Health-related quality-of-life and receipt of women-centered HIV care among women living with HIV in Canada

Syndemic conditions and quality of life in the PISCIS Cohort of people living with HIV in Catalonia and the Balearic Islands: a cross sectional study

BACKGROUND

People living with HIV (PLWH) face structural and psychosocial factors that affect health-related quality of life (HRQoL). We aimed to evaluate how syndemic conditions affected HRQoL in PLWH.

METHODS

A cross-sectional survey was conducted among 861 PLWH, to determine whether syndemic conditions (monthly income; sexual satisfaction; depressive symptoms; social role satisfaction; social isolation; cognitive function; nicotine dependence; perception of stigma) have an effect on HRQoL. A linear regression model and measures of Additive Interaction (AI) were used to determine the effects of syndemic conditions on HRQoL, controlling for other risk factors.

RESULTS

Overall, the most frequently observed were stigma perception (56.9%), poor cognitive function (50.6%) and the perception of social isolation (51.6%). The presence of depressive symptoms was the risk factor most associated with worse Physical Health (PH) (B 3.93, 2.71-5.15) and Mental Health (MH) (B 5.08, 3.81-6.34) in linear regression model. Specifically, an interaction was observed between poor cognitive function and poor satisfaction with social role on worse PH and MH (AI 2.08, 0.14-4.02; AI 2.69, 0.15-5.22, respectively); and low income and perception of stigma (AI 2.98, 0.26-5.71), low income and perception of social isolation (AI 2.79, 0.27-5.32), and low income and poor satisfaction with social role (AI 3.45, 0.99-5.91) on MH.

CONCLUSION

These findings provide evidence that syndemic factors impact HRQoL. HIV prevention programs should screen and address co-occurring health problems to improve patient-centered health care and outcomes.

Associations between psychosocial factors and antiretroviral therapy outcomes differ by gender and sexual orientation among people living with HIV in British Columbia, Canada

Little is known about how the co-occurrence of psychosocial factors affect sub-populations of people living with HIV (PLWH). We used cross-sectional data from 999 PLWH, aged ≥19, accessing antiretroviral therapy (ART) in British Columbia, Canada (2007-2010) to examine associations between psychosocial factors and ART-related outcomes separately for trans/cis inclusive women; heterosexual men; and gay, bisexual, and other men who have sex with men (gbMSM). Multivariable logistic regression examined associations between psychosocial factors (0-3): any violence in the past 6 months, depressive symptoms in the past week, and current street drug use (heroin, crack, meth or speedball) with sub-optimal adherence (outcome 1: average annual ART adherence <95% from interview until end of follow-up, death, or December 31st, 2018) and ever viral rebound (outcome 2) adjusting for potential confounders. Of 999 PLWH (264 women, 382 heterosexual men, and 353 gbMSM), women and heterosexual men had significantly higher median counts than gbMSM. Overall, higher counts were associated with sub-optimal adherence (adjusted odds ratio [aOR] = 1.26/1-unit increase, 95%CI = 1.07-1.49). All effect estimates were of a greater magnitude among gbMSM, but not significant for women or heterosexual men, highlighting the need for population (e.g., gender and sexual orientation)-centered care and research.

Prevalence and correlates of sexual concerns and associated distress among women living with HIV in Canada

Objectives:

We assessed the prevalence and correlates of sexual concerns and associated distress among women living with HIV in Canada.

Methods:

We analyzed cross-sectional survey data from the Canadian HIV Women’s Sexual and Reproductive Health Cohort Study (2017–2018). Self-identified women living with HIV were asked about sexual concerns post-HIV diagnosis and associated distress (none, mild, moderate, severe). Five areas of concern were assessed, including difficulties related to sexual self-esteem, sexual function, relationships, and emotional and behavioral aspects of sex. Logistic regression analyses identified correlates of reporting any sexual concerns and severe distress about these concerns.

