatment cascade. At the same time, community-level interventions alone are not sufficient. Many articles note the importance of structural-level change, including changes in policies, access to health care services, and broader economic factors.
The second aim of this review was to identify evaluations of interventions relevant to the topic at hand. Thirteen articles about CLF interventions were identified; of those, 7 were purely descriptive so were not included in this review. The 5 interventions that were evaluated were communication interventions designed to influence or alter CLFs. The interventions worked with social networks, community leaders, and clinic staff to increase access across the treatment cascade, including community-based care, which points to the potential for communication programs in the HIV trajectory. In particular, the articles point to the need to work with a broad swathe of community members over a period of time to enable and allow changes to take place. The dearth of relevant evaluation articles suggests several possibilities. One is that assessments of interventions designed to address individual-level factors have failed to examine potential community-level change, whether contextual or compositional. Another possibility is that some articles were overlooked because of search term or search engine limitations, which would suggest the need to conduct a further search in this area. Most likely, however, this study reflects the fact that few interventions designed to have community-level effects have been evaluated. Such evaluations are crucially needed.
Context really does make a difference. It not only defines individuals' abilities to reduce their risk and vulnerability to HIV,12,111 but it also serves as the middle ground9 in which collective action plays out and where social change occurs. Yet, too often research remains at the individual level. As this review demonstrates, compared with hundreds of articles about individual-level factors and the HIV care pathway, relatively few articles actually measure or evaluate the associations between the community-as-context and continuation in the HIV treatment and care cascade. Even fewer explore the causal pathway between community factors and HIV outcomes. Furthermore, of the 100 articles reviewed, only 19 were quantitative. Qualitative research is crucial to understanding context and the need for such studies has not been exhausted as we are still in the early stages of understanding how context affects HIV outcomes. Yet, qualitative research alone is not sufficient, particularly to better understand the pathways to improved treatment and care. At the same time, there is a clear need to standardize, at least at the subregional level, and validate social and gender norm scales so that comparisons of these important CLFs can be rigorously assessed over time and place, if relevant. Although community contexts were described and discussed in the articles reviewed, no clear theoretical model of the causal linkages was presented. The qualitative studies could contribute to such a theoretical model, but would need to be tested with quantitative data.
Moreover, there is a vast body of data that is underutilized and could help us better understand community factors. Data regarding social norms, gender norms, and other such factors could be aggregated at the cluster, neighborhood, or community levels and incorporated into multilevel analysis; this would help elucidate pathways to better treatment and care. Research that rigorously assesses the role of CLFs is urgently needed to help us reach the still-elusive goal of minimizing loss to follow-up across the treatment cascade.
1. Mugglin C, Estill J, Wandeler G, et al.. Loss to programme between HIV diagnosis and initiation of antiretroviral therapy in sub‐Saharan Africa: systematic review and meta‐analysis. Trop Med Int Health. 2012;17:1509–1520.
2. Rosen S, Fox MP. Retention in HIV care between testing and treatment in sub-Saharan Africa: a systematic review. PLoS Med. 2011;8:e1001056.
3. Kranzer K, Govindasamy D, Ford N, et al.. Quantifying and addressing losses along the continuum of care for people living with HIV infection in sub-Saharan Africa: a systematic review. J Int AIDS Soc. 2012;15(2):.
4. Brinkhof MW, Pujades-Rodriguez M, Egger M. Mortality of patients lost to follow-up in antiretroviral treatment programmes in resource-limited settings: systematic review and meta-analysis. PLoS One. 2009;4:e5790.
5. Blankenship KM, Bray SJ, Merson MH. Structural interventions in public health. AIDS. 2000;14:S11–S21.
6. Auerbach J. Transforming social structures and environments to help in HIV prevention. Health Aff (Millwood). 2009;28:1655–1665.
7. Gupta GR, Parkhurst JO, Ogden JA, et al.. Structural approaches to HIV prevention. Lancet. 2008;372:764–775.
8. Underwood C, Skinner J, Osman N, et al.. Structural determinants of adolescent girls' vulnerability to HIV: views from community members in Botswana, Malawi, and Mozambique. Soc Sci Med. 2011;73:343–350.
9. Kippax S, Stephenson N, Parker RG, et al.. Between individual agency and structure in HIV prevention: understanding the middle ground of social practice. Am J Public Health. 2013;103:1367–1375.
