Unveiling the unseen: Exploring unmet needs among people living with HIV in Chittoor, Andhra Pradesh, India

Unveiling the unseen: Exploring unmet needs among people living with HIV in Chittoor, Andhra Pradesh, India | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Unveiling the unseen: Exploring unmet needs among people living with HIV in Chittoor, Andhra Pradesh, India Jayanthi Tarugu, Kiranmayi Koni, Sirshendu Chaudhuri, K Udayasree, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4991493/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background and Objective: Discrimination, stigma, and social isolation pervade Indian society, significantly affecting HIV care outcomes. This study aims to investigate the perceived unmet needs of individuals living with HIV (PLWH). Methods: This mixed-method study enrolled adult PLWH from ART centers in Chittoor district, Andhra Pradesh. Data collection involved semi-structured interviews using a pre-tested questionnaire. Analysis encompassed descriptive and thematic approaches. Results: Among the 94 participants, the mean age was 39 years (SD 12 years), and the average duration of HIV diagnosis was 8 years (SD 5 years). The majority were female (n=65, 69%) and residents of rural areas (n=74, 78.7%). While financial needs were most prevalent, other pressing concerns included employment, child's education, housing, nutrition, healthcare, and travel. Participants voiced apprehensions about administrative hurdles and varying degrees of social challenges, such as stigma and discrimination, when accessing social protection services. Conclusion: PLWH exhibit diverse socio-economic needs for themselves and their families, many of which remain unmet due to multifaceted bottlenecks, encompassing administrative complexities, social barriers, and perceived stigma. Discrimination Family support People living with HIV Social protection Social support Stigma Introduction Infection due to Human Immuno Deficiency Virus (HIV) considered a manageable chronic health condition due to the growing availability of effective HIV diagnosis, treatment, and care, including treatment for opportunistic infections (OIs). ( 1 )] As a result, individuals with HIV can enjoy long, healthy lives. With the increase in longevity, the need of the PLWH has changed over time. The needs of PLWH are multifaceted and complex. ( 2 – 5 )] (Addressing these needs are directly linked to the positive treatment outcome. ( 3 )] Hence, the changing need of this vulnerable group must be accounted for in HIV care policy. The fundamental principle of the Sustainable Development Goals (SDGs) is to ensure that no one is excluded. To put an end to the AIDS epidemic, it is crucial to address the needs of individuals living with and affected by HIV, as well as the determinants of health and vulnerability. People living with HIV (PLWH) are frequently discriminated against, marginalized, and affected by inequality and instability, often living in fragile communities. ( 1 )] The lack of social support for the HIV-affected population in India is a significant barrier to their overall health and well-being. Discrimination, stigma, and isolation are prevalent in Indian society, leading to negative impact in HIV care. Social support plays a crucial role in improving treatment outcomes among people living with HIV/AIDS in India. ( 6 – 9 )] Access to social support services remains limited, especially in rural areas. ( 10 ) Moreover, there is a lack of knowledge and awareness about HIV/AIDS among the general population, which further perpetuates stigma and discrimination. ( 11 )] In India, majority of the high burden states have provision for social security schemes but these are non-uniform, often top-down and do not consider the need of the group. ( 12 )] Social support programs that are culturally appropriate and tailored to the specific needs of the HIV-affected population are necessary to mitigate the challenges faced by them. ( 12 )] The aim of the study was to explore the perceived unmet needs of the PLWH. Identifying unmet needs of PLWH can aid in prioritizing evidence-based strategies and planning a roadmap for timely, high-quality reporting. This knowledge can help the policy makers target areas for greatest impact, allocate healthcare resources and public/private assistance, and reduce PLWH unmet needs. It can also improve global understanding of the response to the HIV epidemic, progress towards achieving commitments and global targets, that are linked to SDGs. Methods Study design : It is an embedded mixed methods design, where qualitative data was collected secondary to quantitative data and the interpretation was qualitatively driven. Study duration: The study was conducted betweenFebruary 2021 and January 2022. Study setting : We conducted the study at three ART centres in Chittoor district, namely Tirupati, Chittoor and Madanapalli. Study participants : We recruited adult PLWH whose HIV status was diagnosed at least one year before recruitment and registered at ART centers. To explore the ways to meet unmet needs, we conducted in depth interviews with the stake holders including the medical officers working at ART, field workers working for PLWH, volunteers working under NGOs and staff at village secretariate. Sampling technique and sample size: Purposive sampling was done to recruit the participants. We estimated a sample size of 96 PLHW participants considering expected proportion of people expressing unmet need in any form as 0.5, 10% absolute precision at 95% confidence interval and the calculated size of sample is 96. The number of in-depth interviews was based on the collective judgement of research team about reaching the point of saturation. Study variable: Unmet need of PLWH was the main outcome variable. A need is considered to be unmet if the participants reported a service or support was needed or desired but not received, during the 12 months preceding the interview whereas a need is considered to be met if it had been fulfilled as per PLWH self-report. Land patta: It is a revenue record of a piece of land which contains details about the area of the land, size, ownership of the property. It is issued by the local government (Tshildhar/Village Administrative Officer). Data collection: Interviews were conducted by using a pre-tested semi-structured interview schedule (programmed in Open data kit (ODK)) in a convenient place as suggested by the participants. Information on demographic details and unmet needs of PLWH were collected. Open ended questions were framed within the interview schedule. The open-ended questions were audio-recorded after taking written informed consent from the participants. A few participants preferred telephonic interview, for whom verbal consent was obtained. Additionally, five in-depth interviews were conducted among a medical officer working at ART, a field worker working for PLWH, a volunteer working under NGO, an HIV-affected person and a staff working at village secretariate. All the interviews were audio recorded with written informed consent of the participants. Data entry and analysis: Quantitative data was analyzed using SPSS version 21 by applying descriptive statistics. Qualitative data was analyzed by developing a study specific transcription protocol. One of the researchers (KU) transcribed the qualitative responses manually. A bilingual investigator (KH) in our team listened to the audio files and followed along with the transcripts to ensure adherence to the transcription requirements specified in the protocol. Two translators (KKR, SC) with expertise in the source (Telugu) and target languages (English) were the translators of the transcribed data. Translation review and verification were done by the project PI (principal investigator) (TJ). Two researchers (KKR, KU) independently coded the translated responses. A third researcher (SC) acted as a referee to resolve the conflicts in coding. A uniform coding plan was applied for all the scripts. Human participant protection: Institutional ethics committee clearance was obtained from the institutional review board (Ref: IEC07/AIMSR/07/2020 dated 30/05/2020). Written / verbal informed consent was taken from every participant before data collection. Every member of the project team was trained in Good Clinical Practice (GCP) and the standard operating procedures (SOP). Results A total of 94 participants were recruited for the study. The mean age of the participants was 39 years (± 12 years). The majority were females (n=65, 69%), residing at rural areas (n=74, 78.7%) with an average duration of living with HIV 8 years (±5 years). Average monthly income was 8930 Indian Rupees (INR) (±9535 INR). Unmet needs of PLWH: People living with HIV expressed different unmet needs which were categorised into certain domains. The Major domains which we identified are financial, employment, child’s education, housing, nutrition, health, travel, and assistance for marriage. (Table 1) While the need is largely met in the areas of travel and health; financial need is the most prominent in this population which is mostly unmet. (Table 3) The participants have expressed concern on administrative challenges in availing the services that include- inadequate information (n=76, 80.8%), and slow processing of application (n=71, 75.5%). (Table 2) Also, the participants faced varying degree of social challenges including stigma and discrimination in availing such services. (Table 4) Financial need The commonest need expressed by the participants was financial assistance (n=55, 58.5%) either in terms of pension benefit or subsidized bank loans. A 28-year-old female participant at Chittoor ART said “ I am 28 years old having a girl child, tested positive three years back during my antenatal check-ups. My husband left me after knowing my HIV status. I am alone with my child now. I don’t even have a house to stay. I used to sell flowers at a temple but during COVID-19 pandemic we were not allowed to sell, which made me struggle a lot. I spent days with single meal in a day (participant started crying). It is a great help for me if I receive some monitory assistance either in terms of pension or bank loan.” When enquired with a health care worker (HCW), she replied that ” no newly diagnosed PLWH are receiving financial benefit since 2012”. The village secretariate staff (VSS) who is responsible to apply for pension aid at village-level, mentioned that “Though the state official website shows ART pension benefit for the PLWH, none of them are receiving the benefit for the past six months. In the online application process, the pension eligibility category for PLWH is not active in the drop-down box”. It is given to understand from a VSS that, due to recent policy changes, the PLWH who were receiving double pension (Pensions under two different schemes) have been excluded from one of the benefits due to policy change in eligibility criteria. There were incidences where a PLWH receiving ART pension alone were also excluded from benefit without a clear reason. A District program manager at the State AIDS Control Society (SACS) said- “A uniform state and central monitoring system helps to address these changes in policies.” The participants also expressed their concerns on stoppage of the existing services, requirement of double pension and importance of continuation of the existing services. (Table 3) Child education Majority of the participants (n=81, 86%) had at least one living child. They expressed the need for assistance in their child’s education in terms of reservation or HIV quota in seat allotments or fee waivers. A health care worker says “ Eligible students are given Amma vodi, Vasathi deevena and Vidya deevena as a monitory aid for education. No additional assistance in education is available for HIV infected or affected children. A 35-years-old woman participant expressed her concern “ I have two sons who are studying in 8 th and 10 th classes. We are very much afraid thinking about the financial burden of their higher studies. They are very much interested to study. I feel that there should be special scheme for children with HIV for their higher education in the form of reservation or HIV quota or fee waivers, which will reduce the burden on our family. ” One participant even expressed that pension is crucial for children’s need. (Table 3) Employment A few (n=8, 8.5%) have expressed a need for employment, for which participants commonly asked for- bank loans