Development of an Instrument to Measure ...

Issues in Mental Health Nursing, 32:359–366, 2011 Copyright © Informa Healthcare USA, Inc. ISSN: 0161-2840 print / 1096-4673 online DOI: 10.3109/01612840.2011.575533

Development of an Instrument to Measure Internalized Stigma in Those with HIV/AIDS Kenneth D. Phillips, PhD, RN The University of Tennessee—Knoxville, College of Nursing, Knoxville, Tennessee, USA

Linda Moneyham, DSN, RN, FAAN Issues Ment Health Nurs Downloaded from informahealthcare.com by University of South Carolina on 06/27/13 For personal use only.

University of Alabama—Birmingham, School of Nursing, Birmingham, Alabama, USA

Abbas Tavakoli, DrPH The University of South Carolina—Columbia, College of Nursing, Columbia, South Carolina, USA

Stigma has grave consequences for persons living with HIV/AIDS. Stigma hampers prevention of HIV transmission to sexual partners and to unborn babies, diagnosis, and early treatment, and negatively affects mental and physical health, quality of life, and life satisfaction. Internalized stigma of HIV/AIDS may have even more severe consequences than perceived or enacted stigma. The purpose of this study was to develop an instrument to measure internalized stigma in those with HIV/AIDS. Data were drawn from the Rural Women’s Health Project. Research assistants administered structured interviews at baseline, 3 months, and 6 months. Instruments used in these analyses included a demographic data form, the Centers for Epidemiological Studies Depression Scale (CES-D), the Perceived Stigma Scale (PSS), and the Internalized Stigma of AIDS Tool (ISAT). Exploratory factor analysis confirmed that the ten items of the ISAT measure a single factor that explains 88% of the variance in the construct. Internal consistency was demonstrated by a Cronbach’s alpha of .91 (Time 1), .92 (Time 2), and .92 (Time 3). Convergent validity was supported with significant positive correlations with the CES-D (rho = 0.33, p < 0.0001) and the PSS (rho = 0.56, < 0.0001). The Internalized Stigma of AIDS Tool appears to be a reliable and valid instrument to measure internalization of the stigma of HIV/AIDS. It may be of value in research and clinical assessment.

Thirty years into the pandemic, HIV/AIDS remains one of the most stigmatized medical conditions in the world. In a recent comparative study, persons living with HIV/AIDS reported higher levels of stigma than persons affected by leprosy (Stevelink, van Brakel, & Augustine, 2011). In 1981, HIV/AIDS was a new life threatening illness, first recognized in gay men in the United States (Gottlieb et al., This research was supported by a grant from the National Institute of Nursing Research, National Institutes of Health (1 R01 NR04956). Address correspondence to Kenneth Phillips, University of Tennessee, 1200 Volunteer Blvd., Knoxville, TX 37996-4180. E-mail: [email protected]

1981). Intense mental images formed early in the pandemic linked HIV/AIDS with homosexuality, drug addiction, prostitution, and sexual promiscuity. Stigma associated with these conditions compounded the stigma of AIDS. Stigma, prejudice, and discrimination are major obstacles to preventing further spread of this infectious disease and to treating persons who are already infected. In the words of Peter Piot (n.d.), former president of the International AIDS Society, “Misinformation about the disease and stigma against people living with HIV still hamper prevention, care, and treatment efforts everywhere. If we are to get ahead of the AIDS epidemic, we must tackle stigma, ensure that the available funds are spent effectively to scale-up prevention, care and treatment programs, and mobilize more resources.” STIGMA Goffman’s (1963) seminal work on stigma initiated considerable inquiry by other scholars into the concept of stigma. Goffman viewed stigma as “an attribute that is deeply discrediting” and a mark that reduces the bearer from “from a whole and usual person to a tainted, discounted one” (p. 3). Goffman held that stigma arises from one of three sources: abominations of the body, blemishes of individual character, and tribal identities. Stigma is a mark an individual bears, that brands the individual as a deviant, flawed, different, or undesirable (Jones et al., 1984). Stigma is the dilemma of being different—based on a characteristic perceived to be different from the norm of society. Stigmatized persons “are a category of people who are pejoratively regarded by the broader society and who are devalued, shunned, or otherwise lessened in their life chances and in access to the humanizing benefit of free and unfettered social intercourse” (Alonzo & Reynolds, 1995, p. 304). Link and Phelan (2001) broadened the definition of stigma and suggest that stigma exists when a person is labeled, stereotypes are applied,

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Level Stigma

Description Social interaction that takes place between a marked and an unmarked person. Marks can be any deviation from the norm, such as disease status, inferiority, gender, race, or sexual orientation

Perceived Stigma

Awareness of societal attitudes and discriminatory and prejudicial actions toward persons living with HIV/AIDS

Issues Ment Health Nurs Downloaded from informahealthcare.com by University of South Carolina on 06/27/13 For personal use only.

