HIV Critical Appraisal Report: Stigma, Depression, and Treatment

This report presents a critical appraisal of three research papers concerning HIV-related stigma and its association with depression and other negative psychological outcomes. The appraisal utilizes the Greenhalgh checklist to evaluate a mixed-methods study, a qualitative study, and a quantitative study. The report critically examines the methodologies, findings, and ethical considerations of each paper, focusing on the impact of stigma on people living with HIV (PLWH). It explores the factors contributing to stigma, such as healthcare provider attitudes and societal perceptions, and their effects on mental health, treatment adherence, and overall well-being. The report synthesizes the key findings from the selected articles, addressing the research question of how community engagement programs can help in the prevention of HIV stigma. Furthermore, the report discusses alternative research designs and concludes with a summary of the key insights and implications for public health interventions aimed at reducing stigma and improving the lives of PLWH. The report also provides a detailed discussion of the confounding factors of the study and suggests some strategies to deal with these factors and the HIV-related stigma.

Running head: HIV CRITICAL APPRAISAL
HIV Critical Appraisal
Name of the student
Name of the university
Author’s name

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Table of Contents
Introduction......................................................................................................................................2
Methodology....................................................................................................................................5
Inclusion Criteria.........................................................................................................................6
Exclusion Criteria........................................................................................................................6
Critical Appraisal.............................................................................................................................7
Ethical Aspects..............................................................................................................................13
Alternative epistemological research designs................................................................................15
Conclusion.....................................................................................................................................16
References......................................................................................................................................17
APPENDICES...............................................................................................................................23
APPENDIX 1.............................................................................................................................23
APPENDIX 2.............................................................................................................................24
APPENDIX 4.............................................................................................................................26

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“A critical examination of HIV-related stigma and its association with symptoms of
depression and other negative thoughts among different people.”
Introduction
The human immunodeficiency virus (HIV) is an enclosed retrovirus that consists of two
duplicates of a single-stranded RNA gene. It causes AIDS, which is the last phase of HIV illness.
After HIV enters the body, around four to ten weeks later, the patient may grumble of side
effects of primary diseases. From that point onward, the long interminable HIV disease happens,
which can keep going for a considerable length of time. AIDS is principally portrayed by
adaptable contaminations and tumors, which are typically deadly without treatment (Toledano,
2018). In 2018, the UNAIDS estimated that there are 37.9 million people across the globe who
are suffering due to HIV/AIDS (UNAIDS, 2019). Among these, 36.2 million populations are
adults, and the rest are children below the age of 15 years. It has also been estimated that around
1.7 million have currently come in contact with HIV (UNAIDS, 2019).
In low and middle economic countries (LMICs), common mental disorders (CMDs),
chiefly state of mind and tension issue, have an expected lifetime incidence of 22 percent and
frequently stay undiscovered and untreated. CMDs, particularly sadness, is frequently comorbid
with other interminable ailments, for example, diabetes, epilepsy, cardiovascular infection, and
HIV/AIDS (Kidia et al., 2015).
Since 1981 onwards, there have been gigantic progressions in the treatment of HIV.
Factually, this cannot be questioned. The progressions in ‘Anti-Retroviral Therapy’ (ART) have
reformed the administration of HIV. Thus, in the current days, HIV infection can be stopped, and
its development can be forestalled. Anti-Retroviral Therapy is an excellent success on which

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many epidemiologists, biomedical researchers, and health organizations have worked
consistently to accomplish.
Because antiretroviral treatments (ART) have been adopted, HIV-positive people with
access to medical care may lead longer lives, transforming a once-fatal disease into a more
manageable chronic illness. While significant progress has been made, people living with HIV
(PLWH) are still experiencing potent stressors, one of which is the widespread social stigma
associated with HIV (Sweeney & Vanable, 2016).
Stigma and injustice are one of the most significant challenges facing people living with
HIV today, according to the International Network of People Living with HIV / AIDS. In this
sense, HIV-related stigma was described as discounting, discrediting, and discriminating against
people who consider themselves to have HIV (Rueda et al., 2016). HIV stigma is recognized as
an obstacle to both HIV prevention and HIV treatment, but little is understood about the
processes by which stigma contributes to worse health habits or effects (Turan, Hatcher, Weiser,
Johnson, Rice & Turan, 2017). Generally, in the sense of HIV, shame tends to exist, whether
measured in terms of the behaviors of those who are not diagnosed or in terms of the perceptions
of those living with HIV. Stigma and injustice have a negative effect on HIV-patients. A recent
review of the qualitative evidence showed that HIV-related stigma is a significant and
widespread social phenomenon in many social areas, including healthcare environments (Rueda
et al., 2016).
Depression rates can be as high as 50% for people living with HIV. In many contexts,
HIV-related shame is linked with depressive symptoms that may result in reduced treatment and,
eventually, poor health results (Endeshaw, Walson, Rawlins, Dessie, Alemu, Andrews & Rao,

