Hiring, training, and supporting Peer Research Associates: Operationalizing community-based research principles within epidemiological studies by, with, and for women living with HIV

"As a patient I do not belong to the clinic, I belong to the community": co-developing multi-level, person-centred tuberculosis stigma interventions in Cape Town, South Africa

Background

Anticipated, internal, and enacted stigma are major barriers to tuberculosis (TB) care engagement and directly impact patient well-being. Unfortunately, targeted stigma interventions are lacking. We aimed to co-develop a person-centred stigma intervention with TB-affected community members and health workers in South Africa.

Methods

Using a community-based participatory research approach, we conducted ten group discussions with people diagnosed with TB (past or present), caregivers, and health workers (total n = 87) in Khayelitsha, Cape Town. Group discussions were facilitated by TB survivors. Discussion guides explored experiences and drivers of stigma and used human-centred design principles to co-develop solutions. Recordings were transcribed, coded, thematically analysed, and then further interpreted using the socio-ecological model and behaviour change wheel framework.

Results

Intervention components across socio-ecological levels shared common functions linked to effective behaviour change, namely education, training, enablement, persuasion, modelling, and environmental restructuring. At the individual level, participants recommended counselling to improve TB knowledge and provide ongoing support. TB survivors can guide messaging to nurture stigma resilience by highlighting that TB can affect anyone and is curable, and provide lived experiences of TB to decrease internal and anticipated stigma. At the interpersonal level, support clubs and family-centred counselling were suggested to dispel TB-related myths and foster support. At the institutional level, health worker stigma reduction training informed by TB survivor perspectives was recommended to decrease enacted stigma. Participants discussed how integration of TB/HIV care services may exacerbate TB/HIV intersectional stigma and ideas for restructured service delivery models were suggested. At the community level, participants recommended awareness-raising events led by TB survivors, including TB information in school curricula. At the policy level, solutions focused on reducing the visibility generated by a TB diagnosis and resultant stigma in health facilities and shifting tasks to community health workers.

Conclusions

Decreasing TB stigma requires a multi-level approach. Co-developing a person-centred intervention with affected communities is feasible and generates stigma intervention components that are directed and implementable. Such community-led multi-level intervention components should be prioritised by TB programs, including integrated TB/HIV care services.

Supplementary Information

The online version contains supplementary material available at 10.1186/s44263-024-00084-z.

Mental health service use and shortages among a cohort of women living with HIV in Canada

BACKGROUND

The prevalence of mental health conditions among women with HIV in Canada ranges between 29.5% and 57.4%, highlighting the need for accessible mental health care. We aimed to (1) describe the availability and use of mental health services among women with HIV and (2) identify characteristics associated with reporting that shortages of these services presented a problem in their care.

METHODS

Baseline data from the Canadian HIV Women's Sexual and Reproductive Health Cohort Study were analysed. Self-reported availability and use of mental health services were examined using descriptive statistics. Participants indicated whether a lack of mental health support was a problem in their care. Logistic regression models were constructed to determine associations between sociodemographic, clinical, and psychosocial characteristics and reported problematic shortages.

RESULTS

Of 1422 women, 26.7% (n = 380) used mental health services in the last year, which most accessed through their HIV clinic. Thirty-eight percent (n = 541) reported that a shortage of mental health support was a problem in their care. Among this subset, 22.1% (n = 119) used services at their HIV clinic, 26.5% (n = 143) reported available services but did not use them, and 51.4% (n = 277) either indicated that these services were unavailable, did not know if such services were available, or were unengaged in HIV care. Factors associated with reporting problematic shortages included rural residence [adjusted odds ratio (aOR): 1.69, 95% confidence interval (CI): 1.03-2.77], higher education level (aOR: 1.43, 95% CI: 1.02-2.02), and higher HIV stigma score (aOR: 1.03, 95% CI: 1.02-1.03). Conversely, African/Caribbean/Black identity (aOR: 0.37, 95% CI: 0.26-0.54), history of recreational drug use (aOR: 0.56, 95% CI: 0.39-0.81), and Quebec residence (aOR: 0.69, 95% CI: 0.50-0.96) were associated with lower odds of reporting service shortages.

CONCLUSION

Our findings highlight the HIV clinic as the primary location of mental health service use. However, existing services may not be sufficient to reach all patients or meet specific needs. Furthermore, the low uptake among those reporting a shortage suggests a lack of connection to services or patient knowledge about their availability. Characteristics associated with reporting shortages reflect geographic and socioeconomic disparities that must be accounted for in future service design.

"This is an illness. No one is supposed to be treated badly": community-based stigma assessments in South Africa to inform tuberculosis stigma intervention design

Background

Though tuberculosis (TB)-related stigma is a recognized barrier to care, interventions are lacking, and gaps remain in understanding the drivers and experiences of TB-related stigma. We undertook community-based mixed methods stigma assessments to inform stigma intervention design.

Methods

We adapted the Stop TB Partnership stigma assessment tool and trained three peer research associates (PRAs; two TB survivors, one community health worker) to conduct surveys with people with TB (PWTB, n = 93) and caregivers of children with TB (n = 24) at peri-urban and rural clinic sites in Khayelitsha, Western Cape, and Hammanskraal, Gauteng Province, South Africa. We descriptively analyzed responses for each stigma experience (anticipated, internal, and enacted), calculated stigma scores, and undertook generalized linear regression analysis. We conducted 25 in-depth interviews with PWTB (n = 21) and caregivers of children with TB (n = 4). Using inductive thematic analysis, we performed open coding to identify emergent themes, and selective coding to identify relevant quotes. Themes were organized using the Constraints, Actions, Risks, and Desires (CARD) framework.

Results

Surveys revealed almost all PWTB (89/93, 96%) experienced some form of anticipated, internal, and/or enacted stigma, which affected engagement throughout the care cascade. Participants in the rural setting (compared to peri-urban) reported higher anticipated, internal, and enacted stigma (β-coefficient 0.72, 0.71, 0.74). Interview participants described how stigma experiences, including HIV intersectional stigma, act individually and together as key constraints to impede care, leading to decisions not to disclose a TB diagnosis, isolation, and exclusion. Stigma resilience arose through the understanding that TB can affect anyone and should not diminish self-worth. Risks of stigma, driven by fears related to disease severity and infectiousness, led to care disengagement and impaired psychological well-being. Participants desired counselling, identifying a specific role for TB survivors as peer counselors, and community education.

Conclusions

Stigma is highly prevalent and negatively impacts TB care and the well-being of PWTB, warranting its assessment as a primary outcome rather than an intermediary contributor to poor outcomes. Multi-component, multi-level stigma interventions are needed, including counseling for PWTB and education for health workers and communities. Such interventions must incorporate contextual differences based on gender or setting, and use survivor-guided messaging to foster stigma resilience.

Supplementary Information

The online version contains supplementary material available at 10.1186/s44263-024-00070-5.

Experiences and resultant care gaps among women with HIV in Canada: concept mapping the Canadian HIV Women's Sexual and Reproductive Health Cohort Study (CHIWOS) findings

OBJECTIVES

The community-based, longitudinal, Canadian HIV Women's Sexual and Reproductive Health Cohort Study (CHIWOS) explored the experiences of women with HIV in Canada over the past decade. CHIWOS' high-impact publications document significant gaps in the provision of healthcare to women with HIV. We used concept mapping to analyse and present a summary of CHIWOS findings on women's experiences navigating these gaps.

DESIGN

Concept mapping procedures were performed in two steps between June 2019 and March 2021. First, two reviewers (AY and PM) independently reviewed CHIWOS manuscripts and conference abstracts written before 1 August 2019 to identify main themes and generate individual concept maps. Next, the preliminary results were presented to national experts, including women with HIV, to consolidate findings into visuals summarising the experiences and care gaps of women with HIV in CHIWOS.