10. UNAIDS (Joint United National Programme on HIV/AIDS). Together we will end AIDS. Geneva: UNAIDS; 2012.
11. UNAIDS (Joint United National Programme on HIV/AIDS). Global report: UNAIDS report on the global AIDS epidemic. Geneva: UNAIDS; 2013.
12. Coates TJ. An expanded behavioral paradigm for prevention and treatment of HIV-1 infection. J Acquir Immune Defic Syndr. 2013;63:S179–S182.
13. Macintyre S, Ellaway A, Cummins S. Place effects on health: how can we conceptualise, operationalise and measure them? Soc Sci Med. 2002;55:125–139.
14. Song Y, Li X, Zhang L, et al.. HIV-testing behavior among young migrant men who have sex with men (MSM) in Beijing, China. AIDS Care. 2011;23:179–186.
15. Beattie TSH, Parinita B, Suresh M, et al.. Personal, interpersonal and structural challenges to accessing HIV testing, treatment and care services among female sex workers, men who have sex with men and transgenders in Karnataka state, south India. (special issue: Assessing the role of community mobilisation in a scaled HIV prevention programme among marginalized populations in India—findings from avahan). J Epidemiol Community Health. 2012;66(suppl 2):ii42–ii8.
16. Musheke M, Ntalasha H, Gari S, et al.. A systematic review of qualitative findings on factors enabling and deterring uptake of HIV testing in sub-Saharan Africa. BMC Public Health. 2013;13:220.
17. Lazarus L, Reza-Paul S, Pasha A, et al.. Exploring the role of community-based peer support in improving access to care and antiretroviral treatment for sex workers in Mysore, India. J HIV AIDS Soc Serv. 2012;11:152–168.
18. Posse M, Baltussen R. Barriers to access to antiretroviral treatment in Mozambique, as perceived by patients and health workers in urban and rural settings. AIDS Patient Care STDS. 2009;23:867–875.
19. Govindasamy D, Ford N, Kranzer K. Risk factors, barriers and facilitators for linkage to antiretroviral therapy care: a systematic review. AIDS. 2012;26:2059–2067.
20. Dam Anh T, Shakeshaft A, Anh Duc N, et al.. Structural barriers to timely initiation of antiretroviral treatment in Vietnam: findings from six outpatient clinics. PLoS One. 2012;7:e51289.
21. Kip E, Ehlers VJ, van der Wal DM. Patients' adherence to anti-retroviral therapy in Botswana. J Nurs Scholarsh. 2009;41:149–157.
22. Kagee A, Remien RH, Berkman A, et al.. Structural barriers to ART adherence in southern Africa: challenges and potential ways forward. Glob Public Health. 2011;6:83–97.
23. Zhou YR. Help-seeking in a context of AIDS stigma: understanding the healthcare needs of people with HIV/AIDS in China. Health Soc Care Community. 2009;17:202–208.
24. Xu J, Sullivan SG, Dou Z, et al.. Economic stress and HIV-associated health care utilization in a rural region of China: a qualitative study. AIDS Patient Care & STDS. 2007;21:787–798.
25. Stephenson R, Miriam Elfstrom K, Winter A. Community influences on married men's uptake of HIV testing in eight African countries. AIDS Behav. 2013;17:2352–2366.
26. Kranzer K, McGrath N, Saul J, et al.. Individual, household and community factors associated with HIV test refusal in rural Malawi. Trop Med Int Health. 2008;13:1341–1350.
27. Grant E, Logie D, Masura M, et al.. Factors facilitating and challenging access and adherence to antiretroviral therapy in a township in the Zambian copperbelt: a qualitative study. AIDS Care. 2008;20:1155–1160.
28. Gari S, Malungo JRS, Martin-Hilber A, et al.. HIV testing and tolerance to gender based violence: a cross-sectional study in Zambia. PLoS One. 2013;8(8):e71922.
29. Admassu M, Fitaw Y. Factors affecting acceptance of VCT among different professional and community groups in north and south Gondar administrative zones, north west Ethiopia. Ethiop J Health Dev. 2006;20:24–31.
30. MacPhail CL, Pettifor A, Coates T, et al.. “You must do the test to know your status”: attitudes to HIV voluntary counseling and testing for adolescents among South African youth and parents. Health Educ Behav. 2008;35:87–104.