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2014). Stigma is described as a discrediting attribute that reduces the psychological ability of an
individual. Given its connections with already oppressed activities, including injecting substance
usage, sexual promiscuity, and homosexual activity, HIV-related stigma is considered a
particularly complex phenomenon (Sweeney & Vanable, 2016).
Thirty years into the HIV crisis, people living with HIV (PLWH) continue to report in
clinical facilities witnessing HIV-related stigma. Although advancement in medication has
effectively turned the diagnosis of HIV from a near-death sentence into a controlled chronic
disease, successful HIV treatment needs continued involvement in HIV care (Stringer et al.,
2016). A growing body of research suggests that stigmatizing attitudes and behaviors towards
PLWH act as barriers to PLWH testing, adherence to medication, and retention in care and
adversely affect the quality of life and psychological well-being of both males and females
(Stringer et al., 2016).
This objective of this article is to conduct a critical appraisal of three selected research
papers using the Greenhalgh checklist (Bootland, Coughlan, Galloway, Goubet & McWhirter,
2016). The critical appraisal will ultimately answer the research question, which will be
developed using the PICO method.

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Methodology
In this article, the search strategy method was used to filter out the articles for critical
appraisal. A research question was formed applying the PICO structure to appraise current
research on the HIV related stigma. The resultant question was –
P - HIV related stigma
I – Community engagement programs
C - None
O – Reducing HIV stigma
“Can the involvement of the people facing HIV stigma in community programs help in the
prevention of HIV stigma?”
A search strategy is a system ordered of key terms used to scan a database. The search
approach incorporates the fundamental concepts of the search query to get detailed information.
The search engines like Pub Med, College library, EBSCO, AMED, Psyc info Medline,
EMBASE, CINAHL, NCBI, SAGE, and WHOLIS were used to search for different research
journals published between January 2014 and December 2019 regarding HIV-related stigma.
Medical subject headlines and keyword terms related to HIV/AIDS and stigma were used in the
search strategy.
Initially, we used the keywords such as stigma, depressive symptoms, suicidal behavior,
and people living with HIV/AIDS (PLWH). Several research papers were identified through this

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method, though it was hard to filter out the desired research articles for the critical appraisal.
Thus, to reduce the number of irrelevant articles, Boolean operators were used like AND, OR.
For instance, People living with HIV/AIDS (PLWH) and depressive symptoms; PLWH and
suicidal behavior; PLWH and depressive symptoms or suicidal behavior. Inclusion and exclusion
criteria were also imposed on the search strategy, which helped in further filtering out the
irrelevant papers.
Inclusion Criteria
The review included evidence-based papers, comprising of novel qualitative and
quantitative researches, reviews, perspectives and presentation sessions, as well as chapters from
any book, and theses. The search was conducted focusing on all the geographical areas. Studies
published in English were only selected.
Exclusion Criteria
Studies that did not provide any primary data were excluded. Studies that were not published
in English were excluded. If there was insufficient data, then that paper was also excluded.
The inclusion process of the articles using the search strategy was done through three steps.
The initial step involved the reviewing of the title-and-abstract to check whether the papers
included all the key terms. The second step was reviewing the full article, reading the discussion
parts, methodologies, to check whether they were relevant and suitable to be included for the
assignment, and to do a critical appraisal. This step also involved the review process of the
objective of the article. The final stage involved to check whether the selected research paper
was based on the inclusion and exclusion criteria. To understand the full selection procedure,
please refer to the appendices where a PRISMA diagram documenting the search process

