Human rights and the sexual and reproductive health of women living with HIV--a literature review

Methodological issues in qualitative research on HIV prevention: an integrative review

In view of the growing concern about the use of qualitative approach in health research, this article aims to analyze how the qualitative theoretical-methodological framework of HIV prevention is presented in empirical research. We conducted an integrative literature review with the following guiding questions: "How is the qualitative theoretical-methodological framework expressed in empirical research on HIV prevention?"; "What are the limits and potentials of the qualitative methodological designs employed?". In the qualitative methodological discussion, five dimensions guided the methodological course and the presentation of findings, from the analysis of the characterization of qualitative studies to the contextualization of the studies and the methodological approaches used, highlighting the use of semi-structured interviews with thematic content analysis. We also examined social categories and analytical references, drawing attention to the plurality of these theoretical-conceptual references and to the authors' polyphony, and identified the limits and potentials of qualitative research. This study focuses on a scientific topic that is related to a wide variety of social groups and analyzes how they are affected by it, examining issues related to social inequality and other analytical possibilities surrounding HIV prevention, and providing resources for a comprehensive methodological discussion. Hence, avoiding the risk of conducting qualitative research based on checklists that limit inventiveness and openness to different designs and forms of execution and analysis is as pivotal as ensuring that the research is consistent and detailed in publications.

Challenges and opportunities from using abortion harm reduction and value clarification and attitude transformation engagements for safe abortion advocacy in Uganda

BACKGROUND

From 2018, the International Federation of Gynecologists and Obstetricians (FIGO) implemented the Advocating Safe Abortion project to support national obstetrics and gynecology (Obs/gyn) societies from ten member countries to become leaders of Sexual and Reproductive Health and Rights (SRHR). We share experiences and lessons learnt about using value clarification and attitude transformation (VCAT) and abortion harm reduction (AHR) as strategies for our advocacy engagements.

METHODS

The advocacy goal of ending abortion-related deaths followed predefined pathways from an extensive needs assessment prior to the project. These pathways were strengthening capacity of the Obs/gyn society as safe abortion advocates; establishing a vibrant network of partners; transforming social and gender norms; raising awareness of the legal and policy environment regarding abortion, and promoting the generation and use abortion data for evidence-informed policy and practice. Our advocacy targeted multiple stakeholders including media, policy makers judicio-legal, political and religious leaders, health workers and the public.

RESULTS

During each engagement, facilitators required audiences to identify what roles they can play along the continuum of strategies that can reduce maternal death from abortion complications. The audiences acknowledged abortion complications as a major problem in Uganda. Among the root causes for the abortion context, audiences noted absence of an enabling environment for abortion care, which was characterized by low awareness about the abortion laws and policy, restricted abortion laws, cultural and religious beliefs, poor quality of abortion care services and abortion stigma.

CONCLUSION

VCAT and AHR were critical in enabling us to develop appropriate messages for different stakeholders. Audiences were able to recognize the abortion context, distinguish between assumptions, myths and realities surrounding unwanted pregnancy and abortion; recognize imperative to address conflict between personal and professional values, and identify different roles and values which inform empathetic attitudes and behaviors that mitigate abortion harms. The five pathways of the theory of change reinforced each other. Using the AHR model, we delineate strategies and activities which stakeholders could use to end abortion deaths. VCAT enables critical reflection of views, beliefs and values versus professional obligations and responsibilities, and promotes active attitude and behavior change and commitment to end abortion-related deaths.

Availability of Antidotes for Management of Acute Toxicity Cases at Emergency Departments in Qassim Hospitals: A Retrospective Study

Background: Drug overdose is a medico-social issue worldwide that may occur intentionally or unintentionally. It is one of the most common reasons for emergency department visits, and it is also a frequent cause of morbidity and mortality globally. This study aims to determine the occurrence of acute toxicity cases and their management outcomes at the emergency departments in Qassim Province hospitals in Saudi Arabia. In addition, the study aims to investigate the antidote availabilities at those medical centers.