Internalized Stigma

Socially constructed views and negative stereotypes about HIV/AIDS and persons with HIV/AIDS that become incorporated into the self-concept

Experienced Stigma

Experiencing discriminatory behaviors based on having HIV disease

FIGURE 1 Types of Stigma for Persons Stigmatized with HIV/AIDS

separation ensues, status is lost, and discrimination transpires. For persons with HIV/AIDS, there are three types of stigma: perceived stigma, internalized stigma, and experienced stigma (see Figure 1). For those who stigmatize persons with HIV/AIDS, there are two types of stigma: perceived stigma and enacted stigma (see Figure 2). Jones and colleagues (1984) expanded our understanding of stigma by recognizing that the extent of stigma is influenced by the factors presented in Figure 3. Preju-

dice, discrimination, negative attitudes, abuse, and maltreatment emanate from stigma. AIDS STIGMA HIV/AIDS is a highly stigmatized medical condition because the person is blamed for becoming infected, it is a condition that is incurable at the present time. it is a contagious illness, and the illness becomes progressively more apparent to others

Type

Description

Perceived Stigma Rational and irrational fear of contagion through intimate and casual

Fear of HIV/AIDS

contact with persons with HIV/AIDS Stigma by Association

Stigma is directed toward uninfected persons who provide care or become advocates for persons with HIV/AIDS, such as family members, nurses, and physicians.

Stigmatizing Attitudes

Expressions of attitudes such as pity, blame, guilt, and punishment

Enacted Stigma

Stigmatizing perceptions become stigmatizing actions. Actions include identifying, labeling, ostracizing, distancing, avoiding, isolating, and segregating.

FIGURE 2 Types of Stigma for Persons Who Stigmatize Persons with HIV/AIDS

MEASURING INTERNALIZED STIGMA

Dimension

361

Description

Concealability

Is the condition hidden or obvious? To what extent is its visibility controllable?

Course

What pattern or change over time is usually shown by the condition? What is its ultimate outcome?

Disruptiveness

Does it block or hamper interaction and communication?

Aesthetic Qualities

To what extent does the mark make the possessor repellent, ugly,


or upsetting? Origin

Under what circumstances did the condition originate? Was anyone responsible for it and what was he or she trying to do?

Peril

What kind of danger is posed by the mark and how imminent and serious is it?

FIGURE 3 Dimensions of Stigma Proposed by Jones and Colleagues (1984). Source: Jones, E. E., et al. (1984). Social stigma: The psychology of marked relationships. New York, NY: W. H. Freeman and Company.

(Herek, 1999). AIDS stigma is more common in poorer, less educated, and more rural populations (Amuri, Mitchell, Cockcroft, & Andersson, 2011). However, AIDS stigma and discrimination abounds in resource-rich populations (Herek, Capitanio, & Widaman, 2002) and in better educated and more affluent segments of society, including physicians, nurses, and other health care providers (Andrewin & Chien, 2008). AIDS stigma is associated with failure to disclose the disease to one’s family, health care providers, and sexual partners (Anglewicz & Chintsanya, 2011; Vu et al., 2011). AIDS stigma hinders infected persons from taking advantage of voluntary HIV counseling and testing (Ma et al., 2007) and seeking early treatment (Abaynew, Deribew, & Deribe, 2011). AIDS stigma has been documented as a factor that prevents HIV-infected women from seeking prenatal counseling and antiretroviral treatment (Duff, Kipp, Wild, Rubaale, & Okech-Ojony, 2010), which can greatly reduce the risk of transmission of the virus to their unborn child (Ilboudo et al., 2010). Fear of enacted stigma may cause greater concern about disclosure for women because they believe their families and especially their children will face discriminatory actions (Moneyham et al., 1996a; Murphy, Robert, & Hoffman, 2002).