to start small-scale business, or skill development training. (Table 3) A participant who tried getting bank loan to start a tiffin center expressed that- ” I did not receive a bank loan despite applying for many times. Finally, I took money from a pawn broker shop and started a tiffin center. It will be helpful if people suffering from HIV are given priority in availing loans”. Housing Housing is another domain of need expressed (n=6, 6.3%) asking for ‘ land patta ’ and housing loan to construct a house and few participants especially orphan children affected or infected with HIV and elderly asked care shelter/care homes.A 20-years-old participant said- “My parents passed away due to HIV when I was 10 years. Since then I am residing with my aunty (Mother’s sister) at her place. It is a huge burden for them to bear my expense. I understand that they are uncomfortable with me as I am HIV positive as well. I have no other option to stay. If available, care homes can really help people like me.” Another participant expressed that the amount given for making house is inadequate, Nutrition A very few (n=3, 3.5%) people expressed their concern on nutrition. Additional nutrition either through extra ration (Anthyodaya Anna Yojana (AAY)) or nutritious diet supplementationare the expressed needs in this domain. A VSS says “ Anthyodaya Anna Yojana (AAY) scheme is availed by only old beneficiaries and no new registrations are getting this facility ”. A HCW said “ No additional nutritional support is given for people with HIV. This is a very important point as the HIV medications weaken them. So, it is further emphasized that some nutritional support is considered for this group ”. The major concerns of the participants include- inadequate quantity, and poor-quality ration. (Table 3) A 40-year old female participant expressed her concern on inadequate nutritional support- “ My husband passed away due to HIV in 2016. Then I got to know about my disease. Since then, I am the only earning person in the family. There are 3 people including my children who are dependent on me. ART medications make me feel very weak. In certain days, on waking up from bed, I feel very tiresome and fail to resume even my routine works which is affecting my income as I am a daily wager (expressed with tears in her eyes). I can’t afford buying vegetables also sometime because my income is very low. It would be very helpful if I get some nutritional support in the form of nutritious powders, from government by which I regain some strength and can go for my work regularly.” Health All PLWH receive free consultation, medication, and investigations. But a few participants (n=2, 2.5%) expressed that sometimes at government facilities, they are sending them to private labs for getting their investigations done, especially monthly haemoglobin. Travel Two (n=2, 2.5%) elderly participants expressed their concern on non-existence of travel benefit for this vulnerable group. One of the participants receiving medications from Tirupati ART center expressed that, “My son, my daughter and I are on ART medications. We visit the treatment centre three times in a month., A visit costs 500 rupees which is a big burden to us. It will be of great help if we receive free travel benefit”. Health care worker at ART centre said–“There are families having more than one HIV patients.” The ART staff explained that- “There are individual management plans for each family member with HIV. They must visit the ART centre on their scheduled days to get tested and receive the appropriate medicines. Hence, assigning a same-day visit for all the family members is sometimes inappropriate. Support to avail Government social protection schemes (GSPS) Majority participants(n=80, 85%) expressed that they are failing to avail the existing GSPS due to insufficient information about the schemes (n=76, 80.8%), and administrative delay in processing the applications (n=71, 75.5%). A few participants (n=55, 58.5%) also expressed that they feel shy or guilty to avail the benefit and sometimes they were asked to give bribe (n=15, 16%) to avail GSPS which is preventing them in following up their applications. (Table 2, 3) A 50-year male participant said, “I don’t know about the availability of a pension. I am visiting treatment centre for the past seven years but no one informed me about it”. Another person said “t hough I know about the provision of travel card, I don’t know where to go and how to apply. There should be a designated person for giving such information at each ART centre”. Need for de-stigmatization A few participants expressed their concern about prominent existence of discrimination among the common people towards the PLWH. Even some health care workers indirectly spread discrimination by breaching the confidentiality of HIV status as expressed a few (n=17, 18%) of them. A participant at Chittoor ART said “ Kuppam government hospital is the nearest center for me to get my medication, but I don’t want to transfer my registration from Chittoor (120 kms away from Kuppam) as many people at the Kuppam hospital may identify my HIV status”. Another female participant aged 45 years stated that - “I don’t want to reveal the HIV status by applying for housing loan or ART pension. The village secretariat will call or announce my name in the public to get it enquire as a part of procedure by which my HIV status is revealed. Once HIV status is revealed we cannot stay in the same community, because they may isolate us”. The participants were even concern in availing any scheme that might reveal the HIV status. (Table 3) At least eight participants (8.6%) experienced discrimination in the form of refusal of treatment. A female participant aged 55 years old stated that - “When I wanted my cataract to be operated , one of the speciality hospitals in Tirupati (A district in Andhra Pradesh) refused to operate because of my HIV status, for which I had to travel around 270 kms to Anantapur (Adjacent district) to undergo surgery in a trust hospital”. They also felt that gender discrimination exists in providing GSPS (n=8, 8.6%). (Table 2) A health care worker highlighted that “ Gender plays a critical role in choosing the place of treatment between government and private. We see men are often registered with the private facilities for getting the treatment than women. We have also seen situation where both husband and wife are HIV positive. While the wife is sent to government ART center for treatment, the husband got registered in private centers”, One participant even expressed that family support, as well as people awareness is critical in HIV social support. (Table 3) Six (6.4%) participants wished to avail the benefits of the schemes only if confidentiality of HIV status is ensured. Unmet needs of the PLWH are specific to age and gender. Gender specific unmet needs: Both the genders mainly expressed the need for financial aid (females(n=40) 61.5%) males(n=28) 29.8%) followed by need for housing (n=6, 9.2%) among females; employment (n=5, 17.8%) and child’s education (n=5, 17.8%) among males. The only transgender participant expressed the need for employment. (Table 3) Age specific unmet needs: Participants expressed their need for financial aid in terms of pension aid or subsidized bank loans. Elder populations (41 to 60 years (n=29, 72.5%) and > 60 years (n= 3, 75%)) had a higher need than the younger populations (18 to 40 years (n=25, 50%). Participants belonged to 18 to 40 years expressed need for employment (n=5, 10%), housing aid (n=5, 10%) and child’s education (n=4, 8%). A few participants (Between 41 and 60 years) (n=4, 10%) of group have expressed their concern on child’s education. However, the elderly participants expressed their concern only for financial aid. (Table 3) The other domains of concerns/needs expressed are insufficient provision through available GSPS, failure to avail GSPS, lack of support from family, neighbors and health care workers in availing GSPS and stigmatization towards PLWH. (Table 2) Discussion The present study highlights the various unmet needs of PLWH from a Southern Indian context where burden of HIV is high. We observed that HIV populations in this setting are heavily dependent on the government assistance for their daily living that encompasses various needs but not limited to finance, nutrition, housing, education, health, and travel. These needs are mostly unmet, and hence, the PLWH face various challenges as expressed by them. Besides, there are social and administrative challenges for them to avail the government-supported schemes. The unmet needs depend upon the age, and gender and due to the unmet needs, the PLWH face varying degree of difficulties in their day-to-day life. Social protection plays a pivotal role in surmounting various hurdles for people living with HIV (PLWH). ( 13 )] Free and decentralized HIV services alleviate significant barriers to access, additional economic obstacles such as heightened expenses for nourishing sustenance, transportation costs, and income loss due to antiretroviral therapy (ART) appointments. ( 13 – 15 )] As per the UNAIDS national composite policy index of 2017, a total of 109 countries affirmed the presence of an endorsed social protection strategy, policy, or framework; among these, 99 were actively implementing diverse social protection initiatives, and the strategies of 85 countries exhibited a certain degree of HIV sensitivity. ( 16 )] In India, in accordance with the provisions outlined in Chapter VII of the HIV and AIDS (Prevention and Control) Act of 2017, both the central and state governments bear the responsibility of implementing measures to facilitate the accessibility of welfare schemes aimed at catering to the needs of PLWH. The Act mandates the central government to ensure the dissemination of comprehensive information about the disease and program-related communications to safeguard the rights of PLWH. Encouragingly, both the state and central governments have taken proactive steps to assist PLWH through the creation of various social benefit schemes. These encompass a wide array of services, encompassing financial assistance, employment opportunities, nutritional support, travel concessions, insurance provisions, as well as initiatives targeted at children, among others. ( 12 )] However, the schemes vary widely in number and types of schemes across the states and commonly criticized because of their top-down nature. ( 12 )] Finding of the present study also indicates that the social support for the PLWH from the government in this setting is mostly a top-down approach and hardly need-based. In resource-poor settings a dynamic relationship exists between HIV/AIDS and the economic hardship where both act as an instigator and a consequence of each other. ( 17 )] In this study, we observed that economic crisis is the most common form of need expressed by the participants. In fact, for most of the other unmet needs including housing, education, nutrition, and transposrt, the underlying principle is economic hardship. ( 18 )] In Indian setting, high socio-economic status has a significant association with better quality of life among the PLWH. ( 10 , 19 )] Besides, HIV treatment outcome strongly relies upon reducing poverty. ( 18 )] Socioeconomic factors like- homelessness or housing instability hunger and food insecurity and insufficient transportation are often associated with HIV or pose major obstacles in achieving HIV treatment goals. ( 20 – 26 )] As the population in our study is relatively young, we expect that the need of the population will increase with the increasing age, unless appropriate interventions are taken. Unfortunately, as reported by the health care workers, the provision for multiple schemes including double pension has been stopped. These steps may further be aggravated by the administrative challenges and social stigma. In an earlier study from Rajasthan, India, it was found that administrative bottlenecks are one of the major reasons for the unmet need. ( 15 )] Inadequate information, and delay in processing applications often makes the PLWH reluctant in availing the services as we have found in the present study. The administrative challenges, coupled with stigma makes the ground more complicated in availing the schemes and thereby increases the unmet need. ( 11 )] It is worrisome that a considerable proportion of participants felt that their HIV status is revealed by the healthcare workers