Methods: A retrospective hospital record-based study of acute toxicity cases admitted to the emergency department in hospitals in Qassim during the period from January 1, 2020, to December 31, 2020, was conducted. Data were collected based on hospital resources such as gastrointestinal decontamination, stabilization, elimination enhancement resources, and antidotes from Qassim hospitals, and the availability of antidotes as well as the clinical data of the patients with the management outcome.

Results: A total of 264 patients with acute toxicity were admitted to the emergency departments of 14 hospitals in Qassim Province in 2020. Of the 264 cases, 179 (68%) were males, and 85 (32%) cases were females. Ninety-five percent of the cases were admitted to public hospitals, whereas 5% were admitted to private hospitals. The largest group by age of admitted cases were aged 11-20 years (19.3%). This study showed that 99% received appropriate treatment for their cause of toxicity, whereas 1% did not. The most common causes of toxicity in Qassim were found to be food poisoning (20.5%), followed by intentional suicide attempts with warfarin/enoxaparin/aspirin overdoses (15.9%) and acetaminophen (paracetamol) overdosage seen in 15.5% of admitted cases. Flagyl, in addition to fluids, was used in the management of 16.7% of cases, N-acetyl cysteine was used for 16.3%, and vitamins K and B6 were used for 14.0% of cases. Activated charcoal, atropine, calcium chloride, calcium gluconate, flumazenil, insulin, magnesium, sodium bicarbonate, and vitamin K were available at all the studied hospitals. However, all the hospitals lacked both ethylenediaminetetraacetic acid (EDTA) and a cyanide kit. Methylene blue and leucovorin were available in only one of the studied hospitals.

Reproductive decision-making of Black women living with HIV: A systematic review

Background:

Black women living with HIV account for a higher proportion of new HIV diagnoses than other groups. These women experience restricted access to reproductive services and inadequate support from healthcare providers because their position in society is based on their sexual health and social identity in the context of this stigmatizing chronic disease. By recognizing the analytical relevance of intersectionality, the reproductive decision-making of Black women can be explored as a social phenomenon of society with varied positionality.

Objective:

The purpose of this review was to synthesize the evidence about the reproductive decision-making of Black women living with HIV in high-income countries from the beginning of the HIV epidemic to the present.

Methods:

This systematic review was guided by the JBI evidence synthesis recommendations. Searches were completed in seven databases from 1985 to 2021, and the review protocol was registered with PROSPERO (CRD420180919).

Results:

Of 3503 records, 22 studies were chosen for synthesis, including 19 observational and three qualitative designs. Nearly, all studies originated from the United States; the earliest was reported in 1995. Few studies provided detailed sociodemographic data or subgroup analysis focused on race or ethnicity. Influencing factors for reproductive decision-making were organized into the following seven categories: ethnicity, race, and pregnancy; religion and spirituality; attitudes and beliefs about antiretroviral therapy; supportive people; motherhood and fulfillment; reproductive planning; and health and wellness.

Conclusion:

No major differences were identified in the reproductive decision-making of Black women living with HIV. Even though Black women were the largest group of women living with HIV, no studies reported a subgroup analysis, and few studies detailed sociodemographic information specific to Black women. In the future, institutional review boards should require a subgroup analysis for Black women when they are included as participants in larger studies of women living with HIV.

HIV stigma in the teaching hospitals in Sana'a, Yemen: a conflict and low-resource setting

BACKGROUND

HIV stigma undermines a person's wellbeing and quality of life and hinders HIV control efforts. This study examined the extent and drivers of HIV stigma in the teaching hospitals in Sana'a City, Yemen. The country has low HIV prevalence (4000 (2000-11,000) per 100,000) and limited HIV control funds, worsened by a long conflict and an economic crisis.

METHODS

We conducted a cross-sectional study of 320 Yemeni health professionals in all the four teaching hospitals in Sana'a City. Data were collected anonymously, using an adapted self-completed Arabic version of the Health Policy Project HIV Stigma tool. The questionnaire covered the respondents' background, the stigmatising practices, and potential personal and professional drivers of stigma.