Consequences of Perceived AIDS Stigma AIDS stigma is associated with depression (Vyavaharkar et al., 2010), physical and mental health status (Wolitski, Pals, Kidder, Courtenay-Quirk, & Holtgrave, 2009), utilization of medical care (Wolitski et al., 2009), lower satisfaction with life (Greeff et al., 2010), and poorer quality of life (Abboud,

Noureddine, Huijer, DeJong, & Mokhbat, 2010; Vyavaharkar, Moneyham, Murdaugh, & Tavakoli, 2011). Internalized Stigma Internalization of stigma refers to the process in which stigmatized persons accept the negative views that others in society hold about them and incorporates those views into their selfconcept. The aversive consequences of stigma may result not only from external stereotyping, prejudice, and discrimination, but also from internal perceptions, beliefs, emotions, and values a person holds about him- or herself in light of a stigmatizing condition. Persons who internalize stigma may have greater depression and poorer life satisfaction than persons who are aware of stigmatizing attitudes and behaviors, but do not internalize them. PRIOR INSTRUMENTS TO MEASURE AIDS STIGMA Development of instruments to measure perceived, enacted, and internalized stigma of HIV/AIDS has been an important focus in research. Several instruments have been developed to measure stigma in general populations in various countries (Froman & Owen, 1997, 2001; Kalichman et al., 2005; Moriya, Gir, & Hayashida, 1994) and in specific target groups, such as teachers (Chao, Gow, Akintola, & Pauly, 2010), nurses (Uys et al., 2009), and other health care providers (Froman, Owen, & Daisy, 1992; Mahendra et al., 2007). A number of instruments have been developed to measure stigma (perceived, enacted, and/or internalized) in persons living with HIV/AIDS (PLWHA) (Berger, Ferrans, & Lashley, 2001; Fife & Wright, 2000; Holzemer et al., 2007; Moneyham

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TABLE 1 Prior Instruments to Measure the Stigma of HIV/AIDS Scale


Title: HIV Stigma Scale Authors: Berger et al., 2001 Respondents: PLWHA

Title: HIV/AIDS Stigma Instrument – PLWHA Authors: Holzemer et al., 2007; Uys et al., 2009 Respondents: PLWHA

Title: Social Impact Scale Authors: Fife & Wright, 2000 Respondents: PLWHA

Type of Stigma Perceived Stigma Total scale Personalized stigma scale Disclosure concerns scale Negative self-image scale Public attitudes scale Perceived Stigma Verbal abuse Negative self-perception Healthcare neglect Social isolation Fear of contagion Workplace stigma Perceived Stigma Social rejection Financial insecurity Internalized shame Social Isolation

Title: Perceptions of Stigma of HIV-Positive Women Authors: Moneyham et al., 1996b Respondents: PLWHA

et al., 1996b). The psychometric properties of these instruments are presented in Table 1. METHODS Design The data for this instrument development study were taken from the Rural Women’s Health Project (RWHP) (Moneyham, 2003). The purpose of the RWHP was to test the effectiveness of a peer counseling intervention in decreasing depression, improving quality of life, and improving health outcomes for HIVinfected women living in rural areas of South Carolina. The RWHP is described elsewhere in the literature (Vyavaharkar et al., 2007). A research assistant conducted three separate, structured, face-to-face interviews with each of the participants. These interviews were held at baseline, before the peer counseling intervention was initiated, at three months, and at six months. All study procedures and instruments were approved by the Institutional Review Board of the University of South Carolina prior to any data collection. Participants received $30 compensation for completing each of the three interviews. They received $20 for attending each peer counseling session. Sample The original baseline sample for the parent study included 280 HIV-infected women living in the Southeastern

Cronbach’s Alpha

Number of Items

.96 .93 .90 .91 .93

40 18 10 13 20

.89 .83 .83 .89 .80 .76

8 5 7 5 6 2

.90 .86 .85 .86 Not reported

9 3 5 7 13

United States who were recruited from ten community-based HIV/AIDS service organizations in three states. The sample was limited to 255 women who completed the instruments used for these analyses. Study inclusion and exclusion criteria are presented elsewhere (Vyavaharkar et al., 2007) Instruments Internalized stigma of HIV/AIDS was measured using the Internalized Stigma of AIDS Tool (ISAT). Items were generated from interviews with PLWHAs. A panel of experts reviewed, modified, and came to consensus that the items were tapping the domain of internalized stigma of HIV/AIDS. The ISAT is a selfreport measure of the degree to which a person has internalized the stigma of HIV/AIDS. The ISAT consists of ten items. A fivepoint Likert-type scale of (1) strongly disagree, (2) disagree, (3) neither agree nor disagree, (4) agree, and (5) strongly agree is used for the response format. Participants were instructed to respond to the items in the following way: All the following statements refer to the way you feel about yourself (not what you think others think about you) since you were diagnosed as having HIV infection. Remember: Your answer should indicate how you feel about yourself since you were diagnosed as having HIV infection.