SETTING

British Columbia, Ontario and Quebec, Canada.

PARTICIPANTS

A total of 18 individual CHIWOS team members participated in this study including six lead investigators of CHIWOS and 12 community researchers.

RESULTS

Overall, a total of 60 peer-reviewed manuscripts and conference abstracts met the inclusion criteria. Using concept mapping, themes were generated and structured through online meetings. In total, six composite concept maps were co-developed: quality of life, HIV care, psychosocial and mental health, sexual health, reproductive health, and trans women's health. Two summary diagrams were created encompassing the concept map themes, one for all women and one specific to trans women with HIV. Through our analysis, resilience, social support, positive healthy actions and women-centred HIV care were highlighted as strengths leading to well-being for women with HIV.

CONCLUSIONS

Concept mapping resulted in a composite summary of 60 peer-reviewed CHIWOS publications. This activity allows for priority setting to optimise care and well-being for women with HIV.

"Nobody has written the book about what non-binary people should put forward in relationships": Exploring gender equity in relationships of queer, trans, and non-monogamous young women and non-binary youth in British Columbia, Canada

Understanding the unique ways in which queer, trans, and non-monogamous young women and non-binary youth navigate and negotiate equitable intimate relationships is a first step toward strong research, programs/resources, and policies to support healthy relationship dynamics across the life course. Using a youth-engaged collaborative Reflexive Thematic Analysis, we aimed to explore how youth of diverse genders and relationship experiences understand gender equity in their relationships. Thirty cis- and transgender inclusive young women (46.7%) and non-binary youth (53.3%) aged 17-29 who were in a current (76.6%) or recent (in past 12 months, 23.4%) non-heterosexual and/or non-monogamous intimate relationship and residing in British Columbia, Canada, completed qualitative interviews between August and November 2022. Of the 30 youth, 53.3% reported having experience living as a trans person, 33.3% identified only as bisexual and 10% identified as only lesbian or gay, whereas the remaining 56.7% identified with ≥1 of: queer, pansexual, and demisexual. Participants identified that relationship equity requires: 1) Moving away from cis-heteronormative conceptualizations of gender roles and norms; 2) Actively working to dismantle hierarchal power structures by sharing power, responsibility, labour, and decision-making; and 3) Accommodating and affirming each person's unique needs and identities in a relationship. For theme one, youth further described the ways in which they re-imagined relationship norms and discussed the various challenges to resisting ingrained hierarchical cis-heteronormativity. This research contributes a greater understanding of how to create equitable and healthy relationships and has important implications for healthcare providers, educators, and policymakers working with queer, transgender, and non-monogamous youth.

"As a patient I do not belong to the clinic, I belong to the community." Co-developing a multi-level, person-centred tuberculosis stigma intervention in Cape Town, South Africa

Background

Anticipated, internal, and enacted stigma are major barriers to TB care engagement, and directly impact patient well-being. Unfortunately, targeted stigma interventions are lacking. We aimed to co-develop a person-centred stigma intervention with TB-affected community members and health workers in South Africa.

Methods

Using a community-based participatory research approach, we conducted ten group discussions with people diagnosed with TB (past or present), caregivers, and health workers (total n=87) in Khayelitsha, Cape Town. Group discussions were facilitated by TB survivors. Discussion guides explored experiences and drivers of stigma and used human-centred design principles to co-develop solutions. Recordings were transcribed, coded, thematically analysed and then further interpreted using the socio-ecological model.

Results

Intervention components across socio-ecological levels shared common behaviour change strategies, namely education, empowerment, engagement, and innovation. At the individual level, participants recommended counselling to improve TB knowledge and provide ongoing support. TB survivors can guide messaging to nurture stigma resilience by highlighting that TB can affect anyone and is curable, and provide lived experiences of TB to decrease internal stigma. At the interpersonal level, support clubs and family-centred counselling were suggested to dispel TB-related myths and foster support. At the institutional level, health worker stigma reduction training informed by TB survivor perspectives was recommended. Consideration of how integration of TB/HIV care services may exacerbate TB/HIV intersectional stigma and ideas for restructured service delivery models were suggested to decrease anticipated and enacted stigma. At the community level, participants recommended awareness-raising events led by TB survivors, including TB information in school curricula. At the policy level, solutions focused on reducing the visibility generated by a TB diagnosis and resultant stigma in health facilities and shifting tasks to community health workers.

Conclusions

Decreasing TB stigma requires a multi-level approach. Co-developing a person-centred intervention with affected communities is feasible and generates stigma intervention components that are directed and implementable. Such community-informed intervention components should be prioritised by TB programs, including integrated TB/HIV care services.

Dissemination of the Women-Centred HIV Care Model: A Multimodal Process and Evaluation

BACKGROUND

Using data from a national cohort study and focus groups, the Women-Centred HIV Care (WCHC) Model was developed to inform care delivery for women living with HIV.

METHODS

Through an evidence-based, integrated knowledge translation approach, we developed 2 toolkits based on the WCHC Model for service providers and women living with HIV in English and French (Canada's national languages). To disseminate, we distributed printed advertising materials, hosted 3 national webinars and conducted 2 virtual capacity-building training series.

RESULTS

A total of 315 individuals attended the webinars, and the average WCHC knowledge increased by 29% (SD 4.3%). In total, 131 service providers engaged in 22 virtual capacity-building training sessions with 21 clinical cases discussed. Learners self-reported increased confidence in 15/15 abilities, including the ability to provide WCHC. As of December 2023, the toolkits were downloaded 7766 times.

CONCLUSIONS

We successfully developed WCHC toolkits and shared them with diverse clinical and community audiences through various dissemination methods.

"This is an illness. No one is supposed to be treated badly": Community-based stigma assessments in South Africa to inform TB stigma intervention design

Background

Though TB-related stigma is a recognized barrier to care, interventions are lacking and gaps remain in understanding the drivers and experiences of TB-related stigma. We undertook community-based mixed methods stigma assessments to inform stigma intervention design.

Methods

We adapted the Stop TB Partnership stigma assessment tool, and trained three peer research associates (PRAs; two TB survivors, one community health worker) to conduct surveys with people with TB (PWTB, n=93) and caregivers of children with TB (n=24) at peri-urban and rural clinic sites in Khayelitsha, Western Cape, and Hammanskraal, Gauteng Province, South Africa. We descriptively analyzed responses for each stigma experience (anticipated, internal, and enacted), calculated stigma scores, and undertook generalized linear regression analysis. We further conducted 25 in-depth interviews with PWTB (n=22) and caregivers TB (n=3). Using inductive thematic analysis, we performed open coding to identify emergent themes, and selective coding to identify relevant quotes. Themes were organised using the CARD (Constraints, Actions, Risks and Desires) framework.

Results

Surveys revealed at least one-third of PWTB and one-quarter of caregivers report experiences of anticipated, internal, and/or enacted stigma, which affected engagement throughout the care cascade. Participants in rural locations (compared to peri-urban) reported higher anticipated, internal, and enacted stigma (β-coefficient 0.72, 0.71, and 0.74). Interview participants described how stigma experiences, including HIV intersectional stigma, act individually and in concert as key constraints to impede care, and underpins failure to disclose a TB diagnosis, isolation, and exclusion. Stigma resilience arose through understanding that TB can affect anyone and should not diminish self-worth. Risks of stigma, driven by fears related to disease severity and infectiousness, led to care disengagement and impaired psychological wellbeing. Participants desired counselling, identifying a specific role for TB survivors as peer counsellors, and community education.

Conclusions

Stigma is highly prevalent and negatively impacts TB care and the well-being of PWTB, warranting its assessment as a primary outcome indicator rather than intermediary contributor to poor cascade outcomes. Multicomponent stigma interventions are needed, including counselling for PWTB and education for health workers and communities. Such interventions must incorporate contextual differences based on gender or setting, and use survivor-guided messaging to foster stigma resilience.