31. Gregson S, Nyamukapa CA, Sherr L, et al.. Grassroots community organizations' contribution to the scale-up of HIV testing and counselling services in Zimbabwe. AIDS. 2013;27:1657–1666.
32. Paz-Soldan VA, Bisika T, Graft-Johnson J, et al.. Community, social group, and individual level correlates of rural Malawian men's and women's reproductive health intentions and practices. Afr J Reprod Health. 2012;16:57–67.
33. Underwood C, Boulay M, Snetro-Plewman G, et al.. Community capacity as means to improved health practices and an end in itself: evidence from a multi-stage study. Int Q Community Health Educ. 2012;33:105–127.
34. Dageid W, Govender K, Gordon SF. Masculinity and HIV disclosure among heterosexual South African men: implications for HIV/AIDS intervention. Cult Health Sex. 2012;14:925–940.
35. Mbonu NC, van den Borne B, De Vries NK. Stigma of people with HIV/AIDS in sub-Saharan Africa: a literature review. J Trop Med. 2009;2009:145891:1–14.
36. Babalola S. Readiness for HIV testing among young people in northern Nigeria: the roles of social norm and perceived stigma. AIDS Behav. 2007;11:759–769.
37. Abdool Karim Q, Meyer-Weitz A, Mboyi L, et al.. The influence of AIDS stigma and discrimination and social cohesion on HIV testing and willingness to disclose HIV in rural KwaZulu-natal, South Africa. Glob Public Health. 2008;3:351–365.
38. Smolak A, El-Bassel N. Multilevel stigma as a barrier to HIV testing in central Asia: A context quantified. AIDS Behav. 2013;17:2742–2755.
39. Koku EF. Desire for, and uptake of HIV tests by Ghanaian women: the relevance of community level stigma. J Community Health. 2011;36:289–299.
40. Tenkorang EY, Maticka-Tyndale E. Individual- and school-level correlates of HIV testing among secondary school students in Kenya. Stud Fam Plann. 2013;44:169–187.
41. Berendes S, Rimal RN. Addressing the slow uptake of HIV testing in Malawi: the role of stigma, self-efficacy, and knowledge in the Malawi BRIDGE project. J Assoc Nurses AIDS Care. 2011;22:215–228.
42. Bwambale FM, Ssali SN, Byaruhanga S, et al.. Voluntary HIV counselling and testing among men in rural western Uganda: implications for HIV prevention. BMC Public Health. 2008;8:263.
43. Day JH, Miyamura K, Grant AD, et al.. Attitudes to HIV voluntary counselling and testing among mineworkers in South Africa: will availability of antiretroviral therapy encourage testing? AIDS Care. 2003;15:665–672.
44. Epule ET, Mirielle MW, Peng C, et al.. Utilization rates and perceptions of (VCT) services in Kisii central district, Kenya. Glob J Health Sci. 2012;5:35–43.
45. Ford K, Wirawan DN, Sumantera GM, et al.. Voluntary HIV testing, disclosure, and stigma among injection drug users in Bali, Indonesia. AIDS Educ Prev. 2004;16:487–498.
46. Haraka F, Mohamed A, Kilonzo G, et al.. Factors affecting HIV counselling and testing among adults in Muheza district, Tanzania. Tanzan J Health Res. 2012;14:1–5.
47. Kalichman SC, Simbayi LC. HIV testing attitudes, AIDS stigma, and voluntary HIV counselling and testing in a black township in cape town, South Africa. Sex Transm Infect. 2003;79:442–447.
48. Kitara DL, Aloyo J. HIV/AIDS stigmatization, the reason for poor access to HIV counseling and testing (HCT) among the youths in Gulu (Uganda). Afr J Infect Dis. 2012;6:12–20.
49. Koku EF. Stigma, sexual risk and desire for HIV tests in Ghana. Sex Health. 2011;8:110–119.
50. Leta TH, Syndoy IF, Fylkesnes K. Factors affecting voluntary HIV counselling and testing among men in Ethiopia: a cross-sectional survey. BMC Public Health. 2012;12:438.
51. Ma W, Detels R, Feng Y, et al.. Acceptance of and barriers to voluntary HIV counselling and testing among adults in Guizhou province, China. (from science to policy: China's responses to HIV/AIDS). AIDS. 2007;21(suppl 8):S129–S135.