RESULTS

The majority of the participants were: females (68%), 20-39 years old (85%), nurses (84%), and holding a nursing diploma (69%) or a bachelor's degree (27%). None of the hospitals had institutional policies against HIV stigma, and 93% of the participants believed the current infection control measures were inadequate. Less than half of the participants provided care for people living with HIV (PLHIV) (45%), had received HIV training (33%), and were confident that their HIV knowledge was adequate (23%). The majority indicated a preference to test patients for HIV prior to surgical procedures (77%) and disclose positive HIV results to others (99%) without prior knowledge or consent. All the participants had exhibited a form of HIV-related stigmatization, such as avoiding physical contact with PLHIV (87%) or wearing gloves throughout the consultation (96.5%). These practices were significantly correlated with the fear of infection, high perceived risk of infection, and poor work environment (p < 0.05).

CONCLUSION

PLHIV face widespread stigmatizing behaviour in the teaching hospitals in Sana'a City, consistent with the higher level of stigma in low HIV prevalence countries and its links to the fear of infection, poor HIV knowledge, and limited funding for HIV control. Stigma reduction interventions are required at institutional and individual levels. In addition, anti-discrimination policies and structural adjustments are needed, in combination with training on HIV and universal precautions, and action to tackle negative attitudes towards PLHIV and key populations.

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.

Motherhood and decision-making among women living with HIV in developed countries: a systematic review with qualitative research synthesis

BACKGROUND

Women living with HIV (WLH) lack evidence-based information about reproductive options while managing pressures from family, clinicians, and communities to give up the idea of having children. As the reproduction intentions of WLH are not well understood, stigmatizing behaviors force them to hide their disease to avoid rejection by their family, partner, and social networks. Compliance with social norms, fear of stigma, and discrimination influence their experience. Current research is individual qualitative studies lacking the synthesis perspective necessary to guide intervention development. The purpose of this study was to synthesize the evidence to explain the reproductive decision-making process for WLH in developed countries.

METHODS

A systematic review with qualitative research synthesis was conducted through searches in 10 electronic databases (CINAHL, EMBASE, MEDLINE, Scopus, Social Science Citation Index, Web of Science, Google Scholar, Cuidatge, Cuiden Enfispo, and SciELO). Studies published in journals from 1995 to 2019 with qualitative data about reproductive decision-making among WLH in developed countries were eligible for inclusion. Developed country was operationalized by membership in the OECD for comparative conditions of social wellbeing and economic stability. The CASP and JBI checklists for qualitative research were used to assess study quality and methodological integrity. Thematic analysis and qualitative meta-summary techniques were used for the synthesis.

RESULTS

Twenty studies from 12 developed countries were included in the synthesis. Findings were organized into 3 meta-themes from 15 themes and 45 subthemes, including: (1) Shattered identity, (2) Barriers, inequities, and misinformation, (3) Coping, resiliency, and support. Reproductive decision-making was perceived as a complex process influenced by facilitators and barriers. The facilitators helped WLH cope with their new situation to become more resilient, while the barriers made their situation more difficult to manage.

CONCLUSION

WLH encounter reproductive decision-making with knowledge deficits and limited social support. An integrated approach to holistic care with comprehensive multidisciplinary counseling is needed to support WLH. Clinicians could benefit from professional development to learn how to be authentically present for WLH, including engaging in conversations, demonstrating compassion, and understanding situations. Evidence-based clinical practice guidelines need to be tailored for the family planning and sexual health needs of WLH.

Community Mobilization to Promote and Protect the Sexual and Reproductive Rights of Women Living with HIV in Latin America

Between 2009 and 2014, the International Community of Women Living with HIV in Latin America and the Mexican feminist civil society organization Balance coordinated a five-country community-led intervention that brought together women living with HIV (WLHIV), trans women, sex workers, and feminist lawyers to document and respond to sexual and reproductive health and rights (SRHR) violations of WLHIV and advocate for legal, policy, and programmatic changes to fulfill SRHR. The experiences of involved community leaders (n=26) indicate that knowledge of national, regional, and international human rights commitments and up-to-date medical information positively influenced personal health behaviors, empowered WLHIV as subject matter experts, and emboldened them to hold duty-bearers to account. The research evidence generated through collective action was critical for legitimating SRHR violations of WLHIV with decision-makers and for positioning the issue in the advocacy agendas of national and regional HIV and women's movements. Collective action contributed to social cohesion among diverse groups of women living with and affected by HIV and increased available technical, financial, and organizational resources and political opportunities by linking organizations and networks. Collectively, community leaders mobilized to influence policy, legal frameworks, and service delivery to promote and protect the SRHR of WLHIV.

