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.

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).

Prevalence and Correlates of Forced Sex as a Self-Reported Mode of HIV Acquisition Among a Cohort of Women Living With HIV in Canada

Gender-based violence (GBV) is a global epidemic associated with increased HIV exposure. We assessed the prevalence and correlates of HIV acquisition via forced sex among women living with HIV (WLWH) in Canada. Baseline questionnaire data were analyzed for WLWH (≥16 years) with data on self-reported mode of HIV acquisition, enrolled in a community-based cohort study in British Columbia, Ontario, and Québec. We assessed forced sex (childhood, adulthood) as a self-reported mode of HIV acquisition. Of 1,330 participants, the median age was 42 (interquartile range [IQR] = 35-50) years; 23.5% were Indigenous, 26.3% African/Caribbean/Black, 43% White, and 7.2% of Other ethnicities. Forced sex was the third dominant mode of HIV transmission at 16.5% (n = 219; vs. 51.6% consensual sex, 19.7% sharing needles, 5.3% blood transfusion, 3.8% perinatal, 1.3% contaminated needles, 0.4% other, 1.6% do not know/prefer not to answer). In multivariable analyses, significant correlates of HIV acquisition from forced versus consensual sex included legal status as a landed immigrant (adjusted odds ratio [aOR] = 1.99; 95% confidence interval [CI] = [1.12, 3.54]) or refugee (aOR = 3.62; 95% CI = [1.63, 8.04]) versus Canadian citizen; African/Caribbean/Black ethnicity versus Caucasian (aOR = 2.49; 95% CI = [1.43, 4.35]), posttraumatic stress disorder symptoms (aOR = 3.00; 95% CI = [1.68, 5.38]), histories of group home residence (aOR = 2.40; 95% CI = [1.10, 5.23]), foster care (aOR = 2.18; 95% CI = [1.10, 4.34]), and having one child relative to having three or more children (aOR = 0.52; 95% CI = [0.31, 0.89]). GBV must be considered a distinct HIV risk factor; forced sex is a significant underrecognized risk factor and mode of women's HIV acquistion. Public health reporting systems can separate consensual and forced sex in reporting modes of HIV acquisition. Practitioners can engage in screening practices to meet client needs.

Codesigning care improvements for women living with HIV: a patient-oriented deliberative dialogue workshop in Montréal, Quebec

BACKGROUND

Care services have not been sufficiently adapted to meet the comprehensive care needs of women living with HIV. Our study objective was to engage patients and providers in codesigning care recommendations to improve care for this population in the province of Quebec.

METHODS

We conducted a 5-hour deliberative dialogue workshop in April 2019 in Montréal as the final phase of a mixed-methods study investigating comprehensive care for women living with HIV. The study drew on data from the Canadian HIV Women's Sexual and Reproductive Health Cohort Study (CHIWOS). Recruitment was guided by a purposive maximum-variation sampling strategy to ensure an appropriate mix of participants and was facilitated by our existing CHIWOS networks. Participants included patients (women living with HIV) and HIV care providers (doctors, nurses, pharmacists). The workshop was facilitated professionally and included a synthesis of the evidence, small- and large-group deliberations, and voting on care improvements.

RESULTS

Eight patients and 8 HIV care providers participated. Drawing on identified care priorities, the participants identified 4 relatively rapid care improvements and 3 longer-term improvements. The rapid care improvements included delegating medical acts to members of multidisciplinary care teams; greater involvement of HIV community members within care settings and health care decision-making; creating a women's health information booklet; and increasing HIV education among all health care providers and raising awareness of women's care needs beyond HIV-specific care among HIV care providers. The longer-term care improvements included advocating for complete financial coverage of antiretroviral therapy within the government-sponsored Medicare program, facilitating access to allied care providers (e.g., physiotherapists and psychologists) and launching a population-wide campaign to increase awareness about the Undetectable = Untransmittable (U=U) initiative and other HIV advances.

INTERPRETATION

The deliberative dialogue workshop yielded evidence-based, stakeholder-driven recommendations to improve the comprehensive care of women living with HIV in Quebec.