Results:

Of 906 participants (median age 48, Q1–Q3 = 41–55), 596 (65.8%) reported sexual concerns post-HIV diagnosis. We found a high prevalence of concerns related to relationships (43.3%), sexual self-esteem (49.4%), and emotional aspects of sex (45.4%), relative to sexual functioning (38.4%) and behavioral aspects (33.7%). Of those with sexual concerns, 36.7% reported severe distress. Reports of severe distress were the highest for relationship difficulties (32.5%), relative to other areas of concern (21.4%–22.8%). In adjusted analyses, women reporting sexual dissatisfaction and high HIV-related stigma had significantly higher odds of reporting sexual concerns. Conversely, those reporting higher resilience, better mental health, African, Caribbean, and Black identity, and sex as somewhat unimportant, not at all important, or neutral to their lives had lower adjusted odds. Factors associated with severe distress about sexual concerns included older age, body dissatisfaction, sexual dissatisfaction, and high HIV-related stigma, while better mental health and getting support from someone living with HIV were protective. While 84.4% of women had discussed with a provider how viral load impacts transmission risk, only 40.6% had conversations about sexual wellbeing.

Conclusion:

More attention to women’s sexual wellbeing within social and relational contexts is critical to ensure the sexual rights of women living with HIV are upheld.

Mapping HIV-related services for women in Eastern Canada: A qualitative study

Background:

Geographic health disparities have been well described in parts of Canada; however, little is known about the experiences of women living with HIV in the Maritime Provinces. This article focuses on the complex health system women living with HIV navigate geographically to access care in New Brunswick and Nova Scotia, Canada.

Method:

This study includes interviews with 10 women living with HIV and 39 community-based workers whose organizations provide services to this group of women in New Brunswick and Nova Scotia. Purposive sampling was used to recruit both women living with HIV and community workers. Interviews were recorded and transcribed into a Microsoft word document. Transcripts were imported into NVivo 11 for thematic analyses and used to map the services women with HIV were accessing in their communities in ArcGIS 10.2 for Windows.

Results:

The study found that there are a number of barriers women with HIV face in the Maritime Provinces, including the low number of specialist physicians, long travel distances to major urban centers for care, and the loss of HIV-specific supports and resources. In response to these difficulties, community-based organizations are leading efforts in their communities to increase outreach programs and the number of available peer workers to improve the health outcomes of women living with HIV. Furthermore, it showed that women living with HIV and community workers were interested in creating a women-centered HIV care system in the Maritime Provinces, but were uncertain how to move forward with this initiative.

Conclusion:

There is a need for women-centered HIV services. This study proposes streamlining the healthcare pathway and decreasing obstacles to increase women’s access to care in the Maritime Provinces.

“I do the she and her”: A qualitative exploration of HIV care providers’ considerations of trans women in gender-specific HIV care

Objectives:

Women of all genders, including cisgender (cis) and transgender (trans) women, experience social and structural drivers of HIV inequities and pervasive barriers to HIV care. Yet, little is known about how HIV care providers address gender diversity in health care. Through a critical feminist lens informed by intersectionality theory, medical anthropology, and critical sociology, we explored (1) how do HIV care providers describe women living with HIV’s care needs and barriers; (2) what are their perspectives on optimal HIV care for women; and (3) to what extent do these conceptualizations include/exclude trans women.

Methods:

Utilizing a community-based exploratory qualitative study design, we conducted 60–90 minute semi-structured individual interviews from March 2019–April 2020 with eight HIV care providers (n = 4 social service providers; n = 4 physicians) practicing across seven counties representative of rural, suburban, and urban Michigan, United States. Data were analyzed utilizing a reflexive thematic approach.

Results:

Three overarching themes emerged: (1) Emphasis on (different) clinical needs: key considerations in cis and trans women’s HIV care; (2) Recognition of the structural: barriers to HIV care affecting women of all genders; and (3) Proposed solutions: piecing together individual, social, and organizational interventions to increase access to HIV care that may benefit women living with HIV of all genders but are disproportionately framed as being for cis women. While HIV care providers recognized both cis and trans women living with HIV’s clinical care needs and structural barriers to care, they rarely envisioned optimal HIV care inclusive of gender affirmation and structural interventions.

Conclusions:

Findings suggest that HIV care providers can avoid reducing gender to biology and making assumptions about reproductive care needs, endocrinological care needs, caregiving responsibilities, and other life circumstances; provide gender-affirming medical care; and address structural barriers to HIV care to enhance intersectional and structurally focused gender-affirming—that is, trans-inclusive—women-centered HIV care.

Prevalence and correlates of having sexual and reproductive health priorities met by HIV providers among women living with HIV in a Canadian setting

OBJECTIVE

To: (1) describe the prevalence of key reproductive health outcomes (e.g., pregnancy, unintended pregnancy; abortion); and (2) examine social-structural correlates, including HIV stigma, of having key sexual and reproductive health (SRH) priorities met by participants' primary HIV provider, among women living with HIV.