The ISAT was scored by reversing the one positive item (number 7, which indicated less internalization of HIV/AIDS stigma) and summing scores for all ten items. Possible scores can



range from 10 to 50. A higher score indicates greater internalized stigma of HIV/AIDS. Perceived stigma was measured using the Perceived Stigma Scale developed for use in the Family Coping Project (Sowell, Moneyham, & Demi, 1992). The scale consists of 12 items that are measured on a four-point Likert-type scale. Responses range from never (1) to always (4). Potential scores can range from 12 to 48. Internal consistency is supported by a Cronbach’s alpha of .78. Depressive symptoms were measured using the Centers for Epidemiological Studies–Depression Scale (CES-D; Radloff, 1977). The CES-D is a 20-item Likert-type scale. The items encompass six components of depressive symptoms: depressed mood, feelings of guilt and worthlessness, feelings of helplessness and hopelessness; psychomotor retardation, loss of appetite, and sleep disturbance. Participants respond whether they experienced a particular symptom rarely or none of the time (0), occasionally or a moderate amount of the time (2), or most or all of the time (3). Possible scores range from 0 to 60. Internal consistency has been demonstrated in the general population and in a psychiatric population. The instrument significantly discriminated between a sample from the general population and a sample from the psychiatric population. A higher score indicates greater depressive symptoms (Radloff, 1977).

Data Analysis Plan Descriptive statistics were calculated for each demographic variable and the ten items for the ISAT, the CES-D and the PSS. Descriptive statistics included frequencies, percentages, means, standard deviations, and ranges for the responses. Internal consistency of the total ISAT score was calculated using Cronbach’s coefficient alpha. Alpha scores can range from 0.00 to 1.00, indicating low to high internal consistency. An alpha score of .70 or greater is considered adequate for an attitudinal scale (Nunnally & Bernstein, 1994). Exploratory factor analysis was the statistical test used to describe the variability among the observed variables and to reduce the observed variables to a lower number of unobserved (latent) variables known as factors. With exploratory factor analysis there is no underlying theory, and factor loadings (correlations coefficients between items and factors) reveal the underlying factor structure. Statistical significance of the factor loadings was set at equal to or greater than 0.35. Responses from the sample were subjected to exploratory factor analysis using squared multiple correlations as prior communality estimates. The maximum likelihood method was used to extract the factors. And this was followed by promax (oblique) rotation. A scree test, eigenvalues, and the proportion of variance explained by each factor suggested one meaningful factor for all three times. In interpreting the rotated factor pattern, an item was said to load on a given factor if the factor loading was .35 or greater for that factor, and was less than .35 for the other. Using these criteria, one factor emerged for the ISAT. Using Kaiser’s (1960) crite-