Transition from Pediatric to Adult HIV Care for Young Women Living with HIV

Transitioning from pediatric to adult care is a complicated process for youth with chronic illnesses. This study elucidates the unique factors affecting transition preparedness and perception of adult HIV care among a cohort of young women with HIV. Between 2013 and 2015, 48 women with HIV, who had experience with pediatric HIV care, were enrolled in a large Canadian cohort study. Variables were self-reported during peer-administered surveys. Only 60% reported feeling prepared for transition. Having never had contact with child protection services (P = .049), never been in foster care (P = .011), never been in a group home (P = .036), reporting a higher current CD4 count (P = .033), and reporting a younger ideal age for transition (P = .041) were associated with transition preparedness. Eighty-four percent reported equivalent or better HIV care following transition. Correlates of equivalent/better care following transition included lower personal income (P = .023), higher CD4 count (P = .021), care by an adult infectious diseases specialist (P = .002), and transition preparedness (P = .005). Our findings highlight the importance of adequate transition preparation and its effect on perception of care following transition.

Strategies for Recruiting Women Living with Human Immunodeficiency Virus in Community-Based Research: Lessons from Canada

OBJECTIVES

This study sought to describe the recruitment of women living with HIV (WLWH) into the community-based Canadian HIV Women's Sexual and Reproductive Health Cohort Study (CHIWOS), because women are under-represented in HIV research.

METHODS

There were 1,424 WLWH were enrolled from British Columbia, Ontario, and Québec, who completed detailed questionnaires administered by peer research associates (PRAs; WLWH with research training). During screening, participants were asked: "How did you hear about the study?" We describe recruitment strategies by subpopulation and offer reflections on challenges and successes.

RESULTS

Of 1,131 participants with complete data, 40% identified as White, 33% African/Caribbean/Black, and 19% Indigenous. The median age was 45 years (interquartile range, 37-51) and 4% identified as trans women. Overall, 35% were recruited through PRAs/peers, 34% clinics, and 19% AIDS service organizations (ASOs). PRAs/peers were the predominant recruitment method in Ontario (49%), compared with clinics in British Columbia (40%), and Québec (43%). Nationally, PRAs/peers were more successful in recruiting WLWH commonly considered to be "harder to reach" (e.g., women identifying as trans, using drugs, not receiving HIV care). Clinics were more effective in recruiting younger women (16-29 years) and women not using ASOs. Recruitment challenges centered on engaging these harder to reach women. Successes included hiring PRAs who built participant trust, linking with clinics to reach women isolated from HIV communities, involving outreach workers to engage street-involved women, and disseminating study information to diverse stakeholders.

CONCLUSIONS

Having multiple approaches, engaging a diverse team of PRAs, ensuring flexibility, and cultivating reciprocal relationships with community stakeholders were key to recruiting a diverse and representative sample of WLWH.

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

BACKGROUND

A community-based research (CBR) approach is critical to redressing the exclusion of women-particularly, traditionally marginalized women including those who use substances-from HIV research participation and benefit. However, few studies have articulated their process of involving and engaging peers, particularly within large-scale cohort studies of women living with HIV where gender, cultural and linguistic diversity, HIV stigma, substance use experience, and power inequities must be navigated.

METHODS

Through our work on the Canadian HIV Women's Sexual and Reproductive Health Cohort Study (CHIWOS), Canada's largest community-collaborative longitudinal cohort of women living with HIV (n = 1422), we developed a comprehensive, regionally tailored approach for hiring, training, and supporting women living with HIV as Peer Research Associates (PRAs). To reflect the diversity of women with HIV in Canada, we initially hired 37 PRAs from British Columbia, Ontario, and Quebec, prioritizing women historically under-represented in research, including women who use or have used illicit drugs, and women living with HIV of other social identities including Indigenous, racialized, LGBTQ2S, and sex work communities, noting important points of intersection between these groups.

RESULTS

Building on PRAs' lived experience, research capacity was supported through a comprehensive, multi-phase, and evidence-based experiential training curriculum, with mentorship and support opportunities provided at various stages of the study. Challenges included the following: being responsive to PRAs' diversity; ensuring PRAs' health, well-being, safety, and confidentiality; supporting PRAs to navigate shifting roles in their community; and ensuring sufficient time and resources for the translation of materials between English and French. Opportunities included the following: mutual capacity building of PRAs and researchers; community-informed approaches to study the processes and challenges; enhanced recruitment of harder-to-reach populations; and stronger community partnerships facilitating advocacy and action on findings.

CONCLUSIONS

Community-collaborative studies are key to increasing the relevance and impact potential of research. For women living with HIV to participate in and benefit from HIV research, studies must foster inclusive, flexible, safe, and reciprocal approaches to PRA engagement, employment, and training tailored to regional contexts and women's lives. Recommendations for best practice are offered.