METHODS

Data were drawn from a longitudinal community-based open cohort (SHAWNA) of women living with HIV. The associations between social-structural factors and two outcomes representing having SRH priorities met by HIV providers ('being comfortable discussing sexual health [SH] and/or getting a Papanicolaou test' and 'being comfortable discussing reproductive health [RH] and/or pregnancy needs') were analyzed using bivariate and multivariable logistic regression models with generalized estimating equations for repeated measures over time. Adjusted odds ratios (AOR) and 95% confidence intervals [95% CIs] are reported.

RESULTS

Of 314 participants, 77.1% reported having SH priorities met while 64.7% reported having RH priorities met by their primary HIV provider at baseline. In multivariable analysis, having SH priorities met was inversely associated with: sexual minority identity (AOR: 0.59, 95% CI: 0.37-0.94), gender minority identity (AOR: 0.52, 95% CI: 0.29-0.95) and recent verbal or physical violence related to HIV status (AOR: 0.55, 95% CI: 0.31-0.97) and positively associated with recently accessing women-centred services (Oak Tree Clinic) (AOR: 4.25, 95% CI: 2.20-8.23). Having RH priorities met was inversely associated with: sexual minority identity (AOR: 0.56, 95% CI: 0.40-0.79), gender minority identity (AOR: 0.45, 95% CI: 0.25-0.81) and being born in Canada (AOR: 0.29, 95% CI: 0.15-0.56) and positively associated with recently accessing women-centred services (AOR: 1.81, 95% CI: 1.29-2.53) and a history of pregnancy (AOR: 2.25, 95% CI: 1.47-3.44).

CONCLUSION

Our findings suggest that there remain unmet priorities for safe SRH care and practice among women living with HIV, and in particular, for women living with HIV with sexual and/or gender minority identity and those who experience enacted HIV stigma. HIV providers should create safe, non-judgmental environments to facilitate discussions on SRH. These environments should be affirming of all sexual orientations and gender identities, culturally safe, culturally humble and use trauma-informed approaches.

Development of the Canadian Women-Centred HIV Care Model Using the Knowledge-to-Action Framework

In Canada, women make up 25% of the prevalent HIV cases and represent an important population of those living with HIV, as a high proportion are racialized and systemically marginalized; furthermore, many have unmet healthcare needs. Using the knowledge-to-action framework as an implementation science methodology, we developed the "Women-Centred HIV Care" (WCHC) Model to address the needs of women living with HIV. The WCHC Model is depicted in the shape of a house with trauma- and violence-aware care as the "foundation". Person-centred care with attention with attention to social determinants of health and family make up the "first" floor. Women's health (including sexual and reproductive health and rights) and mental and addiction health care are integrated with HIV care, forming the "second" floor. Peer support, leadership, and capacity building make up the "roof". To address the priorities of women living with HIV in all their diversity and across their life course, the WCHC Model should be flexible in its delivery (e.g., single provider, interdisciplinary clinic or multiple providers) and implementation settings (e.g., urban, rural).

Quality of life of older women living with HIV: comparative assessment of physical and mental health-related markers using a large Canadian Sexual and Reproductive Health Cohort Study

Objective: This study assessed and compared physical and mental health components of quality of life (QoL) for older and younger women living with HIV (WLWH). Method: Using survey data from the Canadian HIV Women's Sexual and Reproductive Health Cohort Study, demographic, well-being, and physical and mental health-related QoL (HR-QoL) variables were compared between older (≥50 years) and younger (<50 years) WLWH. As the only significantly different QoL component, bivariate analyses and linear regression were used to assess factors associated with physical HR-QoL of older women. Results: The sample frame comprised 1,422 women (28.0% older women). Younger WLWH's mean age was 37.8 years (SD = 7.4) compared to older WLWH (55.8 years, SD = 5.3). Compared to younger WLWH, older WLWH had poorer physical HR-QoL (40.0 vs. 50.7; p < 0.001) but similar mental HR-QoL (42.7 vs. 42.1; p > 0.001). Older WLWH had lower social support (p < 0.001) with no significant differences in depressive symptoms or resilience. Resilience was associated with improved physical HR-QOL. Food insecurity, poorer mental HR-QoL and depressive symptoms were associated with poorer physical health. Discussion: Compared to younger WLWH, older WLWH had poorer physical HR-QoL, which was associated with resilience, food insecurity and mental health factors, highlighting the complex interactions of health-related social-ecological factors impacting aging WLWH.