Understanding sexual violence in sex working populations-Law, legal consciousness and legal practice in four countries (2021-2023): Study Protocol v2.5

BACKGROUND

Globally, the most important human rights and public health issue that sex workers face is their experience of high levels of violence (Kinnell, 2006, Kinnell, 2008, Alexander, 1999). Deering's systematic review estimated levels of sexual violence in sex working populations as being between 14% and 54% (Deering et al, 2014).

AIMS

This international, robust mixed methods study will explore the frequency of sexual violence against sex workers, barriers in criminal justice and the legal consciousness of sex workers regarding their rights and consent. The hypothesis to be tested is that the safety of sex workers from sexual violence is mediated by the differing legal contexts of sex work environments. We will compare experiences across research sites in the context of legalisation (Nevada USA), client criminalisation (Northern Ireland), decriminalisation (New Zealand) and partial criminalisation (England, Scotland and Wales) [henceforth ESW].

METHODS

An international survey (n = 1,000) will be translated into several languages, to disaggregate experiences by demographic categories (gender, ethnicity, sexual orientation) and sex work sector (including online, street-based and brothels). Interviews (n = 100) with sex workers, police, prosecutors and service providers will be thematically analysed to explore legal consciousness, why the patterns occur and contextualise the statistical findings. These data will be supplemented with comparative legislative, policy and case analysis. Research study data will be used to compare the social factors and legal norms shaping sex workers experiences of sexual violence, justice and support interventions. Recommendations for a 'best practice' review of legal improvements and support interventions will be produced following completion of the study. Given the sensitive nature of the research, robust ethical and data protection mechanisms are in place. The research has ethical approval from each research site, an Advisory Board and trained, paid peer researchers to assist with data gathering, analysis and dissemination. The study will report findings in 2023/2024.

Sexual Satisfaction of Midlife Women Living With HIV in Canada: A Prospective Cohort Analysis

BACKGROUND

Although sexual activity and function decline in older women living with HIV, positive dimensions of sexual health, such as satisfaction, are relatively unexplored. We evaluated the prevalence of sexual satisfaction for midlife women with HIV and assessed its relation to women's physical, mental, and sociostructural experiences.

SETTING

We studied women in the Canadian HIV Women's Sexual and Reproductive Health Cohort Study (CHIWOS) over 3 survey waves (2013-2018).

METHODS

We included women living with HIV aged ≥45 years who reported ever having consensual sex. Sexual satisfaction was assessed using an item from the Sexual Satisfaction Scale for Women and was dichotomized into satisfactory ("completely/very/reasonably satisfactory") and not satisfactory ("not very/not at all satisfactory"). Probable depression was based on CES-D ≥10. Multivariable logistic regression and fixed effects models determined correlates of sexual satisfaction. Reasons for sexual inactivity and alternate forms of sexual expression were also explored.

RESULTS

Among 508 midlife women, 61% were satisfied with their sexual lives at baseline. Women with probable depression had lower odds of sexual satisfaction than those without (aOR: 0.44; 95% CI: 0.27 to 0.71) and worsening depressive symptoms over time were associated with poorer sexual satisfaction ( P = 0.001). Increased sexual activity was associated with higher sexual satisfaction (aOR: 2.75; 95% CI: 1.54 to 4.91); however, 51% of women reporting sexual satisfaction were sexually inactive. Sexually inactive women engaged in alternate forms of sexual expression such as self-pleasure (37%) and intimate relationships without sex (13%).

CONCLUSION

Midlife women with HIV have high rates of sexual satisfaction, even in the absence of sexual activity. Depressive symptoms were closely associated with sexual dissatisfaction, alerting providers to the importance of screening for depression and sexual health together.

Community-Engaged Research Ethics Training (CERET): developing accessible and relevant research ethics training for community-based participatory research with people with lived and living experience using illicit drugs and harm reduction workers

BACKGROUND

Community-based participatory research (CBPR) can directly involve non-academic community members in the research process. Existing resources for research ethics training can be inaccessible to team members without an academic background and do not attend to the full spectrum of ethical issues that arise through community-engaged research practices. We detail an approach to capacity building and training in research ethics in the context of CBPR with people who use(d) illicit drugs and harm reduction workers in Vancouver's Downtown Eastside neighborhood.

METHODS

A project team comprised of academic and community experts in CBPR, research ethics, and harm reduction met over five months to develop the Community-Engaged Research Ethics Training (CERET). The group distilled key principles and content from federal research ethics guidelines in Canada, and developed case examples to situate the principles in the context of research with people who use(d) illicit drugs and harm reduction workers. In addition to content related to federal ethics guidelines, the study team integrated additional content related to ethical issues that arise through community-based research, and ethical principles for research in the Downtown Eastside. Workshops were evaluated using a pre-post questionnaire with attendees.

RESULTS

Over the course of six weeks in January-February 2020, we delivered three in-person workshops for twelve attendees, most of whom were onboarding as peer research assistants with a community-based research project. Workshops were structured around key principles of research ethics: respect for persons, concern for welfare, and justice. The discussion-based format we deployed allowed for the bi-directional exchange of information between facilitators and attendees. Evaluation results suggest the CERET approach was effective, and attendees gained confidence and familiarity with workshop content across learning objectives.

CONCLUSIONS

The CERET initiative offers an accessible approach to fulfill institutional requirements while building capacity in research ethics for people who use(d) drugs and harm reduction workers. This approach recognizes community members as partners in ethical decision making throughout the research process and is aligned with values of CBPR. Building capacity around intrinsic and extrinsic dimensions of research ethics can prepare all study team members to attend to ethical issues that arise from CBPR.

HIV care cascade for women living with HIV in the Greater Toronto Area versus the rest of Ontario and Canada

BACKGROUND

The Greater Toronto Area (GTA) is home to 39% of Canada's population living with HIV. To identify gaps in access and engagement in care and treatment, we assessed the care cascade of women living with HIV (WLWH) in the GTA versus the rest of Ontario and Canada (in this case: Quebec and British Columbia).

METHODS

We analyzed 2013-2015 self-reported baseline data from the Canadian HIV Women's Sexual and Reproductive Health Cohort Study for six care cascade stages: linked to care, retained in care, initiated antiretroviral therapy (ART), currently on ART, ART adherence (≥90%), and undetectable (<50 copies/mL). Multivariable logistic regression was used to reveal associations with being undetectable.

RESULTS

Comparing the GTA to the rest of Ontario and Canada, respectively: 96%, 98%, 100% were linked to care; 92%, 94%, 98% retained in care; 72%, 89%, 96% initiated ART; 67%, 81%, 90% were currently using ART; 53%, 66%, 77% were adherent; 59%, 69%, 81% were undetectable. Factors associated with viral suppression in the multivariable model included: living outside of the GTA (Ontario: aOR = 1.72, 95% CI: 1.09-2.72; Canada: aOR = 2.42, 95% CI: 1.62-3.62), non-Canadian citizenship (landed immigrant/permanent resident: aOR = 3.23, 95% CI: 1.66-6.26; refugee/protected person/other status: aOR = 4.77, 95% CI: 1.96-11.64), completed high school (aOR = 1.77, 95% CI: 1.15-2.73), stable housing (aOR = 2.13, 95% CI: 1.33-3.39), income of ≥$20,000 (aOR = 1.52, 95% CI: 1.00-2.31), HIV diagnosis <6 years (6-14 years: aOR = 1.75, 95% CI: 1.16-2.63; >14 years: aOR = 1.87, 95% CI: 1.19-2.96), and higher resilience (aOR = 1.02, 95% CI: 1.00-1.04).

CONCLUSION

WLWH living in the GTA had lower rates of viral suppression compared to the rest of Ontario and Canada even after adjustment of age, ethnicity, and HIV diagnosis duration. High-impact programming for WLWH in the GTA to improve HIV outcomes are greatly needed.