and the administrative staff in various offices. Perceived breach of confidentiality is known to cause reduction in utilization of services, conversely increases the unmet need. ( 27 , 28 )] On top of everything, family and social support empower PLWH towards care and treatment outcomes. Unfortunately, these supports were grossly compromised for the study participants. ( 8 )] The study had a few limitations. First, the participants were selected non-randomly and hence, the selection methods are expected to reduce the generalizability of the study finding. To overcome this problem, we selected participants from all the three centres of the district. Also, we interviewed the health personnel to triangulate the responses of the PLWH. To avoid interviewers’ bias, a structured questionnaire and an interviewers’ guide were given to the interviewers to avoid leading questions. Additional training was imparted to the interviewers. Conclusion The people living with HIV in this setting have varying degrees of socio-economic need for themselves and their families. Most of these needs are unmet due to bottlenecks at different levels including administrative challenges, social challenges, and perceived stigma. Efforts to increase awareness, reduce stigma and discrimination, and providing culturally appropriate social support programs and healthcare services are crucial in improving the health and well-being of these vulnerable populations. Declarations Funding: nil Conflicts of interest/Competing interests : The authors have no relevant financial or non-financial interests to disclose. Ethics approval: This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of Apollo Institute of Medical Sciences and Research (AIMSR), Chittoor and the reference number is IEC07/AIMSR/07/2020 dated 30/05/2020. Consent to participate: Informed consent was obtained from all individual participants included in the study. Consent for publication: The authors affirm that the participants signed informed consent regarding publishing their data Availability of data and material (data transparency) : The anonymous data can be made available on reasonable requests. Code availability (software application or custom code): Not available Author Contribution JT, KK, and SC: Concept development JT, KK, SC and KH: MethodsKK, UK and KH: Data acquisitionSC, KK: Data analysisSC and UK: Writing first draftJT, KK, SC, UK, KH: Reviewed manuscript Data Availability The anonymous data will be made available on reasonable reqest. References Katz IT, Maughan-Brown B. Improved life expectancy of people living with HIV: who is left behind? The Lancet HIV. 2017 Aug 1;4(8):e324–6. Fang L, Chuang DM, Al-Raes M. Social support, mental health needs, and HIV risk behaviors: a gender-specific, correlation study. BMC Public Health. 2019 May 28;19(1):651. Maulsby CH, Ratnayake A, Hesson D, Mugavero MJ, Latkin CA. A Scoping Review of Employment and HIV. AIDS Behav. 2020 Oct;24(10):2942–55. Arum C, Fraser H, Artenie AA, Bivegete S, Trickey A, Alary M, et al. Homelessness, unstable housing, and risk of HIV and hepatitis C virus acquisition among people who inject drugs: a systematic review and meta-analysis. The Lancet Public Health. 2021 May 1;6(5):e309–23. P. Zinyemba T, Pavlova M, Groot W. Effects of Hiv/Aids on Children’s Educational Attainment: A Systematic Literature Review. Journal of Economic Surveys. 2020;34(1):35–84. Steward WT, Bharat S, Ramakrishna J, Heylen E, Ekstrand ML. Stigma is Associated with Delays in Seeking Care Among HIV-Infected People in India. J Int Assoc Provid AIDS Care. 2013 Mar;12(2):103–9. Mukoswa GM, Charalambous S, Nelson G. The association between social capital and HIV treatment outcomes in South Africa. PLOS ONE. 2017 Nov 9;12(11):e0184140. Birore CMS, Wu L, Abrefa-Gyan T, Lewis MW. Social Support and Quality of Life Among People Living With HIV/AIDS (PLWHA) in Ghana. Journal of Family Issues. 2022 Aug 1;43(8):2159–80. Damulira C, Mukasa MN, Byansi W, Nabunya P, Kivumbi A, Namatovu P, et al. Examining the relationship of social support and family cohesion on ART adherence among HIV-positive adolescents in southern Uganda: baseline findings. Vulnerable Children and Youth Studies. 2019 Apr 3;14(2):181–90. Nyamathi AM, Sinha S, Ganguly KK, William RR, Heravian A, Ramakrishnan P, et al. Challenges Experienced by Rural Women in India Living with AIDS and Implications for the Delivery of HIV/AIDS Care. Health Care Women Int. 2011 Apr;32(4):300–13. Lalhruaimawii I, Danturulu MV, Rai S, Chandrashekar UK, Radhakrishnan R. Determinants of stigma faced by people living with Human Immunodeficiency Virus: A narrative review from past and present scenario in India. Clinical Epidemiology and Global Health. 2022 Sep 1;17:101117. Koni K, Chaudhuri S, Tarugu J, Udayasree K, Hema K. HIV care policy in India: A review of social security schemes. Journal of Family Medicine and Primary Care. 2022 May;11(5):1648. Temin M. HIV - Sensitive Social Protection What does the evidence say? 2010; Kyaw NTT, Kumar AMV, Oo MM, Oo HN, Kyaw KWY, Thiha S, et al. Long-term outcomes of second-line antiretroviral treatment in an adult and adolescent cohort in Myanmar. Glob Health Action. 2017;10(1):1290916. Gowthamghosh B, Huidrom R, Arumugam V, Pathak N, Purohit N, Shewade HD, et al. Implementation of social protection schemes for people living with HIV in three districts of Rajasthan state, India – a mixed methods study [Internet]. F1000Research; 2020 [cited 2023 Aug 16]. Available from: https://f1000research.com/articles/9-248 UNAIDS. What needs to be done to Fast-Track social protection to end AIDS? [Internet]. [cited 2023 Aug 16]. Available from: https://www.unaids.org/en/resources/presscentre/featurestories/2018/may/fast-track-social-protection-to-end-aids International Labour Organization. HIV/AIDS and poverty - the critical connection. Kalichman SC. Ending HIV Hinges on Reducing Poverty. AIDS Behav. 2023 Jan 1;27(1):1–3. Arjun BY, Unnikrishnan B, Ramapuram JT, Thapar R, Mithra P, Kumar N, et al. Factors Influencing Quality of Life among People Living with HIV in Coastal South India. J Int Assoc Provid AIDS Care. 2017 May 1;16(3):247–53. Chen NE, Meyer JP, Avery AK, Draine J, Flanigan TP, Lincoln T, et al. Adherence to HIV treatment and care among previously homeless jail detainees. AIDS Behav. 2013 Oct;17(8):2654–66. Leaver CA, Bargh G, Dunn JR, Hwang SW. The Effects of Housing Status on Health-Related Outcomes in People living with HIV: A Systematic Review of the Literature. AIDS Behav. 2007 Nov 1;11(2):85–100. Milloy MJ, Kerr T, Bangsberg DR, Buxton J, Parashar S, Guillemi S, et al. Homelessness as a Structural Barrier to Effective Antiretroviral Therapy Among HIV-Seropositive Illicit Drug Users in a Canadian Setting. AIDS Patient Care and STDs. 2012 Jan;26(1):60–7. Anema A, Vogenthaler N, Frongillo EA, Kadiyala S, Weiser SD. Food insecurity and HIV/AIDS: Current knowledge, gaps, and research priorities. Curr HIV/AIDS Rep. 2009 Nov 1;6(4):224–31. Franke MF, Murray MB, Muñoz M, Hernández-Díaz S, Sebastián JL, Atwood S, et al. Food Insufficiency is a Risk Factor for Suboptimal Antiretroviral Therapy Adherence among HIV-Infected Adults in Urban Peru. AIDS Behav. 2011 Oct 1;15(7):1483–9. McLinden T, Stover S, Hogg RS. HIV and Food Insecurity: A Syndemic Amid the COVID-19 Pandemic. AIDS Behav. 2020;24(10):2766–9. Lankowski AJ, Siedner MJ, Bangsberg DR, Tsai AC. Impact of Geographic and Transportation-Related Barriers on HIV Outcomes in Sub-Saharan Africa: A Systematic Review. AIDS Behav. 2014 Jul;18(7):1199–223. Bayisa L, Wakuma B, Abera T, Mulisa D, Mosisa G, Tolossa T, et al. Are the Things Told to Care Providers Kept Confidential?: Perceived Breaches of Confidentiality and Associated Factors Among HIV/AIDS Clients on ART at Nekemte Specialized Hospital, Western Ethiopia, 2021. HIV AIDS (Auckl). 2022 Jan 15;14:1–12. Dapaah JM, Senah KA. HIV/AIDS clients, privacy and confidentiality; the case of two health centres in the Ashanti Region of Ghana. BMC Medical Ethics. 2016 Jul 16;17(1):41. Tables T able :1 Domains of unmet needs expressed by PLWH at Chittoor district, A.P, India , 2021. Domains of unmet needs Eligible participants, n (%) Never utilized, n (%) Unmet need expressed, n (%) Explored ways to meet unmet needs Finance 94 (100) 57 (60.6) 57 (60.6) Pension benefit or subsidized bank loans. A uniform state and central monitoring system Child's education 49 (52) 24 (25.5) 8 (16.3) Reservation or HIV quota in seat allotments Fee waivers. Employment 94 (100) 81 (86) 8 (8.5) Bank loan to start a small-scale business, Priority to PLWH in provision of GSPS/skill training Housing 78* (82.9) 44 (46.8) 6 (7.7) Land ‘ patta ’ and housing loan 8. Shelter/care homes Additional Nutrition (AAY) 94 (100) 82 (87.2) 3 (3.2) Extra ration-Anthyodaya Anna Yojana (AAY) Nutritious diet supplementation Health 94 (100) 84 (89) 2 (2.1) Updated IEC on schemes to be displayed at ART, Regular updation of concerned websites Help line number to address the doubts Equitable provision of GSPS throughout the nation Single point of contact (single window approach) at ART itself to apply and receive any social assistance. Travel 94 (100) 0 2 (2.1) Free travel charges Assistance for marriage 4 (4.3) 0 1 (25.0) Premarital counselling. Provision for marriages among positive networks. * 16 members had their own houses T able: 2 Administrative challenges and stigma faced by PLWH at Chittoor district, A.P, India , 2021. (n=94) Social and administrative domains Obstacles expressed n(%) Administrative challenges Information related to the available schemes are inadequate 76(80.8) Provision given in the schemes are not adequate 66(70.2) Processing of application for GSPS is slow 71(75.5) I bribe to avail social protection schemes 15(16) I feel shy/guilty to avail the benefits of the scheme 55(58.5) Stigma towards PLWH I feel health care team doesn’t keep HIV status confidential 17 (18) Gender discrimination in provision of Exclusive GSPS 8 (8.5) Health care team discriminates PLWH 4 (4.2) Hospitals refused to provide treatment 8 (8.5) Social challenge Health care workers and family are not supporting me in availing GSPS 67(71.2) T able :3 Age and gender specific unmet needs of PLWH at Chittoor district, A.P, India , 2021. Variables n (%) Domains of unmet need Finance n(%) Child’s education n=49 F=30; M=19 Employment n=94 Housing aid n=78 F=47 M=31 Nutrition n=94 Health Aid n=94 Travel pass n=94 Aid for marriage n=4 Gender Female 65(69) Male 28 (29.8) Transgender 1(1.1) 41(61.5) 16(53.5) - 3(10) 5(26.3) - 2(3) 5(17.8) 1(1.53) 6(12.8) 2(3) 1(1.53) - 1(1.53) 1(1.53) - 1(1.53) 1(1.53) - - 1(25) - Age in y ears 18-40 50 (53.2) 41-60 40(42.5) > 60 4(4.25) 23(46) 29(72.5) 3(75) 4(8) 4(10) - 5(10) 2(5) 1(25) 5(10) 1(2.5) - - 2(5) 1(25) 2(4) - - - - 2(50) 1(25) - - Table 4: Thematic analysis of the unmet need of people living with HIV, Chittoor, India, 2021-22 Verbatim Codes Themes Bus pass can significantly reduce the travel cost Travel Concession Requirement It will be helpful if both ART and widow pensions are given together Dual pension The amount given for housing is inadequate, need additional amount Additional requirement It will be helpful if additional ration is given Financial aid should be increased to 4000 Rupees per month Instead of introducing new things, it is important to continue the existing services without stopping in between Continuation of schemes If I get a cattle, it will be helpful for me to generate some income Rehabilitation Some skill training can be extremely helpful for daily living I need any kind of aid to earn my livelihood Pension is crucial to support my children's need Financial aid With financial aid, I can start my own business I am planning to start a plastic recycling business for which I need financial aid I need financial aid to start a tiffin centre Provision for education should be there for the children Education A permanent job may be helpful to improve our condition Permanent employment I am a railway employee and I do not require any scheme Not required I am satisfied with what I got Satisfied Awareness about the schemes should be given to public as well Public awareness Awareness HIV-infected people should be aware of the existence of the schemes available Awareness of PLWH More information is required from the government about the schemes More information I am not aware if such schemes are available for the HIV positive people Poor awareness If at all a house is given or constructed, the area should