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(Appendix 1), a table demonstrating the papers provided by all the search engines (Appendix 2)
and a table outlining the selected research papers (Appendix 3) can be found.
Critical Appraisal
A critical appraisal using the Greenhalgh checklist will be conducted on the following
three selected research papers (Greenhalgh, Robert, Bate, Macfarlane & Kyriakidou, 2008).
Zeng, C., Li, L., Hong, Y. A., Zhang, H., Babbitt, A. W., Liu, C., ... & Cai, W. (2018). A
structural equation model of perceived and internalized stigma, depression, and suicidal
status among people living with HIV/AIDS. BMC public health, 18(1), 138.
Zeng et al., (2018) conducted a cross-sectional study using structural equation modeling
to assess the link between perceived and internalized stigma (PIS), sadness, and suicidal
behavior in the PLWH in the country of China. 411 PLWH people from March to June 2013
were hired from the Number Eight People's Hospital in Guangzhou, China. Respondents were
surveyed regarding their PIS, symptoms of depression, suicidal behaviors, and cultural-
demographic characteristics.
In a report, the authors must provide clear criteria for inclusion and exclusion, which they
established before the study participants were recruited. In the following study, the eligibility
requirements included HIV-seropositive status (enrolled in the health service or an official
report), at minimum 18 years of age (self-reported and checked by the official document as
necessary), willing to give written prior consent and willingly participate in the research. PLWH,
who stated being unable to complete the questionnaire due to mental disorder or other causes (for
example, due to lack of time) were exempted.

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The study subjects and the setting were appropriately described and in a detailed manner.
Subjects were selected from an outpatient and inpatient wards of HIV/AIDS research center in
Guangzhou, China, since 2013. Guangzhou, the Guangdong province's capital city, is China's
third-largest city and South China's largest, with a total of 8.54 million citizens as recorded in
2015. The hospital is the primary provider of PLWH services in the Guangzhou metropolitan
area.
In the study, a total of 450 PLWH were selected, and 39 questionnaires became invalid as
participants for various reasons (such as review, emergency appointment) did not finish such
questionnaires, resulting in 411 PLWH in the current study. Fourteen assertions originating from
the HIV Stigma Scale assessed perceived and internalized stigma (PIS). The efficacy and
consistency of both the initial HIV Stigma Scale (Cronbach alpha= 0.95) and the 14-item variant
used in the current study (Cronbach alpha > 0.90) were validated and developed in China.
Depressive symptoms were assessed using the Chinese version of the Center for Epidemiological
Studies Depression Scale (CES-D), a four-dimensional 20-point scale involving stressed, happy,
somatic and retarded behavior, and interpersonal issues
Objective and standard criteria were used for the measurement of the condition. In
addition to analyzing the proportions of depression and suicidal status among PLWH, the
researchers used the structural equation model (SEM) to examine the mediating impact of stress
and pathways between PIS, depression, and suicidal status in PLWH.
The authors have also stressed out to identify the confounding factors of the study. It was
found that socio-demographic characteristics, Perceived and internalized stigma, Depressive
Symptoms, and Suicidal status were the confounding factors of the study. To deal with the

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confounding factors and the HIV related stigma, the authors have suggested a few strategies
which can help in reducing the factors and problems surrounding the PLWH.
The authors indicated that it is of considerable significance and earnestness to strengthen
their mental health condition in order to prevent suicide in PLWH because depression can
contribute to suicidal thinking and attempt. It has also been proposed that efficient and successful
Aids preventive and recovery measures should be developed and incorporated at both
community and individual levels to minimize depression in PLWH. At the societal level,
organized steps should be taken to improve public awareness about HIV-related information to
both the general populace and healthcare professionals, to increase awareness and minimize
stigma against HIV/AIDS and its carriers.
The authors have used a wide range of indicators to evaluate the goodness of fit of
measurement and structural models in the current study. The indicators included were Chisquare
Statistic, Comparative Fit Index (CFI), Root Mean Square Error of Approximation (RMSEA),
Standardized Root Mean Square Residual (SRMR), and Weighted Root Mean Square Residual
(WRMR). Using version 9.4 of the SAS software, descriptive statistics, correlation analysis, and
bivariate analysis were performed. CFA and SEM were carried out using version 7.0 of Mplus
and then CFA was evaluated using a rigorous maximum probability method. The SEM method
was evaluated using robust, weighted least squares (WLS).
Zeng et al., (2018) had also provided a range of statistical data collected and analyzed
accurately. Statistical information demonstrated that PLWH experienced from considerably
higher PIS levels as well as some PLWH had conceptions of HIV-related prejudice and poor
self-images with the more significant part (63.8%) of respondents experiencing a medium PIS