A snapshot of reproductive and sexual health and rights of women living with HIV in Asia

OBJECTIVE

A brief review of status of sexual and reproductive health and rights of women living with human immunodeficiency virus (HIV) in Asia with a focus on their access to related services.

SUBJECT(S) AND METHODS

The content has primarily emerged from several meetings, workshops and research studies that regional networks of women living with HIV have conducted in the region. We used published and unpublished literature in English after the year 2000.

RESULTS

We found many hindrances to realization of sexual and reproductive rights by HIV-positive women and their access to related health services. Rampant stigma and discrimination by service providers take the form of denial of contraceptive and maternal health services, forced sterilization, breach of confidentiality and disclosure of status to others without the consent of the woman. Families blaming women for bringing HIV and male partners objecting to using condoms affect the well-being of HIV-positive women. Sexual rights specifically aspects of positive sexuality such as sexual pleasure have not received attention.

CONCLUSION

Findings suggest the need to enhance capacities of HIV-positive women's organizations to meaningfully participate in decisions on positive women's sexual, reproductive health and rights and sensitize service providers to adequately address HIV-positive women's concerns.

Discussing Reproductive Plans with Healthcare Providers by Sexually Active Women Living with HIV in Western Ethiopia

Discussing reproductive plans with healthcare providers by women living with HIV (WLHIV) can assist in promoting safe reproductive health practices, but little research has been undertaken in this area. A cross-sectional survey was conducted in western Ethiopia in 2018 among 475 sexually active WLHIV. One hundred and twenty seven (26.8%) participants reported becoming pregnant in the last 5 years after being aware of their HIV-positive status; 33.6% reported their intention to have children in the future, and 26.9% were ambivalent about having children. WLHIV who reported general and personalized discussions of reproductive plans with healthcare providers were 30.7% and 16.8%, respectively. Unmarried sexually active women and WLHIV accessing health centers for antiretroviral therapy (ART) were less likely to report both general and personalized discussions than married women and women who accessed ART through hospitals, respectively. WLHIV are both having and intending to have children, highlighting discussions with healthcare providers can deliver support that reduces the risk of vertical and horizontal HIV transmission.

Social Determinants of Breastfeeding Preferences among Black Mothers Living with HIV in Two North American Cities

The study is motivated by the need to understand the social determinants of breastfeeding attitudes among HIV-positive African, Caribbean, and Black (ACB) mothers. To address the central issue identified in this study, analysis was conducted with datasets from two North American cities, where unique country-specific guidelines complicate infant feeding discourse, decisions, and practices for HIV-positive mothers. These national infant feeding guidelines in Canada and the US present a source of conflict and tension for ACB mothers as they try to navigate the spaces between contradictory cultural expectations and national guidelines. Analyses in this paper were drawn from a broader mixed methods study guided by a community-based participatory research (CBPR) approach to examine infant feeding practices among HIV-positive Black mothers in three countries. The survey were distributed through Qualtrics and SPSS was used for data cleaning and analysis. Results revealed a direct correlation between social determinants and breastfeeding attitude. Country of residence, relatives' opinion, healthcare providers' advice and HIV-related stigma had statistically significant association with breastfeeding attitude. While the two countries' guidelines, which recommend exclusive formula feeding, are cardinal in preventing vertical transmission, they can also be a source of stress. We recommend due consideration of the cultural contexts of women's lives in infant feeding guidelines, to ensure inclusion of diverse women.

Examining Multilevel Factors Associated with the Process of Resilience among Women Living with HIV in a Large Canadian Cohort Study: A Structural Equation Modeling Approach

Objectives:

We examined how multiple, nested, and interacting systems impact the protective process of resilience for women living with HIV (WLWH).

Methods:

Using data from a Cohort Study, we conducted univariate analyses, multivariable logistic regression, and a 2-step structural equation modeling for the outcome, high resilience (N = 1422).