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

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

Cervical cancer screening among women living with HIV: a cross-sectional study using the baseline questionnaire data from the Canadian HIV Women's Sexual and Reproductive Health Cohort Study (CHIWOS)

BACKGROUND

Cisgender women with HIV experience an elevated risk of cervical cancer compared with HIV-negative women, but this cancer can be prevented through regular cervical cancer screening. Our study objective was to measure adherence to current national cervical cancer screening guidelines among women with HIV in 3 Canadian provinces and identify factors associated with delays.

METHODS

We conducted a cross-sectional study using the baseline questionnaire of the Canadian HIV Women's Sexual and Reproductive Health Cohort Study (CHIWOS). Participants were recruited through clinics, peers and community organizations in British Columbia, Ontario and Quebec. Women were eligible for inclusion if they were cisgender female with HIV, aged 21-70 years, and never had cervicectomy/hysterectomy.

RESULTS

Of 1189 eligible participants, 815 (68.5%) had received cervical cancer screening less than 1 year ago (i.e., as recommended), 211 (17.7%) 1-3 years ago (i.e., moderate delay) and 163 (13.7%) at least 3 years ago or never (i.e., long delay). Overall, 309 (26.0%) had never discussed the need for a Papanicolaou smear with a nurse/doctor. Factors associated with a long delay were living in Ontario (adjusted odds ratio [OR] 2.51, 95% confidence interval [CI] 1.29-4.88) or Quebec (adjusted OR 3.70, 95% CI 1.79-7.67) (v. BC), being sexually inactive in the past 6 months (adjusted OR 2.02, 95% CI 1.25-3.25), having unknown or < 200 cells/mm³ CD4 counts (adjusted OR 1.78, 95% CI 1.11-2.85) and having a male HIV care provider (adjusted OR 2.15, 95% CI 1.36-3.42).

INTERPRETATION

Over one-third of women reported cervical cancer screening delays, and one-quarter had never discussed cervical cancer screening recommendations with a health care provider. Additional efforts are needed to improve women's and health care providers' awareness of cervical cancer screening recommendations, particularly among women who are sexually inactive, who are immunosuppressed and who have male HIV care providers.

Previous experiences of pregnancy and early motherhood among women living with HIV: a latent class analysis

Previous maternity experiences may influence subsequent reproductive intentions and motherhood experiences. We used latent class analysis to identify patterns of early motherhood experience reported for the most recent live birth of 905 women living with HIV enrolled in the Canadian HIV Women's Sexual and Reproductive Health Cohort Study (CHIWOS). Four indicators were used: difficulties getting pregnant, feelings when finding out pregnancy, feelings during pregnancy, and feelings during the first year postpartum. Most (70.8%) pregnancies analyzed occurred before HIV diagnosis. A four-class maternity experience model was selected: "overall positive experience" (40%); "positive experience with postpartum challenges" (23%); "overall mixed experience" (14%); and "overall negative experience" (23%). Women represented in the "overall negative experience" class were more likely to be younger at delivery, to not know the HIV status of their pregnancy partner, and to report previous pregnancy termination. Women represented in the "positive experience with postpartum challenges" class were more likely to report previous miscarriage, stillbirth or ectopic pregnancy. We found no associations between timing of HIV diagnosis (before, during or after pregnancy) and experience patterns. Recognition of the different patterns of experiences can help providers offer a more adapted approach to reproductive counseling of women with HIV.

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

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

Geographic differences in the experiences of HIV-related stigma for women living with HIV in northern and rural communities of Ontario, Canada

INTRODUCTION

In Canada, individuals living in northern and rural regions report more barriers to health service access. For people living with HIV, these barriers may be exacerbated by experiences of HIV-related stigma, and women living with HIV can be disproportionately affected because of intersections of multiple forms of oppression, including racism, sexism and classism. To further understand the impact of geography on the wellbeing of women living with HIV, this study assessed geographic differences in HIV-related stigma experiences among women in the Canadian HIV Women's Sexual & Reproductive Health Cohort Study (CHIWOS).