Longitudinal assessment of coping and quality of life over 24 months postpartum in mothers living with HIV

This study investigated the influence of coping strategies on quality of life of mothers living with HIV over 24 months postpartum. Fifty-six Brazilian mothers living with HIV answered quality of life and coping scales at pregnancy, 3rd, 12th, and 24th month postpartum. Mixed model longitudinal regressions were conducted. Quality of life improved in physical, level of independence, and environmental domains over time. While problem-focused coping was positively associated with all changes in quality of life, emotionally focused strategies showed inverse association with physical and environmental quality of life. Health care should help mothers living with HIV to actively cope with HIV together with political and community efforts to address their social vulnerability.

A longitudinal study of associations between HIV-related stigma, recent violence and depression among women living with HIV in a Canadian cohort study

INTRODUCTION

Women living with HIV (WLHIV) experience stigma and elevated exposure to violence in comparison with HIV-negative women. We examined the mediating role of experiencing recent violence in the relationship between stigma and depression among WLHIV in Canada.

METHODS

We conducted a cohort study with WLHIV in three Canadian provinces. Recent violence was assessed through self-reported experiences of control, physical, sexual or verbal abuse in the past three months. At Time 1 (2013-2015) three forms of stigma were assessed (HIV-related, racial, gender) and at Time 2 (2015-2017) only HIV-related stigma was assessed. We conducted structural equation modelling (SEM) using the maximum likelihood estimation method with Time 1 data to identify direct and indirect effects of gender discrimination, racial discrimination and HIV-related stigma on depression via recent violence. We then conducted mixed effects regression and SEM using Time 1 and Time 2 data to examine associations between HIV-related stigma, recent violence and depression.

RESULTS

At Time 1 (n = 1296), the direct path from HIV-related stigma (direct effect: β = 0.200, p < 0.001; indirect effect: β = 0.014, p < 0.05) to depression was significant; recent violence accounted for 6.5% of the total effect. Gender discrimination had a significant direct and indirect effect on depression (direct effect: β = 0.167, p < 0.001; indirect effect: β = 0.050, p < 0.001); recent violence explained 23.15% of the total effect. Including Time 1 and Time 2 data (n = 1161), mixed-effects regression results indicate a positive relationship over time between HIV-related stigma and depression (Acoef: 0.04, 95% CI: 0.03, 0.06, p < 0.001), and recent violence and depression (Acoef: 1.95, 95% CI: 0.29, 4.42, p < 0.05), controlling for socio-demographics. There was a significant interaction between HIV-related stigma and recent violence with depression (Acoef: 0.04, 95% CI: 0.01, 0.07, p < 0.05). SEM analyses reveal that HIV-related stigma had a significant direct and indirect effect on depression over time (direct effect: β = 0.178, p < 0.001; indirect effect: β = 0.040, p < 0.001); recent violence experiences accounted for 51% of the total effect.

CONCLUSIONS

Our findings suggest that HIV-related stigma is associated with increased experiences of recent violence, and both stigma and violence are associated with increased depression among WLHIV in Canada. There is an urgent need for trauma-informed stigma interventions to address stigma, discrimination and violence.

Love with HIV: A Latent Class Analysis of Sexual and Intimate Relationship Experiences Among Women Living with HIV in Canada

Love remains hidden in HIV research in favor of a focus on risk. Among 1424 women living with HIV in Canada, we explored (1) whether eight facets of sex and intimacy (marital status, sexual activity, physical intimacy, emotional closeness, power equity, sexual exclusivity, relationship duration, and couple HIV serostatus) may coalesce into distinct relationship types, and (2) how these relationship types may be linked to love as well as various social, psychological, and structural factors. Five latent classes were identified: no relationship (46.5%), relationships without sex (8.6%), and three types of sexual relationships-short term (15.4%), long term/unhappy (6.4%), and long term/happy (23.2%, characterized by equitable power, high levels of physical and emotional closeness, and mainly HIV-negative partners). While women in long-term/happy relationships were most likely to report feeling love for and wanted by someone "all of the time," love was not exclusive to sexual or romantic partners and a sizeable proportion of women reported affection across latent classes. Factors independently associated with latent class membership included age, children living at home, sexism/genderism, income, sex work, violence, trauma, depression, HIV treatment, awareness of treatment's prevention benefits, and HIV-related stigma. Findings reveal the diversity of women's experiences with respect to love, sex, and relationships and draw attention to the sociostructural factors shaping intimate partnering in the context of HIV. A nuanced focus on promoting healthy relationships and supportive social environments may offer a more comprehensive approach to supporting women's overall sexual health and well-being than programs focused solely on sexual risk reduction.