not be named as HIV colony Stigma Social challenge If a house is constructed through such schemes, I fear of social discrimination I don't want any social schemes because of stigma All PLWH should get support of their family first, which is often lacking Family support Schemes are required, but without revealing my status Confidentiality Training can be given but without revealing the HIV status I have made multiple applications for ART pension, but yet to receive a response Application process Administrative challenge Provision for home loan or land patta is needed to make a house for my children Land patta Government has withdrawn the travel pass since COVID-19 Stoppage of benefit Rice that is distributed is not of good quality, it is causing stomach upset Quality Quality issue Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4991493","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":347258375,"identity":"7c5f6772-3dfc-4b7d-845f-fb5a2a6593db","order_by":0,"name":"Jayanthi Tarugu","email":"","orcid":"","institution":"Apollo College of Nursing","correspondingAuthor":false,"prefix":"","firstName":"Jayanthi","middleName":"","lastName":"Tarugu","suffix":""},{"id":347258376,"identity":"bb7fe81a-ffd1-45de-8717-03a2afdd9105","order_by":1,"name":"Kiranmayi Koni","email":"","orcid":"","institution":"Apollo College of Nursing","correspondingAuthor":false,"prefix":"","firstName":"Kiranmayi","middleName":"","lastName":"Koni","suffix":""},{"id":347258377,"identity":"f0b2cdcf-5e44-4fd2-bef2-d9a8886e8e6e","order_by":2,"name":"Sirshendu Chaudhuri","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9klEQVRIiWNgGAWjYDACZjBiYGwAIYYKkAhzAylazoBEGAloYYBrAZFtDHA2TiDfzvv4c0HFHdkN5w83f+adVxvN3w7U8qNiG04tBofZzaRnnHlmvOFGYps077bjuTMOMzYw9py5jVsLMxsbM2/b4cQNNxjbmHm3HcttAGphZmzDrUW+mY35M+8/oJbzB4EOm3Msdz4hLQyH2RikeRuAWg4kNgAZNbkbCGkxOMzGJs1z7LDxTKBfJOccO5C7EajlID6/yPcfY/7MU3NYtu/88ccf3tTU5c47f/jggx8VeByG7k4weYBo9UBQR4riUTAKRsEoGCEAAKZnXctvPwpjAAAAAElFTkSuQmCC","orcid":"","institution":"Indian Institute of Public Health","correspondingAuthor":true,"prefix":"","firstName":"Sirshendu","middleName":"","lastName":"Chaudhuri","suffix":""},{"id":347258379,"identity":"cd22d4ad-e674-4669-b891-e8b394f069c0","order_by":3,"name":"K Udayasree","email":"","orcid":"","institution":"Apollo College of Nursing","correspondingAuthor":false,"prefix":"","firstName":"K","middleName":"","lastName":"Udayasree","suffix":""},{"id":347258380,"identity":"86dcc0be-7cc7-4ba0-9fe0-3ad5adf6fc06","order_by":4,"name":"Kurugundla Hema","email":"","orcid":"","institution":"Apollo College of Nursing","correspondingAuthor":false,"prefix":"","firstName":"Kurugundla","middleName":"","lastName":"Hema","suffix":""}],"badges":[],"createdAt":"2024-08-28 13:38:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4991493/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4991493/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":81928175,"identity":"82653d85-c6b5-4647-ac5c-e90c8c6145a0","added_by":"auto","created_at":"2025-05-05 04:23:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1125522,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4991493/v1/58b01fec-b1ca-4476-996b-22b3c0b7491f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eUnveiling the unseen: Exploring unmet needs among people living with HIV in Chittoor, Andhra Pradesh, India\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eInfection due to Human Immuno Deficiency Virus (HIV) considered a manageable chronic health condition due to the growing availability of effective HIV diagnosis, treatment, and care, including treatment for opportunistic infections (OIs). (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)] As a result, individuals with HIV can enjoy long, healthy lives. With the increase in longevity, the need of the PLWH has changed over time. The needs of PLWH are multifaceted and complex. (\u003cspan additionalcitationids=\"CR3 CR4\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)] (Addressing these needs are directly linked to the positive treatment outcome. (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)] Hence, the changing need of this vulnerable group must be accounted for in HIV care policy. The fundamental principle of the Sustainable Development Goals (SDGs) is to ensure that no one is excluded. To put an end to the AIDS epidemic, it is crucial to address the needs of individuals living with and affected by HIV, as well as the determinants of health and vulnerability. People living with HIV (PLWH) are frequently discriminated against, marginalized, and affected by inequality and instability, often living in fragile communities. (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)]\u003c/p\u003e \u003cp\u003eThe lack of social support for the HIV-affected population in India is a significant barrier to their overall health and well-being. Discrimination, stigma, and isolation are prevalent in Indian society, leading to negative impact in HIV care. Social support plays a crucial role in improving treatment outcomes among people living with HIV/AIDS in India. (\u003cspan additionalcitationids=\"CR7 CR8\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)] Access to social support services remains limited, especially in rural areas. (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) Moreover, there is a lack of knowledge and awareness about HIV/AIDS among the general population, which further perpetuates stigma and discrimination. (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)] In India, majority of the high burden states have provision for social security schemes but these are non-uniform, often top-down and do not consider the need of the group. (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)] Social support programs that are culturally appropriate and tailored to the specific needs of the HIV-affected population are necessary to mitigate the challenges faced by them. (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)] The aim of the study was to explore the perceived unmet needs of the PLWH. Identifying unmet needs of PLWH can aid in prioritizing evidence-based strategies and planning a roadmap for timely, high-quality reporting. This knowledge can help the policy makers target areas for greatest impact, allocate healthcare resources and public/private assistance, and reduce PLWH unmet needs. It can also improve global understanding of the response to the HIV epidemic, progress towards achieving commitments and global targets, that are linked to SDGs.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStudy design\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e:\u0026nbsp;\u003c/em\u003e It is an embedded mixed methods design, where qualitative data was collected secondary to quantitative data and the interpretation was qualitatively driven.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStudy duration:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eThe study was conducted betweenFebruary 2021 and January 2022.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eStudy setting\u003c/strong\u003e\u003c/em\u003e\u003cem\u003e\u003cstrong\u003e:\u003c/strong\u003e\u0026nbsp;\u003c/em\u003eWe conducted the study at three ART centres in Chittoor district, namely Tirupati, Chittoor and Madanapalli.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eStudy participants\u003c/strong\u003e\u003c/em\u003e\u003cem\u003e\u003cstrong\u003e:\u003c/strong\u003e\u0026nbsp;\u003c/em\u003eWe recruited adult PLWH whose HIV status was diagnosed at least one year before recruitment and registered at ART centers. To explore the ways to meet unmet needs, we conducted in depth interviews with the stake holders including the medical officers working at ART, field workers working for PLWH, volunteers working under NGOs and staff at village secretariate.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSampling technique and sample size:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003ePurposive sampling\u0026nbsp;was done to recruit the participants. We estimated a sample size of 96 PLHW participants\u0026nbsp;considering expected proportion of people expressing unmet need in any form as 0.5, 10% absolute precision at\u0026nbsp;95% confidence interval\u0026nbsp;and the calculated size of sample is 96. The number of in-depth interviews was based on the collective judgement of research team about reaching the point of saturation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStudy variable:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eUnmet need of PLWH\u0026nbsp;was the main outcome variable.\u0026nbsp;A need is considered to be unmet if the participants reported a service or support was needed or desired but not received, during the 12 months preceding the interview whereas a need is considered to be met if it had been fulfilled as per PLWH self-report.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eLand patta:\u003c/strong\u003e\u003c/em\u003eIt\u0026nbsp;is a revenue record of a piece of land which contains details about the area of the land, size, ownership of the property. It is issued by the local government (Tshildhar/Village Administrative Officer).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eData collection:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e Interviews were conducted by using\u0026nbsp;a pre-tested semi-structured interview schedule (programmed in Open data kit (ODK)) in a convenient place as suggested by the participants. Information on demographic details and unmet needs of PLWH were collected.\u0026nbsp;Open ended questions were framed within the interview schedule. The open-ended questions were audio-recorded after taking written informed consent from the participants. A few participants preferred telephonic interview, for whom verbal consent was obtained.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAdditionally, five in-depth interviews were conducted among a medical officer working at ART, a field worker working for PLWH, a volunteer working under NGO, an HIV-affected person and a staff working at village secretariate. All the interviews were audio recorded with\u0026nbsp;written informed consent of the participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData entry and analysis:\u003c/strong\u003e Quantitative data was analyzed using SPSS version 21 by applying descriptive statistics. Qualitative data was analyzed by developing a study specific transcription protocol. One of the researchers (KU) transcribed the qualitative responses manually. A bilingual investigator (KH) in our team listened to the audio files and followed along with the transcripts to ensure adherence to the transcription requirements specified in the protocol. Two translators (KKR, SC) with expertise in the source (Telugu) and target languages (English) were the translators of the transcribed data. Translation review and verification were done by the project PI (principal investigator) (TJ). Two researchers (KKR, KU) independently coded the translated responses. A third researcher (SC) acted as a referee to resolve the conflicts in coding. A uniform coding plan was applied for all the scripts.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHuman participant protection:\u003c/strong\u003e Institutional ethics committee clearance was obtained from the institutional review board (Ref: IEC07/AIMSR/07/2020 dated 30/05/2020). Written / verbal informed consent was taken from every participant before data collection. Every member of the project team was trained in Good Clinical Practice (GCP) and the standard operating procedures (SOP).\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 94 participants were recruited for the study. The mean age of the participants was 39 years (± 12 years). The majority were females (n=65, 69%), residing at rural areas (n=74, 78.7%) with an average duration of living with HIV 8 years (±5 years). Average monthly income was 8930 Indian Rupees (INR) (±9535 INR).