52. Meiberg AE, Bos AER, Onya HE, et al.. Fear of stigmatization as barrier to voluntary HIV counselling and testing in South Africa. East Afr J Public Health. 2008;5:49–54.
53. Mugo M, Kibachio C, Njuguna J. Utilization of voluntary counselling and testing services by women in a Kenyan village. J Rural Trop Public Health. 2010;9:36–39.
54. Wolfe WR, Weiser SD, Bangsberg DR, et al.. Effects of HIV-related stigma among an early sample of patients receiving antiretroviral therapy in Botswana. AIDS Care. 2006;18:931–933.
55. Assefa Y, Van Damme W, Mariam DH, et al.. Toward universal access to HIV counseling and testing and antiretroviral treatment in Ethiopia: looking beyond HIV testing and ART initiation. AIDS Patient Care STDS. 2010;24:521–525.
56. MacPherson P, MacPherson EE, Mwale D, et al.. Barriers and facilitators to linkage to ART in primary care: a qualitative study of patients and providers in Blantyre, Malawi. J Int AIDS Soc. 2012;15:18020.
57. Muhamadi L, Nsabagasani X, Tumwesigye MN, et al.. Inadequate pre-antiretroviral care, stock-out of antiretroviral drugs and stigma: policy challenges/bottlenecks to the new WHO recommendations for earlier initiation of antiretroviral therapy (CD <350 cells/micro L) in eastern Uganda. Health Policy. 2010;97:187–194.
58. Kakietek J, Geberselassie T, Manteuffel B, et al.. It takes a village: community-based organizations and the availability and utilization of HIV/AIDS-related services in Nigeria. AIDS Care. 2013;25(suppl 1):S78–S87.
59. Hodgson I, Nakiyemba A, Seeley J, et al.. Only connect—the role of PLHIV group networks in increasing the effectiveness of Ugandan HIV services... people living with HIV. AIDS Care. 2012;24:1368–1374.
60. Wouters E, Van Damme W, van Rensburg D, et al.. Impact of community-based support services on antiretroviral treatment programme delivery and outcomes in resource-limited countries: a synthetic review. BMC Health Serv Res. 2012;12:194.
61. Chakrapani V, Newman PA, Murali S, et al.. Barriers to free antiretroviral treatment access for female sex workers in Chennai, India. AIDS Patient Care STDS. 2009;23:973–980.
62. Chakrapani V, Newman PA, Murali S, et al.. Barriers to free antiretroviral treatment access among kothi-identified men who have sex with men and aravanis (transgender women) in Chennai, India. AIDS Care. 2011;23:1687–1694.
63. Saggurti N, Mishra RM, Proddutoor L, et al.. Community collectivization and its association with consistent condom use and STI treatment-seeking behaviors among female sex workers and high-risk men who have sex with men/transgenders in Andhra Pradesh, India. AIDS Care. 2013;25(suppl 1):S55–S66.
64. Bila B, Egrot M. Gender asymmetry in healthcare-facility attendance of people living with HIV/AIDS in Burkina Faso. Soc Sci Med. 2009;69:854–861.
65. Le Coeur S, Collins IJ, Pannetier J, et al.. Gender and access to HIV testing and antiretroviral treatments in Thailand: why do women have more and earlier access? Soc Sci Med. 2009;69:846–853.
66. Kunihira NR, Nuwaha F, Mayanja R, et al.. Barriers to use of antiretroviral drugs in Rakai district of Uganda. Afr Health Sci. 2010;10:120–129.
67. Mitchell SK, Kelly KJ, Potgieter FE, et al.. Assessing social preparedness for antiretroviral therapy in a generalized AIDS epidemic: a diffusion of innovations approach. AIDS Behav. 2009;13:76–84.
68. Zamberia AM. HIV-related stigma and access to health care among people living with HIV in Swaziland. Dev South Afr. 2011;28:669–680.
69. Mill JE. Shrouded in secrecy: breaking the news of HIV infection to Ghanaian women. J Transcult Nurs. 2003;14:6–16.
70. Adeeba K. Antiretroviral therapy in Malaysia: identifying barriers to universal access. HIV Ther. 2009;3:573–582.
71. Kimani-Murage EW, Manderson L, Norris SA, et al.. “It's my secret”: barriers to paediatric HIV treatment in a poor rural South African setting. AIDS Care. 2013;25:744–747.