Building capacity in quantitative research and data storytelling to enhance knowledge translation: a training curriculum for peer researchers

BACKGROUND

Many community-based HIV research studies incorporate principles of greater involvement and meaningful engagement of people living with HIV (GIPA/MEPA) by training people with HIV as peer researchers. Unfortunately, there are still some aspects of research (e.g., quantitative data analysis and interpretation) where many projects fall short in realizing GIPA/MEPA principles. To address these gaps, we developed an eight-week training course that aimed to build the capacity of peer researchers around the understanding and interpretation of quantitative data and incorporating lived experience to increase the impact of the knowledge transfer and exchange phase of a study.

METHODS

Peer researchers (n = 8) participated from British Columbia, Alberta, and Ontario and lessons learned from the training were implemented throughout the dissemination of research findings from the People Living with HIV Stigma Index study. This paper presents the curriculum and main training components, course evaluation results, and challenges and lessons learned. The manuscript was created in collaboration with and includes the perspectives of both the peer researchers involved in the training, as well the course facilitators.

RESULTS

Throughout the course, peer researchers' self-assessed knowledge and understanding of quantitative research and data storytelling improved and, through interactive activities and practice, they gained the confidence to deliver a full research presentation. This improved their understanding of research findings, which was beneficial for discussing results with community partners and study participants. The peer researchers also agreed that learning about integrating lived experience with quantitative data has helped them to make research findings more relatable and convey key messages in a more meaningful way.

CONCLUSIONS

Our training curriculum provides a template for research teams to build capacity in areas of research where peer researchers and community members are less often engaged. In doing so, we continue to uphold the principles of GIPA/MEPA and enhance the translation of research knowledge in communities most greatly affected.

Does resource insecurity drive HIV-related stigma? Associations between food and housing insecurity with HIV-related stigma in cohort of women living with HIV in Canada

INTRODUCTION

Women living with HIV across global contexts are disproportionately impacted by food insecurity and housing insecurity. Food and housing insecurity are resource insecurities associated with poorer health outcomes among people living with HIV. Poverty, a deeply stigmatized phenomenon, is a contributing factor towards food and housing insecurity. HIV-related stigma-the devaluation, mistreatment and constrained access to power and opportunities experienced by people living with HIV-intersects with structural inequities. Few studies, however, have examined food and housing insecurity as drivers of HIV-related stigma. This study aimed to estimate the associations between food and housing insecurity with HIV-related stigma among women living with HIV in Canada.

METHODS

This prospective cohort study of women living with HIV (≥16 years old) in three provinces in Canada involved three waves of surveys collected at 18-month intervals between 2013 and 2018. To understand associations between food and housing security and HIV-related stigma, we conducted linear mixed effects regression models. We adjusted for socio-demographic characteristics associated with HIV-related stigma.

RESULTS AND DISCUSSION

Among participants (n = 1422), more than one-third (n = 509; 36%) reported baseline food insecurity and approximately one-tenth (n = 152, 11%) housing insecurity. Mean HIV-related stigma scores were consistent across waves 1 (mean [M] = 57.2, standard deviation [SD] = 20.0, N = 1401) and 2 (M = 57.4, SD = 19.0, N = 1227) but lower at wave 3 (M = 52.8, SD = 18.7, N = 918). On average, across time, food insecure participants reported HIV-related stigma scores that were 8.6 points higher (95% confidence interval [CI]: 6.4, 10.8) compared with food secure individuals. Similarly, participants reporting insecure housing at wave 1 tended to experience greater HIV-related stigma (6.2 points, 95% CI: 2.7, 9.6) over time compared to stably housed participants. There was an interaction between time and housing insecurity, whereby baseline housing insecurity was no longer associated with higher HIV-related stigma at the third wave.

CONCLUSIONS

Among women living with HIV in Canada, experiencing food and housing insecurity was associated with consistently higher levels of HIV-related stigma. In addition to the urgent need to tackle food and housing insecurity among people living with HIV to optimize wellbeing, getting to the heart of HIV-related stigma requires identifying and dismantling resource insecurity-related stigma drivers.

Intention to Receive a COVID-19 Vaccine by HIV Status Among a Population-Based Sample of Women and Gender Diverse Individuals in British Columbia, Canada

COVID-19 vaccination is recommended for people living with HIV (PLWH), among whom social inequities and co-morbidities may drive risks of COVID-19 infection and outcome severity. Among a provincial (British Columbia) sample, we determined the prevalence of COVID-19 vaccine intention by HIV status and assessed socio-demographic, vaccine hesitancy, and psychological predictors of vaccine intention. Individuals (25-69 years) recruited from province-wide research cohorts and the general public completed an online survey examining COVID-19 impacts (August/2020-March/2021). In an analysis restricted to women and gender diverse participants (n = 5588), we compared intention to receive a recommended COVID-19 vaccine (Very likely/Likely vs Neutral/Unlikely/Very Unlikely) by self-reported HIV status. Logistic regression models assessed the independent effect of HIV status and other factors on COVID-19 vaccine intention. Of 5588 participants, 69 (1.2%) were living with HIV, of whom 79.7% were on antiretroviral therapy. In bivariate analyses, intention to vaccinate was significantly lower among PLWH compared to participants not living with HIV (65.2% vs 79.6%; OR 0.44; 95%CI 0.32-0.60). However, this association was not statistically significant after adjustment for ethnicity, income, education, and essential worker status (aOR 0.85; 95%CI 0.48-1.55). Among PLWH, those with greater vaccine confidence, positive attitudes towards the COVID-19 vaccine, and more strongly influenced by direct and indirect social norms to vaccinate had significantly higher odds of vaccine intention. Tailored messaging is needed to build vaccine confidence, address questions about vaccine benefits, and support informed vaccination decision-making to promote COVID-19 vaccine uptake among women and gender diverse people living with HIV.

Factors and Priorities Influencing Satisfaction with Care among Women Living with HIV in Canada: A Fuzzy Cognitive Mapping Study

Engagement along the HIV care cascade in Canada is lower among women compared to men. We used Fuzzy Cognitive Mapping (FCM), a participatory research method, to identify factors influencing satisfaction with HIV care, their causal pathways, and relative importance from the perspective of women living with HIV. Building from a map of factors derived from a mixed-studies review of the literature, 23 women living with HIV in Canada elaborated ten categories influencing their satisfaction with HIV care. The most central and influential category was “feeling safe and supported by clinics and healthcare providers”, followed by “accessible and coordinated services” and “healthcare provider expertise”. Participants identified factors that captured gendered social and health considerations not previously specified in the literature. These categories included “healthcare that considers women’s unique care needs and social contexts”, “gynecologic and pregnancy care”, and “family and partners included in care.” The findings contribute to our understanding of how gender shapes care needs and priorities among women living with HIV.

Sexual relationship power equity is associated with consistent condom use and fewer experiences of recent violence among women living with HIV in Canada

BACKGROUND

Sexual relationship power (SRP) inequities, including having a controlling partner, have not been widely examined among women living with HIV (WLWH). We measured prevalence, and key outcomes of relationship control among WLWH in Canada.

METHODS

Baseline data from WLWH (≥16 years), reporting consensual sex in the last month enrolled in a Canadian community-collaborative cohort study in British Columbia, Ontario, and Quebec, included Pulerwitz's (2000) SRP relationship control sub-scale. Scale scores were dichotomized into medium/low [score=1-2.82] vs. high relationship control [score=2.82-4], high scores=greater SRP equity. Cronbach's alpha assessed scale reliability. Bivariate analyses compared women with high vs. medium/low relationship control. Crude and adjusted multinomial regression examined associations between relationship control and condom use (consistent [ref], inconsistent, never), any sexual, physical and/or emotional violence, and physical and/or sexual violence (never [ref], recent [≤3 months ago], and previous [>3 months ago]).