Sexuality and childbearing as it is experienced by women living with HIV in Sweden: a lifeworld phenomenological study

The effectiveness of antiretroviral treatment has reduced sexual HIV transmission and mother-to-child-transmission. To optimally support women living with HIV, health care providers need deepened knowledge about HIV, sexuality and childbearing. The aim of this study was to describe the phenomenon sexuality and childbearing as experienced by women living with HIV in Sweden. Data were collected by phenomenon-oriented interviews with 18 HIV-positive women. A reflective lifeworld analysis based on phenomenological philosophy was conducted, describing the meaning structure of the phenomenon. The essence of the phenomenon is that perceptions about HIV and its contagiousness profoundly influence sexual habits and considerations in relation to pregnancy and childbearing. These perceptions are formed in combination with knowledge and interpretations about HIV by the women themselves and by their environments. The essence is further described by its constituents: Risk of transmission imposes demands on responsibility; The contagiousness of HIV limits sexuality and childbearing; Knowledge about HIV transmission provides confident choices and decisions; and To re-create sexuality and childbearing. Although HIV has a low risk of transmission if being well treated, our study shows that HIV-positive women feel more or less contagious, which influences sexuality and decision-making in relation to become pregnant and give birth.

Supporting the Sexual Rights of Women Living With HIV: A Critical Analysis of Sexual Satisfaction and Pleasure Across Five Relationship Types

In the context of human immunodeficiency virus (HIV), a focus on protecting others has overridden concern about women's own sexual well-being. Drawing on feminist theories, we measured sexual satisfaction and pleasure across five relationship types among women living with HIV in Canada. Of the 1,230 women surveyed, 38.1% were completely or very satisfied with their sexual lives, while 31.0% and 30.9% were reasonably or not very/not at all satisfied, respectively. Among those reporting recent sexual experiences (n = 675), 41.3% always felt pleasure, with the rest reporting usually/sometimes (38.7%) or seldom/not at all (20.0%). Sex did not equate with satisfaction or pleasure, as some women were completely satisfied without sex, while others were having sex without reporting pleasure. After adjusting for confounding factors, such as education, violence, depression, sex work, antiretroviral therapy, and provider discussions about transmission risk, women in long-term/happy relationships (characterized by higher levels of love, greater physical and emotional intimacy, more equitable relationship power, and mainly HIV-negative partners) had increased odds of sexual satisfaction and pleasure relative to women in all other relational contexts. Those in relationships without sex also reported higher satisfaction ratings than women in some sexual relationships. Findings put focus on women's rights, which are critical to overall well-being.

Envisioning Women-Centered HIV Care: Perspectives from Women Living with HIV in Canada

BACKGROUND

Women comprise nearly one-quarter of people living with human immunodeficiency virus (HIV) in Canada. Compared with men, women living with HIV experience inequities in HIV care and health outcomes, prompting a need for gendered and tailored approaches to HIV care.

METHOD

Peer and academic researchers from the Canadian HIV Women's Sexual and Reproductive Health Cohort Study conducted focus groups to understand women's experience of seeking care, with the purpose of identifying key characteristics that define a women-centered approach to HIV care. Eleven focus groups were conducted with 77 women living with HIV across Quebec, Ontario, and British Columbia, Canada.

RESULTS

Women envisioned three central characteristics of women-centered HIV care, including i) coordinated and integrated services that address both HIV and women's health care priorities, and protect against exclusion from care due to HIV-related stigma, ii) care that recognizes and responds to structural barriers that limit women's access to care, such as violence, poverty, motherhood, HIV-related stigma, and challenges to safe disclosure, and iii) care that fosters peer support and peer leadership in its design and delivery to honor the diversity of women's experiences, overcome women's isolation, and prioritize women's ownership over the decisions that affect their lives.

CONCLUSION

Despite advances in HIV treatment and care, the current care landscape is inadequate to meet women's comprehensive care needs. A women-centered approach to HIV care, as envisioned by women living with HIV, is central to guiding policy and practice to improve care and outcomes for women living with HIV in Canada.