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eUnmet needs of PLWH:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePeople living with HIV expressed different unmet needs which were categorised into certain domains. The Major domains which we identified are financial, employment, child’s education, housing, nutrition, health, travel, and assistance for marriage. (Table 1) While the need is largely met in the areas of travel and health; financial need is the most prominent in this population which is mostly unmet. (Table 3) The participants have expressed concern on administrative challenges in availing the services that include- inadequate information (n=76, 80.8%), and slow processing of application (n=71, 75.5%). (Table 2) Also, the participants faced varying degree of social challenges including stigma and discrimination in availing such services. (Table 4)\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFinancial need\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe commonest need expressed by the participants was financial assistance (n=55, 58.5%) either in terms of\u0026nbsp;pension benefit or subsidized bank loans.\u0026nbsp;A 28-year-old female participant at Chittoor ART said “\u003cem\u003eI am 28 years old having a girl child, tested positive three years back during my antenatal check-ups. My husband left me after knowing my HIV status. I am alone with my child now. I don’t even have a house to stay. I used to sell flowers at a temple but during COVID-19 pandemic we were not allowed to sell, which made me struggle a lot. I spent days with single meal in a day (participant started crying). It is a great help for me if I receive some monitory assistance either in terms of pension or bank loan.”\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWhen enquired with a health care worker (HCW), she replied that ”\u003cem\u003eno newly diagnosed PLWH are receiving financial benefit since 2012”.\u0026nbsp;\u003c/em\u003eThe village secretariate staff (VSS) who is responsible to apply for pension aid at village-level, mentioned that \u003cem\u003e“Though the state official website shows ART pension benefit for the PLWH, none of them are receiving the benefit for the past six months. In the online application process, the pension eligibility category for PLWH is not active in the drop-down box”.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIt is given to understand from a VSS that, due to recent policy changes, the PLWH who were receiving double pension (Pensions under two different schemes) have been excluded from one of the benefits due to policy change in eligibility criteria. There were incidences where a PLWH receiving ART pension alone were also excluded from benefit without a clear reason. A District program manager at the State AIDS Control Society (SACS) said- “A uniform state and central monitoring system\u0026nbsp;helps to address these changes in policies.” The participants also expressed their concerns on stoppage of the existing services, requirement of double pension and importance of continuation of the existing services. (Table 3)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eChild education\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMajority of the participants (n=81,\u0026nbsp;86%) had at least one living child. They expressed the need for assistance in their child’s education in terms of reservation or HIV quota in seat allotments or fee waivers.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA health care worker says “\u003cem\u003eEligible students are given Amma vodi, Vasathi deevena and Vidya deevena as a monitory aid for education.\u0026nbsp;\u003c/em\u003eNo additional assistance in education is available for HIV infected or affected children. A 35-years-old woman participant expressed her concern “\u003cem\u003eI have two sons who are studying in 8\u003csup\u003eth\u003c/sup\u003e and 10\u003csup\u003eth\u003c/sup\u003e classes. We are very much afraid thinking about the financial burden of their higher studies. They are very much interested to study. I feel that there should be special scheme for children with HIV for their higher education in the form of reservation or HIV quota or fee waivers, which will reduce the burden on our family.\u003c/em\u003e” One participant even expressed that pension is crucial for children’s need. (Table 3)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEmployment\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA few (n=8, 8.5%) have expressed a need for employment, for which participants commonly\u0026nbsp;asked for- bank loans to start small-scale business, or skill development training. (Table 3)\u003c/p\u003e\n\u003cp\u003eA participant who tried getting bank loan to start a tiffin center expressed that- ”\u003cem\u003eI did not receive a bank loan despite applying for many times. Finally, I took money from a pawn broker shop and started a tiffin center. It will be helpful if people suffering from HIV are given priority in availing loans”.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eHousing\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Housing is another domain of need expressed (n=6, 6.3%) asking for\u003cstrong\u003e\u0026nbsp;‘\u003c/strong\u003e\u003cem\u003eland patta\u003c/em\u003e’ and housing loan\u0026nbsp;to construct a house and few participants especially orphan children affected or infected with HIV and elderly asked care\u0026nbsp;shelter/care homes.A 20-years-old participant said-\u003cem\u003e\u0026nbsp;“My parents passed away due to HIV when I was 10 years. Since then I am residing with my aunty (Mother’s sister) at her place. It is a huge burden for them to bear my expense. I understand that they are uncomfortable with me as I am HIV positive as well. I have no other option to stay. If available, care homes can really help people like me.” Another participant expressed that the amount given for making house is inadequate,\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eNutrition\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA very few (n=3, 3.5%) people expressed their concern on nutrition. Additional nutrition either through extra ration (Anthyodaya Anna Yojana (AAY)) or nutritious diet supplementationare the expressed needs in this domain. A VSS says “\u003cem\u003eAnthyodaya Anna Yojana (AAY) scheme is availed by only old beneficiaries and no new registrations are getting this facility\u003c/em\u003e”. A HCW said “\u003cem\u003eNo additional nutritional support is given for people with HIV. This is a very important point as the HIV medications weaken them. So, it is further emphasized that some nutritional support is considered for this group\u003c/em\u003e”. The major concerns of the participants include- inadequate quantity, and poor-quality ration. (Table 3) A 40-year old female participant expressed her concern on inadequate nutritional support- “\u003cem\u003eMy husband passed away due to HIV in 2016. Then I got to know about my disease. Since then, I am the only earning person in the family. There are 3 people including my children who are dependent on me. ART medications make me feel very weak. In certain days, on waking up from bed, I feel very tiresome and fail to resume even my routine works which is affecting my income as I am a daily wager (expressed with tears in her eyes). I can’t afford buying vegetables also sometime because my income is very low. It would be very helpful if I get some nutritional support in the form of nutritious powders, from government by which I regain some strength and can go for my work regularly.”\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eHealth\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll PLWH receive free consultation, medication, and investigations. But a few participants (n=2, 2.5%) expressed that sometimes at government facilities, they are sending them to private labs for getting their investigations done, especially monthly haemoglobin.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTravel\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTwo (n=2, 2.5%) elderly participants expressed their concern on non-existence of travel benefit for this vulnerable group.\u0026nbsp;One of the participants receiving medications from Tirupati ART center expressed that,\u003cem\u003e\u0026nbsp;“My son, my daughter and I are on ART medications. We visit the treatment centre three times in a month., A visit costs 500 rupees which is a big burden to us. It will be of great help if we receive free travel benefit”.\u0026nbsp;\u003c/em\u003eHealth care worker at ART centre said–“There\u003cem\u003e\u0026nbsp;are families having more than one HIV patients.” \u0026nbsp;The ART staff explained that- “There are individual management plans for each family member with HIV. They must visit the ART centre on their scheduled days to get tested and receive the appropriate medicines. Hence, assigning a same-day visit for all the family members is sometimes inappropriate.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSupport to avail Government social protection schemes (GSPS)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMajority participants(n=80, 85%) expressed that they are failing to avail the existing GSPS due to insufficient information about the schemes (n=76, 80.8%), and administrative delay in processing the applications (n=71, 75.5%). A few participants (n=55, 58.5%) also expressed that they feel shy or guilty to avail the benefit and sometimes they were asked to give bribe (n=15, 16%) to avail GSPS which is preventing them in following up their applications. (Table 2, 3)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA 50-year male participant said,\u003cem\u003e\u0026nbsp;“I don’t know about the availability of a pension. I am visiting treatment centre for the past seven years but no one informed me about it”.\u0026nbsp;\u003c/em\u003eAnother person said \u003cem\u003e“t\u003c/em\u003e\u003cem\u003ehough I know about the provision of travel card, I don’t know where to go and how to apply. There should be a designated person for giving such information at each ART centre”.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eNeed for de-stigmatization\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA few participants expressed their concern about prominent existence of discrimination among the common people towards the PLWH.\u0026nbsp;Even some health care workers indirectly spread discrimination by breaching the confidentiality of HIV status as expressed a few (n=17, 18%) of them. A participant at Chittoor ART said \u003cem\u003e“\u003c/em\u003e\u003cem\u003eKuppam government hospital is the nearest center for me to get my medication, but I don’t want to transfer my registration from Chittoor (120 kms away from Kuppam) as many people at the Kuppam hospital may identify my HIV status”.\u003c/em\u003e Another female participant aged 45 years stated that\u003cem\u003e- “I don’t want to reveal the HIV status by applying for housing loan or ART pension. The village secretariat will call or announce my name in the public to get it enquire as a part of procedure by which my HIV status is revealed. Once HIV status is revealed we cannot stay in the same community, because they may isolate us”.\u0026nbsp;\u003c/em\u003eThe participants were even concern in availing any scheme that might reveal the HIV status. (Table 3)\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAt least eight participants (8.6%) experienced discrimination in the form of refusal of treatment.\u003cem\u003e\u0026nbsp;A female participant aged 55 years old stated that - “When I wanted my cataract to be operated\u003c/em\u003e\u003cem\u003e,\u003c/em\u003e\u003cem\u003e\u0026nbsp;one of the speciality hospitals in Tirupati (A district in Andhra Pradesh) refused to operate because of my HIV status, for which I had to travel around 270 kms to Anantapur (Adjacent district) to undergo surgery in a trust hospital”.\u0026nbsp;\u003c/em\u003eThey also felt that gender discrimination exists in providing GSPS (n=8, 8.6%). (Table 2)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eA health care worker highlighted that\u003c/em\u003e “\u003cem\u003eGender plays a critical role in choosing the place of treatment between government and private. We see men are often registered with the private facilities for getting the treatment than women. We have also seen situation where both husband and wife are HIV positive. While the wife is sent to government ART center for treatment, the husband got registered in private centers”,\u0026nbsp;\u003c/em\u003eOne participant even expressed that family support, as well as people awareness is critical in HIV social support. (Table 3)\u003c/p\u003e\n\u003cp\u003eSix (6.4%) participants wished to avail the benefits of the schemes only if confidentiality of HIV status is ensured.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eUnmet needs of the PLWH are specific to age and gender.