RESULTS

Overall, 473 sexually active WLWH (33% of cohort), median age=39 (IQR=33-46), 81% on antiretroviral therapy and 78% with viral loads <50copies/mL were included. The sub-scale demonstrated good reliability (Cronbach's alpha=0.92). WLWH with high relationship control (80%) were more likely (p<0.05) to: be in a relationship; have no children; have greater resilience; and report less socio-structural inequities. In adjusted models, high relationship control was associated with lower odds of: inconsistent vs. consistent condom use (aOR:0.39[95%CI:0.18-0.85]); any recent (aOR:0.14[0.04-0.47]); as well as recent physical and/or sexual (aOR=0.05[0.02,0.17]) but not previous violence (vs. never).

DISCUSSION

Prioritizing relationship equity and support for WLWH is critical for addressing violence and promoting positive health outcomes.

Brief Report: Undertreated Midlife Symptoms for Women Living With HIV Linked to Lack of Menopause Discussions With Care Providers

BACKGROUND

Increasingly, women living with HIV are entering menopause (ie, cessation of menses for ≥1 year) and experiencing midlife symptoms. Menopausal hormone therapy (MHT) is first-line therapy for bothersome hot flashes and early menopause (ie, before age 45 years); however, its use in women living with HIV is poorly described. We conducted a cross-sectional assessment of MHT uptake and barriers to use in this group.

SETTING

This study was conducted across 3 Canadian provinces from 2015 to 2017.

METHODS

Perimenopausal and postmenopausal women living with HIV (35 years or older) in the Canadian HIV Women's Sexual and Reproductive Health Cohort Study who answered questions related to MHT use were included. Univariable/multivariable logistic regression evaluated factors associated with MHT use, adjusted for age and contraindications.

RESULTS

Among 464 women, 47.8% (222 of 464) had a first-line indication for MHT; however, only 11.8% (55 of 464) reported ever using MHT and 5.6% (26 of 464) were current users. Only 44.8% had ever discussed menopause with their care provider despite almost all women having regular HIV care (97.8%). African/Caribbean/Black women had lower unadjusted odds of MHT treatment compared with White women [odds ratio (OR) 0.42 (0.18-0.89); P = 0.034]. Those who had discussed menopause with their care provider had higher odds of treatment [OR 3.13 (1.74-5.86); P < 0.001]. In adjusted analyses, only women having had a menopause discussion remained significantly associated with MHT use [OR 2.97 (1.62-5.61); P < 0.001].

CONCLUSION

Women living with HIV are seldom prescribed MHT despite frequent indication. MHT uptake was associated with care provider-led menopause discussions underscoring the need for care provider education on menopause management within HIV care.

Recent sex work and associations with psychosocial outcomes among women living with HIV: findings from a longitudinal Canadian cohort study

INTRODUCTION

Sex workers are disproportionately impacted by the HIV pandemic across global contexts, in part due to social and structural contexts of stigma and criminalization. Among women living with HIV, there is a dearth of longitudinal information regarding dynamics of sex work engagement and associated social and health outcomes. In order to better understand the social contexts and health needs of sex working women living with HIV, this study aimed to understand recent sex work prevalence and its longitudinal associations with stigma, psychosocial and clinical HIV outcomes among women living with HIV in Canada.

METHODS

We conducted a three-wave prospective cohort survey at 18-month intervals with women living with HIV aged 16 and older in three Canadian provinces between 2013 and 2018. We used generalized estimating equations to examine longitudinal associations between recent (past 6-month) sex work with three types of outcomes: psychosocial (recent violence, recent injection drug use, hazardous alcohol use, clinical depression and post-traumatic stress disorder), clinical HIV (CD4 count and viral load) and stigma (HIV-related stigma, racial discrimination and gender discrimination). Equations were adjusted for socio-demographic factors associated with sex work across all three waves: province, age, income, gender identity, sexual orientation, education level, ethnicity and housing security.

RESULTS AND DISCUSSION

Of 1422 participants, 129 (9.1%) reported recent sex work during at least one wave (82 at baseline, 73 at first follow-up and 32 at second follow-up). In adjusted analyses, recent sex work was associated with psychosocial outcomes, including: past 3-month violence (adjusted odds ratio [AOR] = 2.47, 95% CI = 1.70, 3.60), past 6-month injection drug use (AOR = 3.49, 95% CI = 2.21-5.52), hazardous alcohol use (AOR = 2.00, 95% CI = 1.04-3.89) and depression (AOR = 1.51, 95% CI = 1.06-2.15). In unadjusted analyses, sex work was also associated with clinical HIV outcomes and gender discrimination, but not racial discrimination/HIV-related stigma.

CONCLUSIONS

Among women living with HIV in Canada, sex work engagement is dynamic, and sex workers are more likely to report recent violence, recent injection drug use, problematic alcohol use and clinical depression. Violence prevention and support, harm reduction, mental health promotion and sex work-affirming programs could be employed to optimize health and rights for sex working women living with HIV.

A peer-delivered intervention to reduce harm and improve the well-being of homeless people with problem substance use: the SHARPS feasibility mixed-methods study

BACKGROUND

For people experiencing homelessness and problem substance use, access to appropriate services can be challenging. There is evidence that development of trusting relationships with non-judgemental staff can facilitate service engagement. Peer-delivered approaches show particular promise, but the evidence base is still developing. This study tested the feasibility and acceptability of a peer-delivered intervention, through 'Peer Navigators', to support people who are homeless with problem substance use to address a range of health and social issues.

OBJECTIVES

The study objectives were to design and implement a peer-delivered, relational intervention to reduce harms and improve health/well-being, quality of life and social functioning for people experiencing homelessness and problem substance use, and to conduct a concurrent process evaluation to inform a future randomised controlled trial.

DESIGN

A mixed-methods feasibility study with concurrent process evaluation was conducted, involving qualitative interviews [staff interviews (one time point), n = 12; Peer Navigator interviews (three or four time points), n = 15; intervention participant interviews: first time point, n = 24, and second time point, n = 10], observations and quantitative outcome measures.

SETTING

The intervention was delivered in three outreach services for people who are homeless in Scotland, and three Salvation Army hostels in England; there were two standard care settings: an outreach service in Scotland and a hostel in England.

PARTICIPANTS

Participants were people experiencing homelessness and problem substance use (n = 68) (intervention).

INTERVENTION

This was a peer-delivered, relational intervention drawing on principles of psychologically informed environments, with Peer Navigators providing practical and emotional support.

MAIN OUTCOME MEASURES

Outcomes relating to participants' substance use, participants' physical and mental health needs, and the quality of Peer Navigator relationships were measured via a 'holistic health check', with six questionnaires completed at two time points: a specially created sociodemographic, health and housing status questionnaire; the Patient Health Questionnaire-9 items plus the Generalised Anxiety Disorder-7; the Maudsley Addiction Profile; the Substance Use Recovery Evaluator; the RAND Corporation Short Form survey-36 items; and the Consultation and Relational Empathy Measure.

RESULTS

The Supporting Harm Reduction through Peer Support (SHARPS) study was found to be acceptable to, and feasible for, intervention participants, staff and Peer Navigators. Among participants, there was reduced drug use and an increase in the number of prescriptions for opioid substitution therapy. There were reductions in risky injecting practice and risky sexual behaviour. Participants reported improvements to service engagement and felt more equipped to access services on their own. The lived experience of the Peer Navigators was highlighted as particularly helpful, enabling the development of trusting, authentic and meaningful relationships. The relationship with the Peer Navigator was measured as excellent at baseline and follow-up. Some challenges were experienced in relation to the 'fit' of the intervention within some settings and will inform future studies.

LIMITATIONS

Some participants did not complete the outcome measures, or did not complete both sets, meaning that we do not have baseline and/or follow-up data for all. The standard care data sample sizes make comparison between settings limited.