Results:

Participants reported high overall resilience scores with a mean of 62.2 (standard deviation = 8.1) and median of 64 (interquartile range = 59-69). The odds of having high resilience were greater for those residing in Quebec compared to Ontario (adjusted odds ratio [aOR] = 2.1 [1.6, 2.9]) and British Columbia (aOR = 1.8 [1.3, 2.5]). Transgender women had increased odds of high resilience than cisgender women (aOR = 1.9 [1.0, 3.6]). There were higher odds of resilience for those without mental health diagnoses (aOR = 2.4 [1.9, 3.0]), non-binge drinkers (aOR=1.5 [1.1, 2.1]), and not currently versus previously injecting drugs (aOR = 3.6 [2.1, 5.9]). Structural equation modeling confirmed that factors influencing resilience lie at multiple levels: micro, meso, exo, and macro systems of influence.

Conclusion:

There is a need to consider resilience as the interaction between the person and their environments, informing the development of multilevel interventions to support resilience among WLWH.

Prevalence of institutional delivery and its correlates amongst women of reproductive age in Mozambique: a cross-sectional analysis

Background

The healthcare system in Mozambique is striving to reduce the high maternal and child mortality rates and stay on par with the Sustainable Development Goals (SDG 3.1). A key strategy to curb maternal and child mortality is to promote the use of professional childbirth services proven to be highly effective in averting maternal deaths. Currently, little is known about the use of childbirth services in Mozambique. The present study investigated the prevalence of professional healthcare delivery services and identified their sociodemographic correlates.

Methods

This study used cross-sectional data on 7080 women aged 15–49 years who reported having a child during the past 5 years. The data were collected from the 2011Mozambique Demographic and Health Survey. The outcome variables were the choice of childbirth services that included 1) place of delivery (respondent’s home versus health facility), and mode of delivery (caesarean section versus vaginal birth). Data were analyzed using descriptive and multivariate regression methods.

Results

The prevalence of health facility and C-section delivery was 70.7 and 5.6%, respectively. There was a difference in the use of professional birthing services between urban and rural areas. Having better educational status and living in households of higher wealth quintiles showed a positive association with the use of facility delivery services among both urban and rural residents. Regarding ethnicity, women of Portugais [2.688,1.540,4.692], Cindau [1.876,1.423,2.474] and Xichangana [1.557,1.215,1.996] had relatively higher odds of using facility delivery services than others. Antenatal care (ANC) visits were a significant predictor of facility delivery services both in urban [OR = 1.655, 95%CI = 1.235,2.218] and rural [OR = 1.265, 95%CI = 1.108,1.445] areas. Among rural women, ANC visit was a significant predictor of C-section delivery [1.570,1.042,2.365].

Conclusion

More than a quarter of the women in Mozambique were not using health facility delivery services, with the prevalence being noticeably lower in the rural areas.

Program implementation gaps and ethical issues in the prevention of HIV infection among infants, children, and adolescents in sub-Saharan Africa

Strategies for HIV prevention among infants, children, and adolescents have evolved significantly over the past 20 years. These include the global scale-up of simplified multidrug HIV regimens for pregnant women, leading to impressive reductions in new child HIV infections. However, significant gaps remain, especially in high HIV-burden sub-Saharan African countries. For example, many pregnant women living with HIV (WLHIV) are unable to access and sustain HIV testing and treatment partly due to low agency and harmful gender norms. Among pregnant WLHIV, adolescent girls face an additional layer of societal and health-system barriers in accessing care for themselves and their exposed infants. Legal and structural barriers limit access to HIV prevention-related sexual and reproductive health services among high-risk adolescents, including girls and young men who have sex with men. Key ethical issues underlying HIV prevention gaps for infants, children, and adolescents prevail. This narrative review explores these issues and highlights counter-measures for programming and policy, including gender empowerment, improving access to and appropriateness of critical health services, rights-based policy and legislation, closing research gaps, and considering the values and preferences of young people for HIV prevention and treatment services.