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGender specific unmet needs:\u003c/strong\u003e\u0026nbsp; Both the genders mainly expressed the need for financial aid (females(n=40) 61.5%) males(n=28) 29.8%) followed by need for housing (n=6, 9.2%) among females; employment (n=5, 17.8%) and child’s education (n=5, 17.8%) among males. The only transgender participant expressed the need for employment. (Table 3)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAge specific unmet needs:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants expressed their need for financial aid in terms of pension aid or subsidized bank loans. Elder populations (41 to 60 years (n=29, 72.5%) and \u0026gt; 60 years (n= 3, 75%)) had a higher need than the younger populations (18 to 40 years (n=25, 50%). Participants belonged to 18 to 40 years expressed need for employment (n=5, 10%), housing aid (n=5, 10%) and child’s education (n=4, 8%). A few participants (Between 41 and 60 years) (n=4, 10%) of group have expressed their concern on child’s education. \u0026nbsp;However, the elderly participants expressed their concern only for financial aid. (Table 3)\u003c/p\u003e\n\u003cp\u003eThe other domains of concerns/needs expressed are insufficient provision through available GSPS, failure to avail GSPS, lack of support from family, neighbors and health care workers in availing GSPS and stigmatization towards PLWH. (Table 2)\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe present study highlights the various unmet needs of PLWH from a Southern Indian context where burden of HIV is high. We observed that HIV populations in this setting are heavily dependent on the government assistance for their daily living that encompasses various needs but not limited to finance, nutrition, housing, education, health, and travel. These needs are mostly unmet, and hence, the PLWH face various challenges as expressed by them. Besides, there are social and administrative challenges for them to avail the government-supported schemes. The unmet needs depend upon the age, and gender and due to the unmet needs, the PLWH face varying degree of difficulties in their day-to-day life.\u003c/p\u003e \u003cp\u003eSocial protection plays a pivotal role in surmounting various hurdles for people living with HIV (PLWH). (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)] Free and decentralized HIV services alleviate significant barriers to access, additional economic obstacles such as heightened expenses for nourishing sustenance, transportation costs, and income loss due to antiretroviral therapy (ART) appointments. (\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e–\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)] As per the UNAIDS national composite policy index of 2017, a total of 109 countries affirmed the presence of an endorsed social protection strategy, policy, or framework; among these, 99 were actively implementing diverse social protection initiatives, and the strategies of 85 countries exhibited a certain degree of HIV sensitivity. (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)] In India, in accordance with the provisions outlined in Chapter VII of the HIV and AIDS (Prevention and Control) Act of 2017, both the central and state governments bear the responsibility of implementing measures to facilitate the accessibility of welfare schemes aimed at catering to the needs of PLWH. The Act mandates the central government to ensure the dissemination of comprehensive information about the disease and program-related communications to safeguard the rights of PLWH. Encouragingly, both the state and central governments have taken proactive steps to assist PLWH through the creation of various social benefit schemes. These encompass a wide array of services, encompassing financial assistance, employment opportunities, nutritional support, travel concessions, insurance provisions, as well as initiatives targeted at children, among others. (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)] However, the schemes vary widely in number and types of schemes across the states and commonly criticized because of their top-down nature. (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)] Finding of the present study also indicates that the social support for the PLWH from the government in this setting is mostly a top-down approach and hardly need-based.\u003c/p\u003e \u003cp\u003eIn resource-poor settings a dynamic relationship exists between HIV/AIDS and the economic hardship where both act as an instigator and a consequence of each other. (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e)] In this study, we observed that economic crisis is the most common form of need expressed by the participants. In fact, for most of the other unmet needs including housing, education, nutrition, and transposrt, the underlying principle is economic hardship. (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)] In Indian setting, high socio-economic status has a significant association with better quality of life among the PLWH. (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e)] Besides, HIV treatment outcome strongly relies upon reducing poverty. (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)] Socioeconomic factors like- homelessness or housing instability hunger and food insecurity and insufficient transportation are often associated with HIV or pose major obstacles in achieving HIV treatment goals. (\u003cspan additionalcitationids=\"CR21 CR22 CR23 CR24 CR25\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e–\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e)] As the population in our study is relatively young, we expect that the need of the population will increase with the increasing age, unless appropriate interventions are taken. Unfortunately, as reported by the health care workers, the provision for multiple schemes including double pension has been stopped.\u003c/p\u003e \u003cp\u003eThese steps may further be aggravated by the administrative challenges and social stigma. In an earlier study from Rajasthan, India, it was found that administrative bottlenecks are one of the major reasons for the unmet need. (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)] Inadequate information, and delay in processing applications often makes the PLWH reluctant in availing the services as we have found in the present study. The administrative challenges, coupled with stigma makes the ground more complicated in availing the schemes and thereby increases the unmet need. (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)] It is worrisome that a considerable proportion of participants felt that their HIV status is revealed by the healthcare workers and the administrative staff in various offices. Perceived breach of confidentiality is known to cause reduction in utilization of services, conversely increases the unmet need. (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e)] On top of everything, family and social support empower PLWH towards care and treatment outcomes. Unfortunately, these supports were grossly compromised for the study participants. (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)]\u003c/p\u003e \u003cp\u003eThe study had a few limitations. First, the participants were selected non-randomly and hence, the selection methods are expected to reduce the generalizability of the study finding. To overcome this problem, we selected participants from all the three centres of the district. Also, we interviewed the health personnel to triangulate the responses of the PLWH. To avoid interviewers’ bias, a structured questionnaire and an interviewers’ guide were given to the interviewers to avoid leading questions. Additional training was imparted to the interviewers.\u003c/p\u003e \u003cp\u003e\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe people living with HIV in this setting have varying degrees of socio-economic need for themselves and their families. Most of these needs are unmet due to bottlenecks at different levels including administrative challenges, social challenges, and perceived stigma. Efforts to increase awareness, reduce stigma and discrimination, and providing culturally appropriate social support programs and healthcare services are crucial in improving the health and well-being of these vulnerable populations.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003enil\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest/Competing interests\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e The\u0026nbsp;authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval:\u003c/strong\u003e This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of Apollo Institute of Medical Sciences and Research (AIMSR), Chittoor and the reference number is \u003cstrong\u003eIEC07/AIMSR/07/2020\u0026nbsp;\u003c/strong\u003edated 30/05/2020.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate:\u0026nbsp;\u003c/strong\u003eInformed consent was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eThe authors affirm that the participants signed informed consent regarding publishing their data\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material (data transparency)\u003c/strong\u003e\u003cstrong\u003e:\u0026nbsp;\u003c/strong\u003eThe anonymous data\u0026nbsp;can be made available on reasonable requests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCode availability (software application or custom code):\u0026nbsp;\u003c/strong\u003eNot available\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eJT, KK, and SC: Concept development JT, KK, SC and KH: MethodsKK, UK and KH: Data acquisitionSC, KK: Data analysisSC and UK: Writing first draftJT, KK, SC, UK, KH: Reviewed manuscript\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe anonymous data will be made available on reasonable reqest.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKatz IT, Maughan-Brown B. Improved life expectancy of people living with HIV: who is left behind? The Lancet HIV. 2017 Aug 1;4(8):e324\u0026ndash;6. \u003c/li\u003e\n\u003cli\u003eFang L, Chuang DM, Al-Raes M. Social support, mental health needs, and HIV risk behaviors: a gender-specific, correlation study. BMC Public Health. 2019 May 28;19(1):651. \u003c/li\u003e\n\u003cli\u003eMaulsby CH, Ratnayake A, Hesson D, Mugavero MJ, Latkin CA. A Scoping Review of Employment and HIV. AIDS Behav. 2020 Oct;24(10):2942\u0026ndash;55. \u003c/li\u003e\n\u003cli\u003eArum C, Fraser H, Artenie AA, Bivegete S, Trickey A, Alary M, et al. Homelessness, unstable housing, and risk of HIV and hepatitis C virus acquisition among people who inject drugs: a systematic review and meta-analysis. The Lancet Public Health. 2021 May 1;6(5):e309\u0026ndash;23. \u003c/li\u003e\n\u003cli\u003eP. Zinyemba T, Pavlova M, Groot W. Effects of Hiv/Aids on Children\u0026rsquo;s Educational Attainment: A Systematic Literature Review. Journal of Economic Surveys. 2020;34(1):35\u0026ndash;84. \u003c/li\u003e\n\u003cli\u003eSteward WT, Bharat S, Ramakrishna J, Heylen E, Ekstrand ML. Stigma is Associated with Delays in Seeking Care Among HIV-Infected People in India. J Int Assoc Provid AIDS Care. 2013 Mar;12(2):103\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eMukoswa GM, Charalambous S, Nelson G. The association between social capital and HIV treatment outcomes in South Africa. PLOS ONE. 2017 Nov 9;12(11):e0184140. \u003c/li\u003e\n\u003cli\u003eBirore CMS, Wu L, Abrefa-Gyan T, Lewis MW. Social Support and Quality of Life Among People Living With HIV/AIDS (PLWHA) in Ghana. Journal of Family Issues. 2022 Aug 1;43(8):2159\u0026ndash;80. \u003c/li\u003e\n\u003cli\u003eDamulira C, Mukasa MN, Byansi W, Nabunya P, Kivumbi A, Namatovu P, et al. Examining the relationship of social support and family cohesion on ART adherence among HIV-positive adolescents in southern Uganda: baseline findings. Vulnerable Children and Youth Studies. 2019 Apr 3;14(2):181\u0026ndash;90. \u003c/li\u003e\n\u003cli\u003eNyamathi AM, Sinha S, Ganguly KK, William RR, Heravian A, Ramakrishnan P, et al. Challenges Experienced by Rural Women in India Living with AIDS and Implications for the Delivery of HIV/AIDS Care. Health Care Women Int. 2011 Apr;32(4):300\u0026ndash;13. \u003c/li\u003e\n\u003cli\u003eLalhruaimawii I, Danturulu MV, Rai S, Chandrashekar UK, Radhakrishnan R. Determinants of stigma faced by people living with Human Immunodeficiency Virus: A narrative review from past and present scenario in India. Clinical Epidemiology and Global Health. 