CONCLUSIONS

A randomised controlled trial is recommended to assess the effectiveness of the Peer Navigator intervention.

FUTURE WORK

A definitive cluster randomised controlled trial should particularly consider setting selection, outcomes and quantitative data collection instruments.

TRIAL REGISTRATION

This trial is registered as ISRCTN15900054.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 14. See the NIHR Journals Library website for further project information.

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.

Key recommendations for developing a national action plan to advance the sexual and reproductive health and rights of women living with HIV in Canada

Action on the World Health Organization Consolidated guideline on sexual and reproductive health and rights of women living with HIV requires evidence-based, equity-oriented, and regionally specific strategies centred on priorities of women living with HIV. Through community–academic partnership, we identified recommendations for developing a national action plan focused on enabling environments that shape sexual and reproductive health and rights by, with, and for women living with HIV in Canada. Between 2017 and 2019, leading Canadian women’s HIV community, research, and clinical organizations partnered with the World Health Organization to convene a webinar series to describe the World Health Organization Consolidated guideline, define sexual and reproductive health and rights priorities in Canada, disseminate Canadian research and best practices in sexual and reproductive health and rights, and demonstrate the importance of community–academic partnerships and meaningful engagement of women living with HIV. Four webinar topics were pursued: (1) Trauma and Violence-Aware Care/Practice; (2) Supporting Safer HIV Disclosure; (3) Reproductive Health, Rights, and Justice; and (4) Resilience, Self-efficacy, and Peer Support. Subsequent in-person (2018) and online (2018–2021) consultation with > 130 key stakeholders further clarified priorities. Consultations yielded five cross-cutting key recommendations:

1. Meaningfully engage women living with HIV across research, policy, and practice aimed at advancing sexual and reproductive health and rights by, with, and for all women.

2. Centre Indigenous women’s priorities, voices, and perspectives.

3. Use language that is actively de-stigmatizing, inclusive, and reflective of women’s strengths and experiences.

4. Strengthen Knowledge Translation efforts to support access to and uptake of contemporary sexual and reproductive health and rights information for all stakeholders.

5. Catalyse reciprocal relationships between evidence and action such that action is guided by research evidence, and research is guided by what is needed for effective action.

Topic-specific sexual and reproductive health and rights recommendations were also identified. Guided by community engagement, recommendations for a national action plan on sexual and reproductive health and rights encourage Canada to enact global leadership by creating enabling environments for the health and healthcare of women living with HIV. Implementation is being pursued through consultations with provincial and national government representatives and policy-makers.

Impact of Canadian human immunodeficiency virus non-disclosure case law on experiences of violence from sexual partners among women living with human immunodeficiency virus in Canada: Implications for sexual rights

OBJECTIVES

People living with human immunodeficiency virus in Canada can face criminal charges for human immunodeficiency virus non-disclosure before sex, unless a condom is used and their viral load is <1500 copies/mL. We measured the reported impact of human immunodeficiency virus non-disclosure case law on violence from sexual partners among women living with human immunodeficiency virus in Canada.

METHODS

We used cross-sectional survey data from wave 3 participant visits (2017-2018) within Canadian HIV Women's Sexual and Reproductive Health Cohort Study; a longitudinal, community-based cohort of women living with human immunodeficiency virus in British Columbia, Ontario and Quebec. Our primary outcome was derived from response to the statement: '[HIV non-disclosure case law has] increased my experiences of verbal/physical/sexual violence from sexual partners'. Participants responding 'strongly agree/agree' were deemed to have experienced increased violence due to the law. Participants responding 'not applicable' (i.e. those without sexual partners) were excluded. Multivariate logistic regression identified factors independently associated with increased violence from sexual partners due to human immunodeficiency virus non-disclosure case law.

RESULTS

We included 619/937 wave 3 participants. Median age was 46 (interquartile range: 39-53) and 86% had experienced verbal/physical/sexual violence in adulthood. Due to concerns about human immunodeficiency virus non-disclosure case law, 37% had chosen not to have sex with a new partner, and 20% had disclosed their human immunodeficiency virus status to sexual partners before a witness. A total of 21% self-reported that human immunodeficiency virus non-disclosure case law had increased their experiences of verbal/physical/sexual violence from sexual partners. In adjusted analyses, women reporting non-White ethnicity (Indigenous; African/Caribbean/Black; Other), unstable housing and high human immunodeficiency virus-related stigma had significantly higher odds of reporting increased violence from sexual partners due to human immunodeficiency virus non-disclosure case law.

CONCLUSION

Findings bolster concerns that human immunodeficiency virus criminalization is a structural driver of intimate partner violence, compromising sexual rights of women living with human immunodeficiency virus. Human immunodeficiency virus non-disclosure case law intersects with other oppressions to regulate women's sexual lives.

Standardized Comparison of Cardiovascular Risk Factors Prevalence in Spanish Women and Men Living with HIV and in the General Population

People living with HIV (PLWH) have an increased risk of cardiovascular (CV) disease, likely due to a higher prevalence of CV risk factors. We compared the age-standardized prevalence and management of CV risk factors in PLWH to that of the general population in Spain. Blood pressure, lipid, glucose, and anthropometric profiles were cross-sectionally compared along with the treatment of hypertension, dyslipidemia, and diabetes in a general population cohort and a PLWH cohort. Prevalence rates were standardized by the direct method by 10-year age groups in European standard populations and stratified by gender. We included 47,593 individuals aged 35 to 74 years, 28,360 from the general population cohort and 19,233 from the PLWH cohort. Compared to the general population, PLWH had a higher concentration of triglycerides (>35 mg/dL in women and >26 mg/dL in men) and a higher prevalence of smoking (>23% and >17%) and diabetes (>9.9% and >8.5%). The prevalence of treated diabetes, hypertension, and dyslipidemia were up to three-fold lower in both women and men living with HIV. There was a significant difference in PLWH compared to the general population in the lipid, glucose, and anthropometric profile. In addition, PLWH were less often treated for diagnosed diabetes, hypertension, and dyslipidemia.

Patterns of changing pregnancy intentions among women living with HIV in Canada

Background

Women with an undetectable viral load can become pregnant and have children with no risk of HIV transmission to their sexual partners and low risk of transmission to their infants. Contemporary pregnancy intentions of women living with HIV in Canada are poorly understood, evidenced by high rates of unintended pregnancy and low uptake of contraceptives.

Methods

We used longitudinal survey data from the Canadian HIV Women’s Sexual and Reproductive Health Cohort Study (CHIWOS) to measure and compare pregnancy intentions (Yes vs No vs Unsure) at baseline, 18-months and 36-months follow-up (from 2013 to 2018) among women living with HIV of reproductive age (16–49 years) and potential. We used Sankey diagrams to depict changes in pregnancy intentions over time and multivariable logistic regression to examine the relationship between pregnancy intention within 2 years and subsequent pregnancy.

Results

At baseline, 41.9% (119/284) of women intended to become pregnant, 43.3% did not, and 14.8% were unsure. Across 36-months of follow-up, 41.9% (119/284) of women changed their pregnancy intentions, with 25% changing from intending to not intending to become pregnant and 13.1% vice versa. Pregnancy intentions were not strongly associated with subsequent pregnancy between baseline and 18-months (aOR 1.44; 95% CI 0.53, 3.72) or between 18 and 36-months (aOR 2.17; 95% CI 0.92, 5.13).

Conclusions

Our findings underscore the need for healthcare providers to engage in ongoing discussions with women living with HIV to support their dynamic pregnancy intentions.