METHODS

CHIWOS is a multisite cohort study of women living with HIV in Canada that operates under community-based participatory research methodology along with GIPA (greater involvement of people with HIV/AIDS) and MIWA (meaningful involvement of women living with HIV/AIDS) principles. This analysis compared peer research associate-administered questionnaire data between participants in northern and southern Ontario, Canada, and between participants in rural and non-rural Ontario. Northern regions were defined by healthcare delivery jurisdiction. The primary outcome was the 10-item shortened HIV Stigma Scale score. Multivariable linear regression models assessed the association between rural and northern regions and stigma score.

RESULTS

Sixteen women were excluded due to incomplete HIV Stigma Scale data. Of 701 women included in the analysis, 66 (9.4%) were from northern regions and 24 (3.4%) were from rural regions. Mean stigma scores were 23.9 (standard deviation (SD) 8.0) overall, 26.7 (SD 8.8) in northern regions, 23.6 (SD 7.9) in southern regions, 28.3 (SD 10.1) in rural regions, and 23.8 (SD 7.8) in non-rural regions. In multivariable analyses, northern and rural regions of residence were associated with a 3.05 (95% confidence interval (CI): 0.77, 5.32) and 4.83 (95% CI: 1.37, 8.28) point increase in stigma score, respectively.

CONCLUSIONS

Living in both northern and rural regions of Ontario was associated with higher HIV Stigma Scale scores. These geographic discrepancies in experiences of HIV-related stigma highlight the need for region-specific programs to reduce HIV-related stigma and to support people living with HIV who are affected by HIV-related stigma, particularly those living in geographically isolated regions. Prior qualitative studies have documented the important impact of HIV-related stigma, and this study supports these observations with quantitative data from a population that is often under-represented in HIV research.

Cohort profile: The Canadian HIV Women's Sexual and Reproductive Health Cohort Study (CHIWOS)

Globally, women are at increased vulnerability to HIV due to biological, social, structural, and political reasons. Women living with HIV also experience unique issues related to their medical and social healthcare, which makes a clinical care model specific to their needs worthy of exploration. Furthermore, there is a dearth of research specific to women living with HIV. Research for this population has often been narrowly focused on pregnancy-related issues without considering their complex structural inequalities, social roles, and healthcare and biological needs. For these reasons, we have come together, as researchers, clinicians and community members in Canada, to develop the Canadian HIV Women's Sexual and Reproductive Health Cohort Study (CHIWOS) to investigate the concept of women-centred HIV care (WCHC) and its impact on the overall, HIV, women's, mental, sexual, and reproductive health outcomes of women living with HIV. Here, we present the CHIWOS cohort profile, which describes the cohort and presents preliminary findings related to perceived WCHC. CHIWOS is a prospective, observational cohort study of women living with HIV in British Columbia (BC), Ontario, and Quebec. Two additional Canadian provinces, Saskatchewan and Manitoba, will join the cohort in 2018. Using community-based research principles, CHIWOS engages women living with HIV throughout the entire research process meeting the requirements of the 'Greater Involvement of People living with HIV/AIDS'. Study data are collected through an interviewer-administered questionnaire that uses a web-based platform. From August 2013 to May 2015, a total of 1422 women living with HIV in BC, Ontario, and Quebec were enrolled and completed the baseline visit. Follow-up interviews are being conducted at 18-month intervals. Of the 1422 participants at baseline, 356 were from BC (25%), 713 from Ontario (50%), 353 from Quebec (25%). The median age of the participants at baseline was 43 years (range, 16-74). 22% identified as Indigenous, 30% as African, Caribbean or Black, 41% as Caucasian/White, and 7% as other ethnicities. Overall, 83% of women were taking antiretroviral therapy at the time of the baseline interview and of them, 87% reported an undetectable viral load. Of the 1326 women who received HIV medical care in the previous year and responded to corresponding questions, 57% (95% CI: 54%-60%) perceived that the care they received from their primary HIV doctor had been women-centred. There were provincial and age differences among women who indicated that they received WCHC versus not; women from BC or Ontario were more likely to report WCHC compared to participants in Quebec. They were also more likely to be younger. CHIWOS will be an important tool to develop care models specific for women living with HIV. Moreover, CHIWOS is collecting extensive information on socio-demographics, social determinants of health, psychological factors, and sexual and reproductive health and offers an important platform to answer many relevant research questions for and with women living with HIV. Information on the cohort can be found on the study website (http://www.chiwos.ca).