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level and 13.9% a high level. Depressive symptoms were reported by 38.4 percent of PLWH. In
the current study, the proportion of depressive symptoms was lower from a systematic review
than the median occurrence of depressing indicators between the general PLWH in China (60.6
percent). Nonetheless, in the systematic review, the median incidence of symptoms of depression
in PLWH was based on research mainly performed in rural China with limited sample sizes (<
200), whereas the present research was conducted in Guangzhou, China's third-largest city, with
a larger sample size (411). In rural China, PLWH often has more mental health issues than in
large cities. The present study sheds some light on the process of how PIS influences the risk of
PLWH suicide. Because HIV / AIDS is often seen in China as a deadly infectious disease and
synonymous with tremendous social rejection and shame, PLWH is suffering from severe
psychological and social pressures. High levels of stigma are correlated with mental illness,
especially depression, which is related to suicidal ideation and attempted suicide.
Valencia-Garcia, D., Rao, D., Strick, L., & Simoni, J. M. (2017). Women's experiences with
HIV-related stigma from health care providers in Lima, Peru:“I would rather die than go
back for care”. Health care for women international, 38(2), 144-158.
Valencia-Garcia, Rao, Strick and Simoni (2017) have addressed a clear research in their
research paper. The paper described the heterosexual women of Peru who have been suffering
from HIV/AIDS. Thus, the researchers conducted a qualitative study on 14 selected women
participants age 18 years. They tried to examine the HIV-related stigma in these women
answering to two major questions – what are the forms of stigma and what was the response of
these women towards stigma? In the qualitative study 14 women were selected from the
“Asociacion Civil Impacta de Salud y Educacion”. The eligibility criterion for the study was that
women should be older than 18 years of age and they should not be pregnant. They were asked

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to participate in a face to face interview. For the participation in the study, the women were
compensated with approx. U.S.$5. Yes, it was appropriate for the author to conduct a qualitative
approach using face to face interviews and a right design was also used as women who were
selected were relevant to the research questions and was also relevant to the main issue described
at the start of the article. To get the answers for the research questions it was appropriate to
conduct an interview session with the women, though interviewing only 14 women would not
have been enough to get a proper answer to the research questions.
The main context of this study was that women of Peru were experiencing stigma from
the healthcare providers. No, the article does not provide with enough findings and necessary
findings so as to relate it to other settings. To elaborate and discuss the evidence, the researchers
have provided many life experiences of women to understand the forms of stigma and responses
of stigma so as to make conceptual generalizations rather than the statistical generalizations. The
article used systematic method for analyzing and reporting themes in the data. A thematic
analysis was done to assess the data. Interviews were initially performed to collect the data. A
common pattern visible in the data was established after the interviews for a generic qualitative
coding system. The article used systematic method to analyze the data. Yes, the analysis took
account of all observations and as such interview data has been sufficiently presented.
The results demonstrated that the women got infected with HIV as a result heterosexual
transmission from the male partner. There were two main reasons for their diagnosis - positive
diagnosis of HIV of their male partner and due to pregnancy. The interesting part of the result of
this study is that it provided recommendations regarding strategies for reducing stigma. Also, the
research did not provide with unintended consequences. The authors have also demonstrated a
transparent relation among the interview data and the context theory. Though, there still

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remained few limitations such as the sample was too small, thus it was not adequate enough to
represent the experiences of stigma. In the whole article, the position and roles of the author have
not been explained neither any kind of bias has been considered. Also, the authors’
preconceptions and ideology were set aside during the study. The article has also not discussed
about any ethical reservations. Though, it was worth to conduct this study, as it helped in
understanding the form of stigma and were able to react too responses of the women.
Endeshaw, M., Walson, J., Rawlins, S., Dessie, A., Alemu, S., Andrews, N., & Rao, D.
(2014). Stigma in Ethiopia: association with depressive symptoms in people with
HIV. AIDS care, 26(8), 935-939.
In the research of Endeshaw et al. (2014), the researchers conducted the study based on a
research question which was to find out the relationship between stigma of HIV/AIDS and
depressive symptoms in Gondar, Ethiopia. In order to gather information and conduct the study,
the researchers have used some complex terms like depression and stigma and this has been
defined clearly and unambiguously. The following study was a cross sectional mixed method
study, where the researchers selected 18 year and older Gondar University Hospital patients who
were suffering due to HIV and were under the antiretroviral therapy. It was the nurses who
approached the patient during their routine appointment. Yes, this study design was appropriate
to the research question as participants selected were residents of Gondar, Ethiopia. The context
of this study was that in numerous settings, HIV-related stigma has been related with
burdensome side effects which may prompt poor commitment in care and at last, more
unfortunate wellbeing results. Stigma has been a significant issue in Ethiopia yet information
examining the connection among stigma and depression in Ethiopia were deficient. Because of
this explanation scientists directed a mixed-methods cross-sectional examination to analyze the