Sex workers as peer researchers - a qualitative investigation of the benefits and challenges

Best practice in sex work research advocates for a 'nothing about us without us' methodology. This study employed sex workers as peer researchers to assist in evaluating the sexual health outcomes and well-being of sex workers in Western Australia. All eight peer researchers were invited to reflect on their experiences as peer researchers through semi-structured interviews, and seven peer researchers participated. Giving sex workers a voice and the opportunity to facilitate change for their peers was the primary driver for participation. Some peer researchers from English speaking backgrounds experienced challenges engaging and communicating with study participants for whom English was not their first language. Others experienced role conflict on hearing viewpoints contrary to their own beliefs. Access to support from the project team and other peer researchers was a key enabler for undertaking the peer researcher role. The majority of peer researchers were motivated to participate in the research by the possibility of future changes to sex work-related legislation, and support for sex workers based on the research findings. Research partnerships with peer researchers that offer employment throughout the research process, including co-authorship of journal articles, opportunities for leadership roles and collaboration in research translation activities can increase research impact.

British Columbia CARMA-CHIWOS Collaboration (BCC3): protocol for a community-collaborative cohort study examining healthy ageing with and for women living with HIV

INTRODUCTION

Women living with HIV (WLWH) experience accelerated ageing and an increased risk of age-associated diseases earlier in life, compared with women without HIV. This is likely due to a combination of viral factors, gender differences, hormonal imbalance and psychosocial and structural conditions. This interdisciplinary cohort study aims to understand how biological, clinical and sociostructural determinants of health interact to modulate healthy ageing in WLWH.

METHODS AND ANALYSIS

The British Columbia Children and Women: AntiRetroviral therapy and Markers of Aging-Canadian HIV Women's Sexual and Reproductive Health Cohort Study (CARMA-CHIWOS) Collaboration (BCC3) study will enrol WLWH (n=350) and sociodemographically matched HIV-negative women (n=350) living in British Columbia. A subset of BCC3 participants will be past participants of CARMA, n≥1000 women and children living with and without HIV, 2008-2018 and/or CHIWOS, n=1422 WLWH, 2013-2018. Over two study visits, we will collect biological specimens for virus serologies, hormones and biological markers as well as administer a survey capturing demographic and sociostructural-behavioural factors. Sociodemographics, comorbidities, number and type of chronic/latent viral infections and hormonal irregularities will be compared between the two groups. Their association with biological markers and psychostructural and sociostructural factors will be investigated through multivariable regression and structural equation modelling. Retrospective longitudinal analyses will be conducted on data from past CARMA/CHIWOS participants. As BCC3 aims to follow participants as they age, this protocol will focus on the first study visits.

ETHICS AND DISSEMINATION

This study has been approved by the University of British Columbia Children's and Women's Research Ethics Board (H19-00896). Results will be shared in peer-reviewed journals, conferences and at community events as well as at www.hivhearme.ca and @HIV_HEAR_me. WLWH are involved in study design, survey creation, participant recruitment, data collection and knowledge translation. A Community Advisory Board will advise the research team throughout the study.

Help-Seeking to Cope With Experiences of Violence Among Women Living With HIV in Canada

Using baseline data from a community-collaborative cohort of women living with HIV in Canada, we assessed the prevalence and correlates of help-seeking among 1,057 women who reported experiencing violence in adulthood (≥16 years). After violence, 447 (42%) sought help, while 610 (58%) did not. Frequently accessed supports included health care providers (n = 313, 70%), family/friends (n = 244, 55%), and non-HIV community organizations (n = 235, 53%). All accessed supports were perceived as helpful. Independent correlates of help-seeking included reporting a previous mental health diagnosis, a history of injection drug use, experiencing childhood violence, and experiencing sexism. We discuss considerations for better supporting women who experience violence.

Discussing reproductive goals with healthcare providers among women living with HIV in Canada: the role of provider gender and patient comfort

Antiretroviral therapy effectively prevents sexual and vertical transmission of HIV. Yet, some women living with HIV report having unmet needs for reproductive health care. This study measured the prevalence of women discussing reproductive goals with any current healthcare provider and assessed the effect of the current HIV care provider's gender on such discussions and whether comfort was a mediator. We analysed baseline and 18-month survey data from 533 women living with HIV enrolled in the Canadian HIV Women's Sexual and Reproductive Health Cohort Study (CHIWOS) (2013-2017), a community-based participatory study, restricting the analysis to participants aged 16-45 years. We used causal mediation analysis to estimate direct and indirect effects of the gender of one's HIV care provider on reproductive discussions, incorporating mediating and interaction effects of women having any provider with whom they felt comfortable discussing reproductive goals. Between the baseline and 18-month follow-up surveys, 34.3% (183/533) of women discussed their reproductive goals with a healthcare provider. Having a woman HIV care provider was associated with a 1.18 excess relative risk (ERR) of discussion (95%CI: 0.15, 2.20). The mediating effect of comfort was primarily explained by the fact that those participants with women providers felt more comfortable discussing their reproductive goals compared to participants with men providers, accounting for 66% (95%CI: 32%, 99%) of the total effect. Findings support that HIV provider gender affects women's comfort and whether they discuss reproductive goals, which must be acknowledged and addressed in care delivery.

Impact of dedicated women's outreach workers (WOWs) on recruitment of women in ACTG clinical studies

BACKGROUND

Despite efforts by the AIDS Clinical Trials Group (ACTG) to enroll representative numbers of diverse women, participation in ACTG studies in the United States remains largely white and male. To address this gap in women's participation in ACTG research, a one-year pilot study of dedicated women's outreach workers (WOWs) was proposed.

OBJECTIVES

included demonstrating that targeted recruitment efforts can expand community awareness of ACTG research and ensuring successful enrollment of women at the respective clinical research sites.

METHODS

The pilot study was conducted at two U.S. sites (Rutgers New Jersey Medical School and Emory Ponce de Leon Center in Atlanta, Georgia). The WOWs worked with site personnel to identify and reach out to women living with HIV and/or Hepatitis B or C at their respective sites and encourage them to join a clinical trial registry for those interested in participating in future clinical trials.

RESULTS

The Rutgers WOW approached 127 potential participants (of whom 100 joined the WOW registry) and screened 35 participants for open ACTG studies. The Emory WOW approached 120 participants, enrolling 86 into the WOW registry, and screened 51 potential participants for open ACTG studies during the WOW's tenure. The majority of women screened at both sites were women of color.

CONCLUSIONS

The WOW study team identified several lessons learned that can inform future efforts to engage women living with HIV in clinical research. First, success in engaging women is proportional to level of funding and institutional support. Second, there is a need for a more gender-inclusive scientific agenda as women are more likely to participate if studies address topics of interest to them. Third, meaningful engagement is a two-way street.

Radical Pleasure: Feminist Digital Storytelling by, with, and for Women Living with HIV

Despite the fact that HIV can be controlled with medication to undetectable levels where it cannot be passed on, stigmatization of women living with HIV persists. Such stigmatization pivots on stereotypes around sex and sexism and has force in women's lives. Our aim was to create an inspirational resource for women living with HIV regarding sex, relationships, and sexuality: www.lifeandlovewithhiv.ca (launched in July 2018). This paper describes the development and mixed-method evaluation of our first year and a half activities. We situated our work within a participatory arts-based knowledge translation planning framework and used multiple data sources (Google Analytics, stories and comments on the website, team reflections over multiple meetings) to report on interim outcomes and impacts. In our first 1.5 years, we recruited and mentored 12 women living with HIV from around the world (Canada, Australia, New Zealand, Kenya, South Africa, Spain, Nigeria, and the U.S.) to write their own stories, with the support of a mentor/editor, as a way of regaining control of HIV narratives and asserting their right to have pleasurable, fulfilling, and safer sexual lives. Writers published 43 stories about pleasure, orgasm, bodies, identities, trauma, resilience, dating, disclosure, self-love, and motherhood. Our social media community grew to 1600, and our website received approximately 300 visits per month, most by women (70%) and people aged 25-44 years (65%), from more than 50 cities globally, with shifts in use and demographics over time. Qualitative data indicated the power of feminist digital storytelling for opportunity, access, validation, and healing, though not without risks. We offer recommendations to others interested in using arts-based digital methods to advance social equity in sexual health.