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

We measured health-related quality of life (HRQOL) using the SF-12 among women living with HIV (WLWH) in Canada between August 2013 and May 2015. We investigated differences by perceived receipt of women-centered HIV care (WCHC), assessed using an evidence-based definition with a 5-point Likert item: "Overall, I think that the care I have received from my HIV clinic in the last year has been women-centered" (dichotomized into agree vs. disagree/neutral). Of 1308 participants, 26.3 percent were from British Columbia, 48.2 percent from Ontario, and 25.5 percent from Québec. The median age was 43 years (interquartile range = 36-51). Most (42.2 percent) were White, 29.4 percent African/Caribbean/Black, and 21.0 percent Indigenous. Overall, 53.4 percent perceived having received WCHC. Mean physical and mental HRQOL scores were 43.8 (standard deviation [SD] = 14.4) and 41.7 (SD = 14.2), respectively. Women perceiving having received WCHC had higher mean physical (44.7; SD = 14.0) and mental (43.7; SD = 14.1) HRQOL scores than those not perceiving having received WCHC (42.9; SD = 14.8 and 39.5; SD = 14.0, respectively; p < .001). In multivariable linear regression, perceived WCHC was associated with higher mental (β = 3.48; 95 percent confidence interval: 1.90, 5.06) but not physical HRQOL. Improving HRQOL among Canadian WLWH, which was lower than general population estimates, is needed, including examining the potential of WCHC as an effective model of clinical care.

Establishing the Canadian HIV Women's Sexual and Reproductive Health Cohort Study (CHIWOS): Operationalizing Community-based Research in a Large National Quantitative Study

Background

Community-based research has gained increasing recognition in health research over the last two decades. Such participatory research approaches are lauded for their ability to anchor research in lived experiences, ensuring cultural appropriateness, accessing local knowledge, reaching marginalized communities, building capacity, and facilitating research-to-action. While having these positive attributes, the community-based health research literature is predominantly composed of small projects, using qualitative methods, and set within geographically limited communities. Its use in larger health studies, including clinical trials and cohorts, is limited. We present the Canadian HIV Women’s Sexual and Reproductive Health Cohort Study (CHIWOS), a large-scale, multi-site, national, longitudinal quantitative study that has operationalized community-based research in all steps of the research process. Successes, challenges and further considerations are offered.

Discussion

Through the integration of community-based research principles, we have been successful in: facilitating a two-year long formative phase for this study; developing a novel survey instrument with national involvement; training 39 Peer Research Associates (PRAs); offering ongoing comprehensive support to PRAs; and engaging in an ongoing iterative community-based research process. Our community-based research approach within CHIWOS demanded that we be cognizant of challenges managing a large national team, inherent power imbalances and challenges with communication, compensation and volunteering considerations, and extensive delays in institutional processes. It is important to consider the iterative nature of community-based research and to work through tensions that emerge given the diverse perspectives of numerous team members.

Conclusions

Community-based research, as an approach to large-scale quantitative health research projects, is an increasingly viable methodological option. Community-based research has several advantages that go hand-in-hand with its obstacles. We offer guidance on implementing this approach, such that the process can be better planned and result in success.

Sexual inactivity and sexual satisfaction among women living with HIV in Canada in the context of growing social, legal and public health surveillance

INTRODUCTION

Women represent nearly one-quarter of the 71,300 people living with HIV in Canada. Within a context of widespread HIV-related stigma and discrimination and on-going risks to HIV disclosure, little is known about the influence of growing social, legal and public health surveillance of HIV on sexual activity and satisfaction of women living with HIV (WLWH).

METHODS

We analyzed baseline cross-sectional survey data for WLWH (≥16 years, self-identifying as women) enrolled in the Canadian HIV Women's Sexual and Reproductive Health Cohort Study (CHIWOS), a multisite, longitudinal, community-based research study in British Columbia (BC), Ontario (ON) and Quebec (QC). Sexual inactivity was defined as no consensual sex (oral or penetrative) in the prior six months, excluding recently postpartum women (≤6 months). Satisfaction was assessed using an item from the Sexual Satisfaction Scale for Women. Multivariable logistic regression analysis examined independent correlates of sexual inactivity.

