Intersecting stigma and HIV testing practices among urban refugee adolescents and youth in Kampala, Uganda: qualitative findings

Abstract

Introduction: HIV-related risks may be exacerbated in humanitarian contexts. Uganda hosts 1.3 million refugees, of which 60% are aged under 18. There are knowledge gaps regarding HIV testing facilitators and barriers, including HIV and intersecting stigmas, among urban refugee youth. In response, we explored experiences and perspectives towards HIV testing strategies, including HIV self-testing, with urban refugee youth in Kampala, Uganda. Methods: We implemented a qualitative study with refugee cisgender youth aged 16 to 24 living in Kampala's informal settlements from February-April 2019. We conducted five focus groups with refugee youth, including two with adolescent boys and young men, two with adolescent girls and young women and one with female sex workers. We also conducted five key informant (KI) interviews with government, non-government and community refugee agencies and HIV service providers. We conducted thematic analyses to understand HIV testing experiences, perspectives and recommendations. Results: Participants (n = 49) included young men (n = 17) and young women (n = 27) originally from the Democratic Republic of Congo [DRC] (n = 29), Rwanda (n = 11), Burundi (n = 3) and Sudan (n = 1), in addition to five KI (gender: n = 3 women, n = 2 men; country of origin: n = 2 Rwanda, n = 2 Uganda, n = 1 DRC). Participant narratives revealed stigma drivers included fear of HIV infection; misinformation that HIV is a "Ugandan disease"; and blame and shame for sexual activity. Stigma facilitators included legal precarity regarding sex work, same-sex practices and immigration status, alongside healthcare mistreatment and confidentiality concerns. Stigma experiences were attributed to the social devaluation of intersecting identities (sex work, youth, refugees, sexual minorities, people living with HIV, women). Participants expressed high interest in HIV self-testing. They recommended HIV self-testing implementation strategies to be peer supported and expressed concerns regarding sexual-and gender-based violence with partner testing. Conclusions: Intersecting stigma rooted in fear, misinformation, blame and shame, legal precarity and healthcare mistreatment constrain current HIV testing strategies with urban refugee youth. Findings align with the Health Stigma and Discrimination Framework that conceptualizes stigma drivers and facilitators that devalue intersecting health conditions and social identities. Findings can inform multi-level strategies to foster enabling HIV testing environments with urban refugee youth, including tackling intersecting stigma and leveraging refugee youth peer support.

Uptake and provision of self-care interventions for sexual and reproductive health: findings from a global values and preferences survey

“…Novel approaches to increase access could train peer health workers to raise awareness among health workers and lay persons in diverse communities on SRH self-care interventions. 19 For instance, peer health workers could have knowledge and experience using the intervention and share lived experiences (such as sex work, refugee experience, sexual minority identity) with communities they are working with. Future research can explore the potential of peer health workers in providing SRH self-care information, products (e.g.…”

“…For instance, HIV self-testing was perceived by urban refugee youth in Uganda as appealing due to increased confidentiality, reduced exposure to stigma, and the potential for increased access to testing, but young refugee women also raised concerns about the potential for violence and coercion with male partners due to inequitable sexual relationship power. 19 Hence, there is an urgent need for attention to both the intersecting stigma and discrimination that can increase interest in SRH self-care interventions among marginalised communities who experience barriers to accessing health systems, 17 while also monitoring implementation strategies to ensure that gender-based inequities, and other intersecting stigmas, 19 , 48 are not exacerbated.…”

“…Even though some self-care SRH interventions can be accessed and conducted autonomously, some persons prefer support, information, or collaboration with healthcare and/or peer support persons (such as with HIV self-testing 19 ), while other interventions require linkages to health care, such as following a positive HIV self-test or pregnancy test. Despite this need for health workers at times to support individuals and their linkage to care across the array of self-care interventions, there is limited research on health workers’ confidence, practices of sharing self-care SRH interventions with patients, and whether their personal uptake of these interventions is linked with their health practice.…”

Exploring linkages between climate change and sexual health: a scoping review protocol

“… 2 35 36 The 2020 Lancet Countdown report indicates that climate change and its contribution to extreme weather events and rising sea levels will increase human migration and displacement, both of which pose risks to human health, 2 including sexual health. 37 38 …”

Stigma Mechanisms and Outcomes among Sub-Saharan African Descendants in Belgium—Contextualizing the HIV Stigma Framework

“…While this demonstrates high HIV prevention needs, the prevention demand in this population has been low [4] for different reasons, such as low self-perceived HIV risk [5,6], lack of information on health services [7], prioritizing legal issues such as obtaining papers over health, the need to learn a new language, find housing and childcare, building up new social relationships [8] and social control associated with fear of being seen at the HIV clinic [9]. HIV stigma has been acknowledged to have a negative impact on uptake of HIV prevention, testing, access to care and treatment, adherence to treatment and HIV status disclosure [10][11][12].…”