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).

Collaborative engagement of Hispanic communities in the planning, conducting, and dissemination of assistive technology research

Introduction

Community engagement (CE) is critical for research on the adoption and use of assistive technology (AT) in many populations living in resource-limited environments. Few studies have described the process that was used for engaging communities in AT research, particularly within low-income communities of older Hispanic with disabilities where limited access, culture, and mistrust must be navigated. We aimed to identify effective practices to enhance CE of low-income Hispanic communities in AT research.

Methods

The community stakeholders included community-based organizations, the community healthcare clinic, the local AT project, and residents of the Caño Martín Peña Community in San Juan, Puerto Rico. The CE procedures and activities during the Planning the Study Phase comprised working group meetings with stakeholders to cocreate the funding proposal for the study and address the reviewers' critiques. During the Conducting the Study Phase, we convened a Community Advisory Board to assist in the implementation of the study. During the Disseminating the Study Results Phase, we developed and implemented plans to disseminate the research results.

Results

We identified seven distinct practices to enhance CE in AT research with Hispanic communities: (1) early and continuous input; (2) building trusting and warm relationships through personal connections; (3) establishing and maintaining presence in the community; (4) power sharing; (5) shared language; (6) ongoing mentorship and support to community members; and (7) adapting to the changing needs of the community.

Conclusion

Greater attention to CE practices may improve the effectiveness and sustainability of AT research with low-income communities.

Barriers in accessing HIV care for Francophone African, Caribbean and Black people living with HIV in Canada: a scoping review

INTRODUCTION

In 2001, 50%-55% of French-speaking minority communities did not have access to health services in French in Canada. Although Canada is officially a bilingual country, reports indicate that many healthcare services offered in French in Anglophone provinces are insufficient or substandard, leading to healthcare discrepancies among Canada's minority Francophone communities.

OBJECTIVES

The primary aim of this scoping systematic review was to identify existing gaps in HIV-care delivery to Francophone minorities living with HIV in Canada.

STUDY DESIGN

Scoping systematic review.

DATA SOURCES

Search for studies published between 1990 and November 2019 reporting on health and healthcare in Francophone populations in Canada. Nine databases were searched, including Medline, Cumulative Index to Nursing and Allied Health Literature, the Cochrane Library, the National Health Service Economic Development Database, Global Health, PsychInfo, PubMed, Scopus and Web of Science.

STUDY SELECTION

English or French language studies that include data on French-speaking people with HIV in an Anglophone majority Canadian province.

RESULTS

The literature search resulted in 294 studies. A total of 230 studies were excluded after duplicates were removed. The full texts of 43 potentially relevant papers were retrieved for evaluation and data extraction. Forty-one studies were further excluded based on failure to meet the inclusion criteria leaving two qualitative studies that met our inclusion criteria. These two studies reported on barriers on access to specialised care by Francophone and highlighted difficulties experienced by healthcare professionals in providing quality healthcare to Francophone patients in Ontario and Manitoba.

CONCLUSION

The findings of this scoping systematic review highlight the need for more HIV research on linguistic minority communities and should inform health policymaking and HIV/AIDS community organisations in providing HIV care to Francophone immigrants and Canadians.

Assessing Gaps in Comprehensive HIV Care Across Settings of Care for Women Living with HIV in Canada

Background: Women living with HIV in Canada experience barriers to comprehensive HIV care. We sought to describe care gaps across a typology of care. Methods: We analyzed baseline data from the Canadian HIV Women's Sexual and Reproductive Health Cohort Study (CHIWOS). A typology of care was characterized by primary HIV physician and care setting. Quality-of-care indicators included the following: Pap test, Pap test discussions, reproductive goal discussions, breast cancer screening, antiretroviral therapy (ART) use, adherence, HIV viral load, and viral load discussions. We defined comprehensive care with three indicators: Pap test, viral load, and either reproductive goal discussions over last 3 years or breast cancer screening, as indicated. Multivariable logistic regression analyses measured associations between care types and quality-of-care indicators. Results: Among women living with HIV accessing HIV care, 56.4% (657/1,164) experienced at least one gap in comprehensive care, most commonly reproductive goal discussions. Women accessed care from three types of care: (1) physicians (specialist and family physicians) in HIV clinics (71.6%); (2) specialists in non-HIV clinics (17.6%); and (3) family physicians in non-HIV clinics (10.8%), with 55.5%, 63.9%, and 50.8% gaps in comprehensive care, respectively. Type 3 care had double the odds of not being on ART: adjusted odds ratio (AOR 2.09, 95% confidence interval [CI] 1.16-3.75), while Type 2 care had higher odds of not having discussed the importance of Pap tests (AOR 1.48, 95% CI 1.00-2.21). Discussion: Women continue to experience gaps in care, across types of care, indicating the need to evaluate and strengthen women-centered models of care.

Social Determinants of Health and Retention in HIV Care Among Recently Incarcerated Women Living with HIV in Canada

Women living with HIV (WLWH) are over-represented in corrections in Canada, yet little is known about women's experiences post-release. We used CHIWOS cross-sectional data from WLWH to estimate associations between social determinants of health and HIV-related care outcomes among WLWH with recent (within past year) or ever (before past year) incarceration experience. Lifetime incarceration prevalence was 36.9% (6.5% recent; 30.4% ever), with significant differences by province of residence (British Columbia: 10% recent; 52% ever; Ontario: 5%; 24%; Quebec: 6%; 22%; p < 0.001). In adjusted multinomial logistic regression analyses, compared with never incarcerated, recent incarceration was associated with Indigenous ancestry, lower annual income (< $20,000 CAD), unstable housing, current sex work, injection drug use (IDU), and sub-optimal antiretroviral therapy (ART) adherence, while ever incarceration was associated with current sex work, IDU, and experiencing adulthood violence. Our findings have implications regarding supports needed by WLWH in the post-release period, including ART adherence and achieving health and social goals.

High prevalence of abnormal menstruation among women living with HIV in Canada

Objectives

To measure the prevalence and correlates of abnormal menstruation among women living with HIV (WLWH) in Canada.

Methods

We used cross-sectional questionnaire data from the community-based Canadian HIV Women’s Sexual and Reproductive Health Cohort Study (CHIWOS), which enrolled WLWH aged ≥16 from British Columbia (BC), Ontario, and Quebec. For this analysis, we excluded women >45 years, who had primary amenorrhea, were pregnant, on hormonal contraception, or who reported history of endometrial cancer, last menstrual period >12 months ago, or premature ovarian failure. The primary outcome was abnormal menstruation (Yes vs No) based on responses to five questions about menstrual regularity, frequency, volume, duration, and intermenstrual bleeding in the six months prior to interview. An exploratory multivariable logistic regression analysis examined independent correlates of abnormal menstruation.

Results

Of 1422 women enrolled, 521 (37%) met eligibility criteria. Overall, 55.9% (95% CI:52%-60%) reported abnormal menstruation. In adjusted analyses, abnormal menstruation was associated with having a biologic sister/mother who entered menopause before age 40 (AOR 5.01, 95%CI 1.39–18.03), Hepatitis B co-infection (AOR 6.97, 95%CI 1.52–31.88), current smoking (AOR 1.69, 95%CI 1.55–3.41); and currently taking antiretroviral therapy (ART) (AOR 2.36, 95%CI 1.25–4.45) compared to being ART-naïve. Women in BC had higher adjusted odds of abnormal menstruation (AOR 2.95, 95%CI 1.61–5.39), relative to women in Ontario and Quebec.

Conclusions

Over half of WLWH in this analysis had abnormal menstruation. Correlates of abnormal menstruation include genetic, socio-behavioural factors (province of residence, smoking), Hepatitis B co-infection, and current ART use.

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.