363

rion, factors with eigenvalues of 1 or greater were retained in the final solution, as factors with low eigenvalues contribute little to the explanation of variances. The level of statistical significance was set at p < .05. RESULTS Description of the Sample The sample for these analyses consisted of 255 HIV-infected women living in the rural southeastern United States. The majority of the participants were African Americans (86.3%), single mothers (76.5%), with one or more children (86.3%) and living below the poverty level (74.0%). Baseline Descriptive Statistics Total scores for the ISAT ranged from 10 to 50 (M = 32.3 ± 9.8). Total scores for the CES-D ranged from 3 to 50 (M = 27.7 ± 9.5). Total scores for the Perceived Stigma Scale ranged from 11 to 48 (M = 23.9 ± 8.1). Exploratory Factor Analysis Construct validity of the ISAT was tested using exploratory factor analysis. Construct validity is the notion that questionnaire items represent the construct of internalized stigma of HIV/AIDS. Our goal was to reduce the items to the smallest number of concepts and to test the dimensionality of the instrument (Tabachnick & Fidell, 2007). Principal components analysis was performed. Using Kaiser’s criterion, only one factor achieved an eigenvalue greater than 1. With only one factor, varimax rotation was neither needed nor possible. Factor loadings are presented in Table 2. Item Analysis Item analysis was performed to determine whether individual items should be retained or deleted. Actual scores for all ten items ranged from 1 to 5. Frequencies for individual items of the ISAT are found in Table 3. Acceptable variability around the means for each item was observed. Using the Shapiro-Wilk test for normality, we determined that neither the items nor the total score for the ISAT was normally distributed (p < .05). Itemto-item and item-to-total score correlations were calculated (Table 4). Acceptable item-to-item and item-to-total ranges are 0.30 to 0.70 (DeVillis, 2003). A low correlation could mean that an item does not contribute significantly to the overall construct. A high correlation may mean some items are redundant and unnecessary. Item-to-total correlations for the 10-item scale ranged from 0.58 to 70 at baseline. All ten items correlated significantly with the total scale, and removing any item did not significantly change Cronbach’s alpha level. Therefore, all ten items were retained. Internal Consistency The internal consistency reliability of the total ISAT was evaluated using Cronbach’s α. The coefficient alpha reliability

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TABLE 2 Factor Loadings for the One Factor Solution of the Internalized Stigma of HIV/AIDS Tool (Times 1 to 3) Factor Loadings No. 1


2 3 4

5 6 7 8 9 10

Item Having HIV infection is like being branded with shame. I feel blemished. I feel ashamed about having HIV/AIDS. HIV infection hinders my ability to interact with other people. I feel that I need to hide my illness. I try to hide that I have HIV. I feel that I am desirable. I feel inhibited from making new friends. I am deceitful when I tell other people about my HIV. HIV infection hinders me from being intimate with other people.

Time 1 Time 2 Time 3

TABLE 3 Frequencies for Individual Items of the Internalized Stigma of AIDS Tool (Time 1). No. 1

80

82

81

76 81

82 83

81 84

69

69

70

71

74

76

72 76 73

74 75 75

77 77 77

7 8

62

66

65

9

58

65

65

Factor loadings are multiplied by 100 and rounded to the nearest integer.

2 3 4

5 6

10

Item

SD

D

N

A

SA

Having HIV infection is like being branded with shame. I feel blemished. I feel ashamed about having HIV/AIDS. HIV infection hinders my ability to interact with other people. I feel that I need to hide my illness. I try to hide that I have HIV. I feel that I am desirable.∗ I feel inhibited from making new friends. I am deceitful when I tell other people about my HIV.∗∗ HIV infection hinders me from being intimate with other people.

24

47

28

89

67

22 35

50 53

30 30

98 75

55 62

37

89

27

69

32

24

59

33

77

62

20

59

34

80

62

34 41

78 106

37 35

70 50

36 23

40

58

35

67

54

22

45

23

85

80

∗

Reverse coded One person refused to respond to this item. SD = strong disagree D = disagree N = neutral A = agree SA = strongly agree ∗∗

estimate for the total ISAT was 0.91 at Time 1, 0.92 at Time 2, and 0.92 at Time 3. Convergent Validity To test convergent validity, we administered the Perceived Stigma of HIV Scale and the Centers for Epidemiological Studies Depression Scale. A significant, but moderate positive relationship between perceived stigma and internalized stigma (r = 0.56, p < 0.0001) suggests that the scale measures a dimension of stigma, but taps a different dimension of stigma. A low, but significant, correlation(r = 0.33, p < 0.0001) between internalized stigma and depression shows that internalized stigma of HIV/AIDS is related to depression. DISCUSSION The purpose of this study was to develop an instrument to measure internalized stigma of HIV/AIDS. We identified a single factor that explains 88% of the variance in the construct. Now that construct validity has been confirmed in HIV-infected women living in the rural southeastern United States, the instrument needs to be tested in various subgroups of people with HIV/AIDS and in different geographical settings. Mental health nurses and other health care providers need to be aware that some women living with HIV/AIDS may hold

these negative perceptions about themselves. Using this instrument may be of benefit in identifying these self-perceptions. This may offer a place to begin counseling to help them come to terms with these feelings. Perceived and internalized stigma of HIV/AIDS has many detrimental consequences such as hindering the prevention of the spread of HIV/AIDS, hindering diagnosis, and impeding treatment. Also devastating is the influence stigma has on mental, physical, social, and spiritual health, quality of life, and life satisfaction. CONCLUSION A number of instruments to measure perceived and internalized stigma exist. Each of these instruments has strengths and weaknesses. The Internalized Stigma of AIDS Tool has been developed and tested in a population of the rural southeastern United States. Its reliability is supported by a strong internal consistency and stability over time. A unidimensional construct of