Accessibility and availability of assistant reproductive technology for people living with HIV in Europe: a thematic literature review

As antiretroviral therapies have transformed HIV into a manageable chronic disease, many individuals have or will choose to have children, and the use of assisted reproductive technology can serve as an effective risk-reducing strategy. In this thematic literature review, we examine the state of research on access to and availability of assisted reproductive health technologies for people living with HIV in Europe, with the aim of identifying gaps for further research. We find that the existing literature is focused on serodiscordant couples consisting of an HIV-positive man and an HIV-negative women. This is in part because more treatment options are available for men living with HIV than women, reflecting underlying gender discrimination in treatment. The existing scholarship largely ignores reproductive options for seroconcordant couples or single individuals, or for men and women with underlying infertility. Finally, very little research addresses the question of financial affordability, which is a known barrier to infertility treatment.

Unintended Pregnancy in Women Living with HIV in Sub-Saharan Africa: A Systematic Review and Meta-analysis

In 2014, about 1.5 million pregnancies occurred among HIV-positive women in low and middle-income countries. To pool magnitude and factors associated with unintended pregnancy in women living with HIV in sub-Saharan Africa, a systematic search of electronic databases was undertaken in November 2016. Pooling the magnitude of unintended pregnancy reported by 14 studies yielded a crude summary prevalence of 55.9%. The magnitude of unwanted pregnancy and mistimed pregnancy in six studies ranged from 14 to 59 and 9 to 47.2%, respectively. Contraceptive failure was an important factor for many unintended pregnancies. The magnitude of unintended pregnancy was significantly higher in HIV-positive women than for HIV-negative women in three out of six studies. The available evidence suggests that there is a high magnitude of unintended pregnancy in this population. Improving effective contraceptive utilization is thus a priority to address unintended pregnancies and to prevent mother to child transmission of HIV. PROSPERO Number: CRD42016051310.

Exploring social ecological pathways from resilience to quality of life among women living with HIV in Canada

Resilience, positive growth in contexts of stress and adversity, is shaped by social ecological factors. Among people living with HIV, resilience is associated with myriad positive health benefits and improved health-related quality of life (HR-QoL). Identifying contextual factors associated with resilience among women living with HIV (WLWH) is particularly important as this population experiences many stressors and inequalities. We examined social-ecological factors associated with resilience and its relationship with HR-QoL among WLWH. We utilized baseline survey data from a national cohort of WLWH (n = 1424) in Canada. We conducted structural equation modelling using maximum likelihood estimation methods to test the direct effects of social support and women-centred HIV care (WCHC) on resilience, and the direct effects of resilience on mental and physical HR-QoL. We also tested the indirect effects of resilience on HR-QoL via HIV disclosure concerns and economic insecurity. Participant median age was 43 years (IQR = 35-50); most participants were women of colour (29% Black; 22% Indigenous; 7% other ethnicities; 41% Caucasian). Social support and WCHC were associated with increased resilience. The direct path from resilience to mental HR-QoL was significant, accounting for the mediation effects of economic insecurity and social support. The direct path from resilience to physical HR-QoL was significant, accounting for the mediation effects of economic insecurity. Economic insecurity partially mediated the relationship between resilience and mental HR-QoL and physical HR-QoL. HIV disclosure concerns partially mediated the relationship between resilience and mental-HR-QoL. Model fit indices suggested that the model fit the data well (χ2[14] = 160.378, P < 0.001; CFI = 0.987; RMSE = 0.048 [90% CI:0.042-0.080]; SRMR = 0.036). Findings suggest social (social support) and structural (WCHC) factors increase resilience. While resilience is associated with improved HR-QoL, social (HIV disclosure concerns) and structural (economic insecurity) factors partially mediate these associations and threaten HR-QoL. Multi-level interventions can address social ecological contexts to advance resilience and HR-QoL among WLWH.

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.

Societal attitudes toward sexual and reproductive rights of HIV-positive women in Iran: A nation-wide web-based survey

The aim of the researchers was to assess the community attitudes toward sexual and reproductive rights of women living with HIV (WLWH) in Iran. A descriptive cross-sectional study was conducted. A national web-based survey was used. A substantial portion of the respondents with a mean percentage of 68.5 ± 13.66 hold negative attitudes toward sexual and reproductive rights of WLWH. Being a female, having a 25-34 age and being a graduate and above were independent predictors of positive attitudes toward sexual and reproductive rights of WLWH. WLWH are faced with discriminatory attitudes in respect of their rights of childbearing and sexuality.