2022 Sep 1;17:101117. \u003c/li\u003e\n\u003cli\u003eKoni K, Chaudhuri S, Tarugu J, Udayasree K, Hema K. HIV care policy in India: A review of social security schemes. Journal of Family Medicine and Primary Care. 2022 May;11(5):1648. \u003c/li\u003e\n\u003cli\u003eTemin M. HIV - Sensitive Social Protection What does the evidence say? 2010; \u003c/li\u003e\n\u003cli\u003eKyaw NTT, Kumar AMV, Oo MM, Oo HN, Kyaw KWY, Thiha S, et al. Long-term outcomes of second-line antiretroviral treatment in an adult and adolescent cohort in Myanmar. Glob Health Action. 2017;10(1):1290916. \u003c/li\u003e\n\u003cli\u003eGowthamghosh B, Huidrom R, Arumugam V, Pathak N, Purohit N, Shewade HD, et al. Implementation of social protection schemes for people living with HIV in three districts of Rajasthan state, India \u0026ndash; a mixed methods study [Internet]. F1000Research; 2020 [cited 2023 Aug 16]. Available from: https://f1000research.com/articles/9-248\u003c/li\u003e\n\u003cli\u003eUNAIDS. What needs to be done to Fast-Track social protection to end AIDS? [Internet]. [cited 2023 Aug 16]. Available from: https://www.unaids.org/en/resources/presscentre/featurestories/2018/may/fast-track-social-protection-to-end-aids\u003c/li\u003e\n\u003cli\u003eInternational Labour Organization. HIV/AIDS and poverty - the critical connection. \u003c/li\u003e\n\u003cli\u003eKalichman SC. Ending HIV Hinges on Reducing Poverty. AIDS Behav. 2023 Jan 1;27(1):1\u0026ndash;3. \u003c/li\u003e\n\u003cli\u003eArjun BY, Unnikrishnan B, Ramapuram JT, Thapar R, Mithra P, Kumar N, et al. Factors Influencing Quality of Life among People Living with HIV in Coastal South India. J Int Assoc Provid AIDS Care. 2017 May 1;16(3):247\u0026ndash;53. \u003c/li\u003e\n\u003cli\u003eChen NE, Meyer JP, Avery AK, Draine J, Flanigan TP, Lincoln T, et al. Adherence to HIV treatment and care among previously homeless jail detainees. AIDS Behav. 2013 Oct;17(8):2654\u0026ndash;66. \u003c/li\u003e\n\u003cli\u003eLeaver CA, Bargh G, Dunn JR, Hwang SW. The Effects of Housing Status on Health-Related Outcomes in People living with HIV: A Systematic Review of the Literature. AIDS Behav. 2007 Nov 1;11(2):85\u0026ndash;100. \u003c/li\u003e\n\u003cli\u003eMilloy MJ, Kerr T, Bangsberg DR, Buxton J, Parashar S, Guillemi S, et al. Homelessness as a Structural Barrier to Effective Antiretroviral Therapy Among HIV-Seropositive Illicit Drug Users in a Canadian Setting. AIDS Patient Care and STDs. 2012 Jan;26(1):60\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eAnema A, Vogenthaler N, Frongillo EA, Kadiyala S, Weiser SD. Food insecurity and HIV/AIDS: Current knowledge, gaps, and research priorities. Curr HIV/AIDS Rep. 2009 Nov 1;6(4):224\u0026ndash;31. \u003c/li\u003e\n\u003cli\u003eFranke MF, Murray MB, Mu\u0026ntilde;oz M, Hern\u0026aacute;ndez-D\u0026iacute;az S, Sebasti\u0026aacute;n JL, Atwood S, et al. Food Insufficiency is a Risk Factor for Suboptimal Antiretroviral Therapy Adherence among HIV-Infected Adults in Urban Peru. AIDS Behav. 2011 Oct 1;15(7):1483\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eMcLinden T, Stover S, Hogg RS. HIV and Food Insecurity: A Syndemic Amid the COVID-19 Pandemic. AIDS Behav. 2020;24(10):2766\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eLankowski AJ, Siedner MJ, Bangsberg DR, Tsai AC. Impact of Geographic and Transportation-Related Barriers on HIV Outcomes in Sub-Saharan Africa: A Systematic Review. AIDS Behav. 2014 Jul;18(7):1199\u0026ndash;223. \u003c/li\u003e\n\u003cli\u003eBayisa L, Wakuma B, Abera T, Mulisa D, Mosisa G, Tolossa T, et al. Are the Things Told to Care Providers Kept Confidential?: Perceived Breaches of Confidentiality and Associated Factors Among HIV/AIDS Clients on ART at Nekemte Specialized Hospital, Western Ethiopia, 2021. HIV AIDS (Auckl). 2022 Jan 15;14:1\u0026ndash;12. \u003c/li\u003e\n\u003cli\u003eDapaah JM, Senah KA. HIV/AIDS clients, privacy and confidentiality; the case of two health centres in the Ashanti Region of Ghana. BMC Medical Ethics. 2016 Jul 16;17(1):41. \u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eT\u003c/strong\u003e\u003cstrong\u003eable\u003c/strong\u003e\u003cstrong\u003e:1\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eDomains of\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eunmet needs\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eexpressed by\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ePLWH at Chittoor district, A.P, India\u003c/strong\u003e\u003cstrong\u003e, 2021.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"104%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 19.3878%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDomains of unmet needs\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEligible participants,\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.2653%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNever utilized,\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.3673%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUnmet need expressed,\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.6531%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExplored ways to meet unmet needs\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 19.3878%;\"\u003e\n \u003cp\u003eFinance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e94\u0026nbsp;(100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.2653%;\"\u003e\n \u003cp\u003e57\u0026nbsp;(60.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.3673%;\"\u003e\n \u003cp\u003e57\u0026nbsp;(60.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.6531%;\"\u003e\n \u003col\u003e\n \u003cli\u003ePension benefit or subsidized bank loans.\u003c/li\u003e\n \u003cli\u003e\u0026nbsp;A uniform state and central monitoring system\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 19.3878%;\"\u003e\n \u003cp\u003eChild\u0026apos;s education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e49\u0026nbsp;(52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.2653%;\"\u003e\n \u003cp\u003e24\u0026nbsp;(25.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.3673%;\"\u003e\n \u003cp\u003e8\u0026nbsp;(16.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.6531%;\"\u003e\n \u003col start=\"3\"\u003e\n \u003cli\u003eReservation\u0026nbsp;or\u0026nbsp;HIV quota\u0026nbsp;in seat allotments\u003c/li\u003e\n \u003cli\u003eFee waivers.\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 19.3878%;\"\u003e\n \u003cp\u003eEmployment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e94\u0026nbsp;(100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.2653%;\"\u003e\n \u003cp\u003e81\u0026nbsp;(86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.3673%;\"\u003e\n \u003cp\u003e8\u0026nbsp;(8.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.6531%;\"\u003e\n \u003col start=\"5\"\u003e\n \u003cli\u003eBank loan to start a small-scale business,\u0026nbsp;\u003c/li\u003e\n \u003cli\u003ePriority to PLWH in provision of GSPS/skill training\u0026nbsp;\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 19.3878%;\"\u003e\n \u003cp\u003eHousing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e78*\u0026nbsp;(82.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.2653%;\"\u003e\n \u003cp\u003e44\u0026nbsp;(46.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.3673%;\"\u003e\n \u003cp\u003e6\u0026nbsp;(7.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.6531%;\"\u003e\n \u003col start=\"7\"\u003e\n \u003cli\u003eLand \u0026lsquo;\u003cem\u003epatta\u003c/em\u003e\u0026rsquo; and housing loan\u003c/li\u003e\n \u003cli\u003e8. \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Shelter/care homes\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 19.3878%;\"\u003e\n \u003cp\u003eAdditional Nutrition (AAY)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e94\u0026nbsp;(100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.2653%;\"\u003e\n \u003cp\u003e82\u0026nbsp;(87.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.3673%;\"\u003e\n \u003cp\u003e3\u0026nbsp;(3.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.6531%;\"\u003e\n \u003col start=\"9\"\u003e\n \u003cli\u003eExtra ration-Anthyodaya Anna Yojana (AAY)\u003c/li\u003e\n \u003cli\u003eNutritious diet supplementation\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 19.3878%;\"\u003e\n \u003cp\u003eHealth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e94\u0026nbsp;(100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.2653%;\"\u003e\n \u003cp\u003e84\u0026nbsp;(89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.3673%;\"\u003e\n \u003cp\u003e2\u0026nbsp;(2.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.6531%;\"\u003e\n \u003col start=\"11\"\u003e\n \u003cli\u003eUpdated IEC on schemes to be displayed at ART,\u003c/li\u003e\n \u003cli\u003e\u0026nbsp;Regular updation of concerned websites\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eHelp line number to address the doubts\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eEquitable provision of GSPS throughout the nation\u003c/li\u003e\n \u003cli\u003eSingle point of contact (single window approach) at ART itself to apply and receive any social assistance.\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 19.3878%;\"\u003e\n \u003cp\u003eTravel\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e94\u0026nbsp;(100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.2653%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.3673%;\"\u003e\n \u003cp\u003e2\u0026nbsp;(2.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.6531%;\"\u003e\n \u003col start=\"16\"\u003e\n \u003cli\u003eFree travel charges\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 19.3878%;\"\u003e\n \u003cp\u003eAssistance for marriage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e4\u0026nbsp;(4.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.2653%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.3673%;\"\u003e\n \u003cp\u003e1\u0026nbsp;(25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.6531%;\"\u003e\n \u003col start=\"17\"\u003e\n \u003cli\u003ePremarital counselling.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eProvision for marriages among positive networks.\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*\u003cem\u003e16 members had their own houses\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eT\u003c/strong\u003e\u003cstrong\u003eable:\u003c/strong\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eAdministrative challenges and stigma faced by\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ePLWH at Chittoor district, A.P, India\u003c/strong\u003e\u003cstrong\u003e, 2021. (n=94)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSocial and administrative domains\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eObstacles expressed\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en(%)\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdministrative challenges\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003eInformation related to the available schemes are inadequate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e76(80.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003eProvision given in the schemes are not adequate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e66(70.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003eProcessing of application for GSPS is slow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e71(75.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003eI bribe to avail social protection schemes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e15(16)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003eI feel shy/guilty to avail the benefits of the scheme\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e55(58.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStigma towards PLWH\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003eI feel health care team doesn\u0026rsquo;t keep HIV status confidential\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e17 (18)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003eGender discrimination\u0026nbsp;in provision of\u0026nbsp;Exclusive GSPS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e8 (8.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003eHealth care team discriminates PLWH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e4 (4.