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connection between stigma of HIV/AIDS and depression in Gondar, Ethiopia. Thus, the context
was well-described to properly relate them with other settings. The following study was funded
by the Strengthening Care Opportunities through Partnership in Ethiopia (SCOPE). To make
conceptual generalizations in the research study rather than the statistical generalizations,
Endeshaw et al. (2014) provided a sufficient amount of quantitative and qualitative data.
To gather the information, the analysts led audio-recorded individual interviews in
Amharic. At that point they gathered socio-segment data, including sex, age, marriage status, and
education. The researchers used G power to estimate sample size and used multiple regression to
assess the impact of HIV-related stigma and gender on depressive symptoms. Yes, sufficient
amount of data were provided. No information was provided on how to deal with the
disconfirming observations. The interesting part of the results was that it provided its strengths
and limitations of the research at the end of the paper. No, there were no unintended
consequences. In the research, the authors have demonstrated a clear link between data and
context of the study. This study inspected how HIV-associated stigma was linked to depressive
signs in Northern Ethiopia. Though, there were few limitations in the study, which were small
sizes was included in the study and the use of measurement tools was not yet authorized in
Ethiopia. In the whole article, the position and roles of the author have not been explained
neither any kind of bias has been considered. The article has also not discussed about any ethical
reservations.
Ethical Aspects
There were important assumptions to be taken while evaluating the three reports as per
ethical constraints. The biggest legal factor to consider was the possibility of a marginalized

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group becoming stigmatized. All the three articles selected utilized different research designs to
explore the lives of people living with HIV (PLWH) and their experiences of HIV-related to
stigma (Brinsdon, Abel & Desrosiers, 2017). Nonetheless, substantial facets of the subject
remain unanswered, indicating a place for more study designs and alternate data analysis
approaches in the delivery of additional information. There were articles which have used small
sample population due to which the statistical data was limited.
In the study of Zeng et al., (2018) the writer has attracted the reader’s attention by using
the key terms in the title of the article such as stigma, depression, and suicidal status in the lives
of PWLH. The article has provided an abstract regarding what has been done throughout the
paper. The abstract clearly demonstrates the study design and the study method. It clearly states
that a cross-sectional approach has been used. The aim of the study was clearly stated in the
abstract. The introduction part of the assignment also shows a number of in-text citations which
makes reference to other research studies as a means of supportive evidence. Though, the article
has not mentioned anything regarding the ethical issues (Zeng et al., 2018).
In the article of Valencia-Garcia, Rao, Strick & Simoni, (2017) the writer has attracted
the reader’s attention by using the phrase ““I would rather die than go back for care”. The study
has also provided an abstract but the abstract does not provide the research study design or
method. Also, the introduction part of the article does not provide the research objective, though
it provides the statistics of HIV-related stigma. Though, the article has not mentioned anything
regarding the ethical issues (Valencia-Garcia, Rao, Strick & Simoni, 2017).
In the study of Endeshaw et al., (2014), the article’s title is not much interesting neither
attractive. The writer has used very simple terms and thus the title does not tells or gives a clear