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TABLE 4 Means, Standard Deviations, Ranges, and Item-to-Total Correlations for the Internalized Stigma of AIDS Tool (Time 1) No.

Item

Mean

SD

Range

Item-to-Total Correlation

1 2 3 4 5 6 7 8 9 10

Having HIV infection is like being branded with shame. I feel blemished. I feel ashamed about having HIV/AIDS. HIV infection hinders my ability to interact with other people. I feel that I need to hide my illness. I try to hide that I have HIV. I feel that I am desirable. I feel inhibited from making new friends. I am deceitful when I tell other people about my HIV. HIV infection hinders me from being intimate with other people.

3.5 3.4 3.3 2.9 3.4 3.4 3.0 2.6 3.2 3.6

1.3 1.3 1.4 1.3 1.3 1.3 1.3 1.2 1.4 1.3

1–5 1–5 1–5 1–5 1–5 1–5 1–5 1–5 1–5 1–5

.81 .78 .73 .73 .74 .71 .72 .66 .62 .62

internalized stigma of AIDS was supported by exploratory factor analysis and significant correlations with depression and perceived stigma were made. We conclude that this instrument may provide a new approach to measuring the internalized stigma of AIDS. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. REFERENCES Abaynew, Y., Deribew, A., & Deribe, K. (2011). Factors associated with late presentation to HIV/AIDS care in South Wollo Zone Ethiopia: A casecontrol study. AIDS Research and Therapy, 8(1), 8. doi:1742-6405-8-8 [pii];10.1186/1742-6405-8-8 [doi] Abboud, S., Noureddine, S., Huijer, H. A., DeJong, J., & Mokhbat, J. (2010). Quality of life in people living with HIV/AIDS in Lebanon. AIDS Care, 22(6), 687–696. doi:922121880 [pii];10.1080/09540120903334658 [doi] Alonzo, A. A., & Reynolds, N. R. (1995). Stigma, HIV, and AIDS: An exploration and elaboration of a stigma trajectory. Social Science and Medicine, 41(3), 303–315. doi:0277953694003846 [pii] Amuri, M., Mitchell, S., Cockcroft, A., & Andersson, N. (2011). Socioeconomic status and HIV/AIDS stigma in Tanzania. AIDS Care, 23(3), 378–382. doi:933833636 [pii];10.1080/09540121.2010.507739 [doi] Andrewin, A., & Chien, L. Y. (2008). Stigmatization of patients with HIV/AIDS among doctors and nurses in Belize. AIDS Patient Care and STDs, 22(11), 897–906. doi:10.1089/apc.2007.0219 Anglewicz, P., & Chintsanya, J. (2011). Disclosure of HIV status between spouses in rural Malawi. AIDS Care, March 9, 1–8. doi:934651717 [pii];10.1080/09540121.2010.542130 [doi] Berger, B. E., Ferrans, C. E., & Lashley, F. R. (2001). Measuring stigma in people with HIV: Psychometric assessment of the HIV stigma scale. Research in Nursing and Health, 24(6), 518–529. doi:10.1002/nur.10011 [pii] Chao, L. W., Gow, J., Akintola, G., & Pauly, M. (2010). HIV/AIDS stigma attitudes among educators in KwaZulu-Natal, South Africa. Journal of School Health, 80(11), 561–569. doi:10.1111/j.1746-1561.2010.00542.x DeVillis, F. F. (2003). Scale development: Theory and appliations. Thousand Oaks, CA: Sage. Duff, P., Kipp, W., Wild, T. C., Rubaale, T., & Okech-Ojony, J. (2010). Barriers to accessing highly active antiretroviral therapy by HIV-positive women attending an antenatal clinic in a regional hospital in western Uganda. Journal of the International AIDS Society, 13, 37. doi:1758-2652-13-37 [pii];10.1186/17582652-13-37 [doi]

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