72. Mtetwa S, Busza J, Chidiya S, et al.. “You are wasting our drugs”: health service barriers to HIV treatment for sex workers in Zimbabwe. BMC Public Health. 2013;13:698.
73. Geiselhart K. Stigma and discrimination—an integrative perspective. Spatial disparities and their impact on the introduction of an antiretroviral therapy scheme for HIV and AIDS treatment in Botswana. Erdkunde. 2010;64:33–45.
74. Kruger A, Greeff M, Watson MJ, et al.. Health care seeking behaviour of newly diagnosed HIV infected people from rural and urban communities in the North West province of South Africa. Afr J Nurs Midwifery. 2009;11:28–45.
75. Attia S, Egger M, Muller M, et al.. Sexual transmission of HIV according to viral load and antiretroviral therapy: systematic review and meta-analysis. AIDS. 2009;23:1397–1404.
76. Campbell C, Skovdal M, Mupambireyi Z, et al.. Building adherence-competent communities: factors promoting children's adherence to anti-retroviral HIV/AIDS treatment in rural Zimbabwe. Health Place. 2012;18:123–131.
77. Tomori C, Kennedy CE, Brahmbhatt H, et al.. Barriers and facilitators of retention in HIV care and treatment services in Iringa, Tanzania: the importance of socioeconomic and sociocultural factors. AIDS Care. 2014;26:907–913.
78. Jones DL, Zulu I, Vamos S, et al.. Determinants of engagement in HIV treatment and care among Zambians new to antiretroviral therapy. J Assoc Nurses AIDS Care. 2013;24:e1–e12.
79. Skovdal M, Campbell C, Nhongo K, et al.. Contextual and psychosocial influences on antiretroviral therapy adherence in rural Zimbabwe: towards a systematic framework for programme planners. Int J Health Plann Manage. 2011;26:296–318.
80. Grimwood A, Fatti G, Mothibi E, et al.. Community adherence support improves programme retention in children on antiretroviral treatment: a multicentre cohort study in South Africa. J Int AIDS Soc. 2012;15:17381.
81. Lyimo RA, Bruin MD, Boogaard JVD, et al.. Determinants of antiretroviral therapy adherence in northern Tanzania: a comprehensive picture from the patient perspective. BMC Public Health. 2012;12:716.
82. Vreeman RC, Nyandiko WM, Ayaya SO, et al.. Factors sustaining pediatric adherence to antiretroviral therapy in western Kenya. Qual Health Res. 2009;19:1716–1729.
83. Wouters E, Damme Wv, Loon Fv, et al.. Public-sector ART in the free state province, South Africa: community support as an important determinant of outcome. Social Sci Med. 2009;69:1177–1185.
84. Lifson AR, Demissie W, Tadesse A, et al.. Barriers to retention in care as perceived by persons living with HIV in rural Ethiopia: focus group results and recommended strategies. J Int Assoc Provid AIDS Care. 2013;12:32–38.
85. Merten S, Kenter E, McKenzie O, et al.. Patient-reported barriers and drivers of adherence to antiretrovirals in sub-Saharan Africa: a meta-ethnography. Trop Med Int Health. 2010;15(suppl 1):16–33.
86. Campbell C, Scott K, Nhamo M, et al.. Social capital and HIV competent communities: the role of community groups in managing HIV/AIDS in rural Zimbabwe. AIDS Care. 2013;25(suppl 1):S114–S122.
87. Roura M, Busza J, Wringe A, et al.. Barriers to sustaining antiretroviral treatment in Kisesa, Tanzania: a follow-up study to understand attrition from the antiretroviral program. AIDS Patient Care STDS. 2009;23:203–210.
88. Mimiaga MJ, Safren SA, Dvoryak S, et al.. “We fear the police, and the police fear us”: structural and individual barriers and facilitators to HIV medication adherence among injection drug users in Kiev, Ukraine. AIDS Care. 2010;22:1305–1313.
89. Ware NC, Idoko J, Kaaya S, et al.. Explaining adherence success in sub-Saharan Africa: an ethnographic study. PLoS Med. 2009;6:e11.
90. Herrera C, Campero L, Caballero M, et al.. Relationship between physicians and HIV patients: influence on adherence and quality of life [in Spanish]. Rev Saude Publica. 2008;42:249–255.
91. Bikaako-Kajura W, Luyirika E, Purcell DW, et al.. Disclosure of HIV status and adherence to daily drug regimens among HIV-infected children in Uganda. AIDS Behav. 2006;10(4 suppl l):S85–S93.