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idea of what will be done in the study. Also, the abstract does not give a proper research design
or method (Endeshaw et al., 2014).
For health related research, there are contrasting concerns on ethics. Many accept
guidance spelling out clear terms for both right and wrong, while others are stipulations that'
shed light on a consistent structure for ethics assessment.' In this way, a legal structure was taken
into consideration in all three experiments. Ultimately, the synthesis of research designs and
information created by a mixed-method study will enable multidimensional and comprehensive
exploration of PLWH and its stigmatic experiences.
Alternative epistemological research designs
In all the three research articles taken, there were several issues which could have been
improved if alternative design would have been chosen. Like in the article of Valencia-Garcia,
Rao, Strick & Simoni, (2017), the researchers have used only fourteen women for the study, thus
there was a limitation in the data acquired through the interview session. More data could have
been acquired if the sample study would have been increased and an online survey would have
been used. The affordability of health care services appears to be a problem presented by many
PLWHA worldwide. Early diagnosis of HIV infection could have significant effects for both
individuals and society, along with effective access to healthcare and therapeutic treatments, and
awareness to minimize the risk of exposure to others.
In the study of Zeng et al., (2018), a longitudinal study could have been conducted as a
longitudinal research could have been carried out as it could validate the mediating impact of
distress on the correlation of PIS with suicidal status. Policies should also be implemented at the
societal level to increase social acceptance for PLWH, strengthen its cognitive well-being and

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health-related attitudes. Policies should be rendered not only for traditional health care agencies
(e.g. clinics, disease control and preventive centers (CDCs), but also for non-governmental
organizations (NGOs) that have played a major role in the treatment of HIV and patient care.
Most of the non-governmental organizations are not officially registered and recognized in
China. Therefore, monetary contributions in NGOs should be expanded and the participation of
NGOs in HIV / AIDS prevention and PLWH treatment promoted. At the level of the individual,
psychological treatment and services are necessary to limit the internalized shame, depression
and suicidal ideation of adolescents and to enhance PLWH's mental health status and quality of
life.
Similarly, in the study of Endeshaw et al., (2014) a very small size was used where some
of the participants did not respond to the study. In the quantitative study out of the 58
participants only 55 people participated in the study. Thus, the researchers could have selected a
more sample size as the more the better. A larger sample size could have allowed the
examination of more factors with the study’s variables. Along with the sample size, the
researchers have used those measurement tools which were not yet validated in Ethiopia. Thus, it
was an ethical issue.
Conclusion
All in all, the research studies selected were successful in meeting the goals of the
assignment. From reviewing the literature it is apparent that more research is needed to find out
various interventions and notions which would help in developing an effective strategy that
would help the PLWH and will help them preventing their experiences with stigma.

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structural equation model of perceived and internalized stigma, depression, and suicidal
status among people living with HIV/AIDS. BMC public health, 18(1), 138.

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APPENDICES
APPENDIX 1
Records identified through database like
NCBI, ENSEMBL, etc. using keyword ‘HIV’
(N = 8612)
Additional records identified through Google
scholar and Google using keyword ‘HIV’, ‘HIV-
related stigma’ (N = 38612)
Records screened using the inclusion
criteria (n = 20102)
After removing the duplicate articles
(N = 97)
Records involving quantitative,
qualitative and mixed method
studies (N = 40)
Fully text articles published before 2001
and not involving the main keyword like
HIV-related stigma were excluded (N = 50)

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APPENDIX 2
Initial search After exclusion
criteria
After removal of
duplicates
Relevant content and
suitable for assignment
Pub Med 954 536 125 14
College library 855 432 221 12
EBSCO 839 401 258 10
AMED 954 506 144 1 (0 new)
PsycInfo Medline 587 325 189 12 (0 new)
EMBASE 458 301 147 5 (0 new)
CINAHL 985 502 197 1 (0 new)
NCBI 994 556 114 6 (2 new)
SAGE 158 81 60 6 (0 new)
WHOLIS 758 236 115 7 (0 new)

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APPENDIX 3
Author Published Year Article Title
Zeng, C., Li, L., Hong, Y. A.,
Zhang, H., Babbitt, A. W.,
Liu, C., ... & Cai, W.
(2018) A structural equation model of
perceived and internalized
stigma, depression, and
suicidal status among people
living with HIV/AIDS
Valencia-Garcia, D., Rao, D.,
Strick, L., & Simoni, J. M.
(2017) Women's experiences with
HIV-related stigma from
health care providers in Lima,
Peru:“I would rather die than
go back for care”
Endeshaw, M., Walson, J.,
Rawlins, S., Dessie, A.,
Alemu, S., Andrews, N., &
Rao, D.
(2014) Stigma in Ethiopia:
association with depressive
symptoms in people with HIV

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APPENDIX 4