Condomless Sex Among Virally Suppressed Women With HIV With Regular HIV-Serodiscordant Sexual Partners in the Era of Treatment as Prevention

BACKGROUND

Sexual HIV transmission does not occur with sustained undetectable viral load (VL) on antiretroviral therapy (ART). Awareness of ART prevention benefits and its influence on condom use among women with HIV (WWH) remain unexplored. We estimated prevalence and correlates of condomless sex with regular HIV-serodiscordant partners among WWH with undetectable VL on ART.

METHODS

We used baseline questionnaire data from the community-based longitudinal Canadian HIV Women's Sexual and Reproductive Health Cohort Study (CHIWOS). We included WWH self-reporting vaginal/anal sex with ≥1 HIV-negative/unknown status regular partner within 6 months, and undetectable VL (<50 copies/mL) on ART. We excluded participants exclusively reporting female partners or missing condom-use data. Condomless sex was defined as <100% condom use within 6 months. The primary explanatory variable was awareness of ART prevention benefits. Logistic regression identified factors independently associated with condomless sex.

RESULTS

Of 271 participants (19% of the CHIWOS cohort), median age was 41 (interquartile range: 34-47), 51% were in a relationship, 55% reported condomless sex, and 75% were aware of ART prevention benefits. Among women aware, 63% reported condomless sex compared with 32% of women not aware (P < 0.001). Factors independently associated with condomless sex included being aware of ART prevention benefits (adjusted odds ratio: 4.08; 95% confidence interval: 2.04 to 8.16), white ethnicity, ≥high-school education, residing in British Columbia, and being in a relationship.

CONCLUSIONS

Virally suppressed women aware of ART prevention benefits had 4-fold greater odds of condomless sex. Advancing safer sex discussions beyond condoms is critical to support women in regular serodiscordant partnerships to realize options for safe and satisfying sexuality in the Treatment-as-Prevention era.

In Women's Eyes: Key Barriers to Women's Access to HIV Treatment and a Rights-Based Approach to their Sustained Well-Being

There is rightly a huge global effort to enable women living with HIV to have long productive lives, through treatment access. However, many women living with HIV experience violence against women (VAW), in both domestic and health care settings. The ways in which VAW might prevent treatment access and adherence for women has not to date been reviewed coherently at the global level, from women's own perspectives. Meanwhile, funding for global health care, including HIV treatment, is shrinking. To optimize women's health and know how best to optimize facilitators and minimize barriers to access and adherence, especially in this shrinking funding context, we need to understand more about these issues from women's own perspectives. In response, we conducted a three-phase review: (1) a literature review (phase one); (2) focus group discussions and interviews with nearly 200 women living with HIV from 17 countries (phase two); and (3) three country case studies (phase three). The results presented here are based predominantly on women's own experiences and are coherent across all three phases. Recommendations are proposed regarding laws, policies, and programs which are rights-based, gendered, and embrace diversity, to maximize women's voluntary, informed, confidential, and safe access to and adherence to medication, and optimize their long-term sexual and reproductive health.

Brief Report: Sexual Violence Against HIV-Positive Women in the Nyanza Region of Kenya: Is Condom Negotiation an Instigator?

For people living with HIV, exposure to sexual violence (SV) is associated with decreased adherence to antiretroviral medication, a primary predictor of their survival. Identification of risk factors for SV is a pressing issue in sub-Saharan Africa, where the global majority of HIV-positive women live and the prevalence of SV against women is high. We used qualitative data to examine SV against HIV-positive women enrolled in HIV care in Kenya. Respondents identified husbands as perpetrators of SV in the context of women's efforts to use condoms as directed by HIV care providers.