92. Braitstein P, Songok J, Vreeman RC, et al.. “Wamepotea” (they have become lost): outcomes of HIV-positive and HIV-exposed children lost to follow-up from a large HIV treatment program in western Kenya. J Acquir Immune Defic Syndr. 2011;57:e40–e46.
93. Van Dyk AC. Treatment adherence following national antiretroviral rollout in South Africa. Afr J AIDS Res. 2010;9:235–247.
94. Sanjobo N, Frich JC, Fretheim A. Barriers and facilitators to patients' adherence to antiretroviral treatment in Zambia: a qualitative study. SAHARA J. 2008;5:136–143.
95. Jones D, Zulu I, Mumbi M, et al.. Strategies for living with the challenges of HIV and antiretroviral use in Zambia. Int Electron J Health Educ. 2009;12:253–270.
96. Wasti SP, Simkhada P, Randall J, et al.. Barriers to and facilitators of antiretroviral therapy adherence in Nepal: a qualitative study. J Health Popul Nutr. 2012;30:410–419.
97. Musheke M, Bond V, Merten S. Individual and contextual factors influencing patient attrition from antiretroviral therapy care in an urban community of Lusaka, Zambia. J Int AIDS Soc. 2012;15(suppl 1):1–9.
98. Mutwa PR, Van Nuil JI, Asiimwe-Kateera B, et al.. Living situation affects adherence to combination antiretroviral therapy in HIV-infected adolescents in Rwanda: a qualitative study. PLoS One. 2013;8:e60073.
99. Van Tam V, Pharris A, Thorson A, et al.. “It is not that I forget, it's just that I don't want other people to know”: barriers to and strategies for adherence to antiretroviral therapy among HIV patients in northern Vietnam. AIDS Care. 2011;23:139–145.
100. Okoror TA, Falade CO, Olorunlana A, et al.. Exploring the cultural context of HIV stigma on antiretroviral therapy adherence among people living with HIV/AIDS in southwest Nigeria. AIDS Patient Care STDS. 2013;27:55–64.
101. Gilbert L, Walker L. “They (ARVs) are my life, without them I'm nothing”—experiences of patients attending a HIV/AIDS clinic in Johannesburg, South Africa. Health Place. 2009;15:1123–1129.
102. World Health Organization (WHO). Global update on HIV treatment 2013: results, impact and opportunities. Geneva: World Health Organization; 2013.
103. Mburu G, Oxenham D, Hodgson I, et al.. Community systems strengthening for HIV care: experiences from Uganda. J Soc Work End Life Palliat Care. 2013;9:343–368.
104. Wube M, Horne CJ, Stuer F. Building a palliative care program in Ethiopia: the impact on HIV and AIDS patients and their families. J Pain Symptom Manage. 2010;40:6–8.
105. Zachariah R, Teck R, Buhendwa L, et al.. Community support is associated with better antiretroviral treatment outcomes in a resource-limited rural district in Malawi. Trans R Soc Trop Med Hyg. 2007;101:79–84.
106. Bernays S, Rhodes T, Jankovic Terzic K. “You should be grateful to have medicines”: continued dependence, altering stigma and the HIV treatment experience in Serbia. AIDS Care. 2010;22:14–20.
107. Choi P, Kavasery R, Desai MM, et al.. Prevalence and correlates of community re-entry challenges faced by HIV-infected male prisoners in Malaysia. Int J STD AIDS. 2010;21:416–423.
108. Rutledge SE, Abell N, Padmore J, et al.. AIDS stigma in health services in the eastern Caribbean. Sociol Health Illn. 2009;31:17–34.
109. Ajayi B, Moses A, Gashau W, et al.. Assessment of knowledge, perception and attitude of people living with HIV/AIDS toward HIV/AIDS in Maiduguri, northeast-Nigeria. Internet J Infect Dis. 2013;12:1.
110. Morrison SD, Banushi VH, Sarnquist C, et al.. Barriers to care, and current medical and social needs of HIV-positive patients in Albania. Cent Eur J Public Health. 2011;19:91–97.
111. Busza JR. Promoting the positive: responses to stigma and discrimination in southeast Asia. AIDS Care. 2001;13:441–456.
community-level factors; HIV/AIDS; treatment cascade
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