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003eHospitals\u0026nbsp;refused to provide\u0026nbsp;treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e8 (8.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSocial challenge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003eHealth care workers and family are not supporting me in availing GSPS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e67(71.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eT\u003c/strong\u003e\u003cstrong\u003eable\u003c/strong\u003e\u003cstrong\u003e:3\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;Age and gender specific unmet needs of PLWH at Chittoor district, A.P, India\u003c/strong\u003e\u003cstrong\u003e, 2021.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 24%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"8\" valign=\"top\" style=\"width: 75%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDomains of unmet need\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 10%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFinance\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003en(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChild\u0026rsquo;s education\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003en=49\u003c/p\u003e\n \u003cp\u003eF=30; M=19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEmployment\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en=94\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHousing aid\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003en=78\u003c/p\u003e\n \u003cp\u003eF=47\u003c/p\u003e\n \u003cp\u003eM=31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNutrition\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003en=94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHealth\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eAid\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003en=94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTravel pass\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003en=94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAid for marriage\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003en=4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eFemale\u0026nbsp;65(69)\u003c/p\u003e\n \u003cp\u003eMale\u0026nbsp;28\u0026nbsp;(29.8)\u003c/p\u003e\n \u003cp\u003eTransgender\u0026nbsp;1(1.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e41(61.5)\u003c/p\u003e\n \u003cp\u003e16(53.5)\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3(10)\u003c/p\u003e\n \u003cp\u003e5(26.3)\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2(3)\u003c/p\u003e\n \u003cp\u003e5(17.8)\u003c/p\u003e\n \u003cp\u003e1(1.53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e6(12.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2(3)\u003c/p\u003e\n \u003cp\u003e1(1.53)\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1(1.53)\u003c/p\u003e\n \u003cp\u003e1(1.53)\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1(1.53)\u003c/p\u003e\n \u003cp\u003e1(1.53)\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e1(25)\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge in y\u003c/strong\u003e\u003cstrong\u003eears\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e18-40 \u0026nbsp; 50 (53.2) \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;41-60 \u0026nbsp;40(42.5)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u0026gt; 60 \u0026nbsp; \u0026nbsp;4(4.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e23(46)\u003c/p\u003e\n \u003cp\u003e29(72.5)\u003c/p\u003e\n \u003cp\u003e3(75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4(8)\u003c/p\u003e\n \u003cp\u003e4(10)\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e5(10)\u003c/p\u003e\n \u003cp\u003e2(5)\u003c/p\u003e\n \u003cp\u003e1(25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e5(10)\u003c/p\u003e\n \u003cp\u003e1(2.5)\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e2(5)\u003c/p\u003e\n \u003cp\u003e1(25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2(4)\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e2(50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1(25)\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 4: Thematic analysis of the unmet need of people living with HIV, Chittoor, India, 2021-22\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eVerbatim\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eCodes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eThemes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eBus pass can significantly reduce the travel cost\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eTravel Concession\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"17\"\u003e\n \u003cp\u003e\u003cstrong\u003eRequirement\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eIt will be helpful if both ART and widow pensions are given together\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eDual pension\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eThe amount given for housing is inadequate, need additional amount\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\"\u003e\n \u003cp\u003eAdditional requirement\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eIt will be helpful if additional ration is given\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eFinancial aid should be increased to 4000 Rupees per month\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eInstead of introducing new things, it is important to continue the existing services without stopping in between\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eContinuation of schemes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eIf I get a cattle, it will be helpful for me to generate some income\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\"\u003e\n \u003cp\u003eRehabilitation\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSome skill training can be extremely helpful for daily living\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eI need any kind of aid to earn my livelihood\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePension is crucial to support my children\u0026apos;s need\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\"\u003e\n \u003cp\u003eFinancial aid\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eWith financial aid, I can start my own business\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eI am planning to start a plastic recycling business for which I need financial aid\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eI need financial aid to start a tiffin centre\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eProvision for education should be there for the children\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eEducation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eA permanent job may be helpful to improve our condition\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePermanent employment\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eI am a railway employee and I do not require any scheme\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eNot required\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eI am satisfied with what I got\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eSatisfied\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAwareness about the schemes should be given to public as well\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePublic awareness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003eAwareness\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHIV-infected people should be aware of the existence of the schemes available\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eAwareness of PLWH\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMore information is required from the government\u0026nbsp;about the schemes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMore information\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eI am not aware if such schemes are available for the HIV positive people\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePoor awareness\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eIf at all a house is given or constructed, the area should not be named as HIV colony\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\"\u003e\n \u003cp\u003eStigma\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"6\"\u003e\n \u003cp\u003e\u003cstrong\u003eSocial challenge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eIf a house is constructed through such schemes, I fear of social discrimination\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eI don\u0026apos;t want any social schemes because of stigma\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAll PLWH should get support of their family first, which is often lacking\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eFamily support\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSchemes are required, but without revealing my status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eConfidentiality\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eTraining can be given but without revealing the HIV status\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eI have made multiple applications for ART pension, but yet to receive a response\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eApplication process\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdministrative challenge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eProvision for home loan or land patta is needed to make a house for my children\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eLand patta\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eGovernment has withdrawn the travel pass since COVID-19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eStoppage of benefit\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eRice that is distributed is not of good quality, it is causing stomach upset\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eQuality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eQuality issue\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Discrimination, Family support, People living with HIV, Social protection, Social support, Stigma ","lastPublishedDoi":"10.21203/rs.3.rs-4991493/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4991493/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground and Objective:\u003c/strong\u003e Discrimination, stigma, and social isolation pervade Indian society, significantly affecting HIV care outcomes. This study aims to investigate the perceived unmet needs of individuals living with HIV (PLWH).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e This mixed-method study enrolled adult PLWH from ART centers in Chittoor district, Andhra Pradesh. Data collection involved semi-structured interviews using a pre-tested questionnaire. Analysis encompassed descriptive and thematic approaches.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eAmong the 94 participants, the mean age was 39 years (SD 12 years), and the average duration of HIV diagnosis was 8 years (SD 5 years). The majority were female (n=65, 69%) and residents of rural areas (n=74, 78.7%). While financial needs were most prevalent, other pressing concerns included employment, child's education, housing, nutrition, healthcare, and travel. Participants voiced apprehensions about administrative hurdles and varying degrees of social challenges, such as stigma and discrimination, when accessing social protection services.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e PLWH exhibit diverse socio-economic needs for themselves and their families, many of which remain unmet due to multifaceted bottlenecks, encompassing administrative complexities, social barriers, and perceived stigma.\u003c/p\u003e","manuscriptTitle":"Unveiling the unseen: Exploring unmet needs among people living with HIV in Chittoor, Andhra Pradesh, India","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-09-27 07:28:07","doi":"10.21203/rs.3.rs-4991493/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"316d4130-d78e-482e-bf2d-96c473cdde92","owner":[],"postedDate":"September 27th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-05-05T04:23:12+00:00","versionOfRecord":[],"versionCreatedAt":"2024-09-27 07:28:07","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4991493","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4991493","identity":"rs-4991493","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}