Using GRADE as a framework to guide research on the sexual and reproductive health and rights (SRHR) of women living with HIV - methodological opportunities and challenges

In March 2016, WHO reviewed evidence to develop global recommendations on the sexual and reproductive health and rights (SRHR) of women living with HIV. Systematic reviews and a global survey of women living with HIV informed the guideline development decision-making process. New recommendations covered abortion, Caesarean section, safe disclosure, and empowerment and self-efficacy interventions. Identification of key research gaps is part of the WHO guidelines development process, but consistent methods to do so are lacking. Our method aimed to ensure consistency and comprised the systematic application of a framework based on GRADE (Grading of Recommendations, Assessment, Development and Evaluation) to the process. The framework incorporates the strength and quality rating of recommendations and the priorities reported by women in the survey to inform research prioritisation. For each gap, we also articulated: (1) the most appropriate and robust study design to answer the question; (2) alternative pragmatic designs if the ideal design is not feasible; and (3) the methodological challenges facing researchers through identifying potential biases. We found 12 research gaps and identified five appropriate study designs to address the related questions: (1) Cross-sectional surveys; (2) Qualitative interview-driven studies; (3) Registries; (4) Randomised controlled trials; and (5) Medical record audit. Methodological challenges included selection, recruitment, misclassification, measurement and contextual biases, and confounding. In conclusion, a framework based on GRADE can provide a systematic approach to identifying research gaps from a WHO guideline. Incorporation of the priorities of women living with HIV into the framework systematically ensures that women living with HIV can shape future policy decisions affecting their lives. Implementation science and participatory research are appropriate over-arching approaches to enhance uptake of interventions and to ensure inclusion of women living with HIV at all stages of the research process.

How Are Gender Equality and Human Rights Interventions Included in Sexual and Reproductive Health Programmes and Policies: A Systematic Review of Existing Research Foci and Gaps

The importance of promoting gender equality and human rights in sexual and reproductive health (SRH) programmes and policies has been affirmed in numerous international and regional agreements, most recently the 2030 Agenda for Sustainable Development. Given the critical role of research to determine what works, we aimed to identify research gaps as part of a broader priority setting exercise on integrating gender equality and human rights approaches in SRH programmes and policies. A systematic literature review of reviews was conducted to examine the question: what do we know about how research in the context of SRH programmes and policies has addressed gender equality and human rights and what are the current gaps in research. We searched three databases for reviews that addressed the research question, were published between 1994–2014, and met methodological standards for systematic reviews, qualitative meta-syntheses and other reviews of relevance to the research question. Additional grey literature was identified based on expert input. Articles were appraised by the primary author and examined by an expert panel. An abstraction and thematic analysis process was used to synthesize findings. Of the 3,073 abstracts identified, 56 articles were reviewed in full and 23 were included along with 10 from the grey literature. The majority focused on interventions addressing gender inequalities; very few reviews explicitly included human rights based interventions. Across both topics, weak study designs and use of intermediate outcome measures limited evidence quality. Further, there was limited evidence on interventions that addressed marginalized groups. Better quality studies, longer-term indicators, and measurement of unintended consequences are needed to better understand the impact of these types of interventions on SRH outcomes. Further efforts are needed to cover research on gender equality and human rights issues as they pertain to a broader set of SRH topics and populations.

Advancing the sexual and reproductive health and human rights of women living with HIV

INTRODUCTION

Many women living with HIV can have safe, healthy and satisfying sexual and reproductive health, but there is still a long way to go for this to be a reality, especially for the most vulnerable amongst them who face repeated violations of their rights.

DISCUSSION

The contributions in this Supplement from researchers, clinicians, programme managers, policy makers, and women living with HIV demands an important appreciation that the field of sexual and reproductive health and human rights for women living with HIV is complex on many levels, and women living with HIV form a very diverse community.

CONCLUSIONS

The manuscripts emphasize that attention must be paid to the following critical dimensions: 1) Placing human rights and gender equality at the centre of a comprehensive approach to health programming, in particular in relation to sexuality and sexual health; 2) Ensuring health systems responsiveness to minimizing inequalities in access to health care and quality of care that often do not meet the needs of women living with HIV; 3) Engaging and empowering women living with HIV in the development of policies and programmes that affect them; and 4) Strengthening monitoring, evaluation and accountability procedures to provide good quality data and ensuring remedies for violations of health and human rights of women living with HIV.