RESULTS

Of 1213 participants (26% BC, 50% ON, 24% QC), median age was 43 years (IQR: 35, 50). 23% identified as Aboriginal, 28% as African, Caribbean and Black, 41% as White and 8% as other ethnicities. Heterosexual orientation was reported by 87% of participants and LGBTQ by 13%. In total, 82% were currently taking antiretroviral therapy (ART), and 77% reported an undetectable viral load (VL<40 copies/mL). Overall, 49% were sexually inactive and 64% reported being satisfied with their current sex lives, including 49% of sexually inactive and 79% of sexually active women (p<0.001). Sexually inactive women had significantly higher odds of being older (AOR=1.06 per year increase; 95% CI=1.05-1.08), not being in a marital or committed relationship (AOR=4.34; 95% CI=3.13-5.88), having an annual household income below $20,000 CAD (AOR: 1.44; 95% CI=1.08-1.92), and reporting high (vs. low) HIV-related stigma (AOR=1.81; 95% CI=1.09-3.03). No independent association was found with ART use or undetectable VL.

CONCLUSIONS

Approximately half of WLWH in this study reported being sexually inactive. Associations with sexual dissatisfaction and high HIV-related stigma suggest that WLWH face challenges navigating healthy and satisfying sexual lives, despite good HIV treatment outcomes. As half of sexually inactive women reported being satisfied with their sex lives, additional research is required to determine whether WLWH are deliberately choosing abstinence as a means of resisting surveillance and disclosure expectations associated with sexual activity. Findings underscore a need for interventions to de-stigmatize HIV, support safe disclosure and re-appropriate the sexual rights of WLWH.

Barriers to health-care and psychological distress among mothers living with HIV in Quebec (Canada)

Health-care providers play a major role in providing good quality care and in preventing psychological distress among mothers living with HIV (MLHIV). The objectives of this study are to explore the impact of health-care services and satisfaction with care providers on psychological distress in MLHIV. One hundred MLHIV were recruited from community and clinical settings in the province of Quebec (Canada). Prevalence estimation of clinical psychological distress and univariate and multivariable logistic regression models were performed to predict clinical psychological distress. Forty-five percent of the participants reported clinical psychological distress. In the multivariable regression, the following variables were significantly associated with psychological distress while controlling for sociodemographic variables: resilience, quality of communication with the care providers, resources, and HIV disclosure concerns. The multivariate results support the key role of personal, structural, and medical resources in understanding psychological distress among MLHIV. Interventions that can support the psychological health of MLHIV are discussed.

Bifurcations biographiques : l’expérience du dévoilement du diagnostic du point de vue d’adolescents infectés par le VIH en période périnatale

Dans le cas de la transmission de la mère à l’enfant du VIH, l’un des principaux enjeux concerne le dévoilement du diagnostic aux jeunes infectés (Champion et al., 1999; Murphy et al., 2002; Wiener et al., 2007), qui pourrait être vécu comme un point de bifurcation biographique. L’objectif est d’explorer l’expérience du dévoilement du diagnostic du point de vue d’adolescents vivant avec le VIH depuis la naissance. Vingt-neuf jeunes (10-18 ans) VIH+ ont accordé une entrevue individuelle semi-dirigée portant sur le dévoilement du statut sérologique. Les données recueillies ont fait l’objet d’une analyse de contenu (Paillé et Mucchielli, 2005; Sabourin, 2008). Le dévoilement du statut sérologique s’inscrit dans une trajectoire en trois temps : 1) une réalité cachée où les adolescents ignorent leur statut sérologique; 2) une réalité enfin dévoilée où ils apprennent, vers l’âge de 11 ans, qu’ils sont infectés par le VIH et; 3) une réalité à intégrer progressivement où le dévoilement participe à leur construction identitaire personnelle et sociale. Le dévoilement s’inscrit dans une continuité biographique en légitimant les traitements ARV reçus alors qu’une transformation progressive semble être envisagée par les jeunes quant à leur intimité et leur sexualité.

Family quality of life in families affected by HIV: the perspective of HIV-positive mothers

The HIV infection of a family member can impact family quality of life (FQoL). The objectives of this study are to (1) describe patterns of FQoL among mothers living with HIV (MLHIV) and (2) identify key factors associated with FQoL in families affected by HIV. Recruitment took place in HIV-specialized clinics and community organizations. A 100 MLHIV and 67 of their children participated in this study. Mothers were on average 40.8 years old and reported having an average of two dependent children at home (M = 2.1, SD = 1.0). Participating children were 16.2 years old, on average. Half of the children were boys (50.8%). More than half were aware of their mother's positive HIV status (68.2%) and 19.7% were diagnosed with HIV. All HIV-positive children were aware of their status. A latent profile analysis was performed on the five continuous indicators of FQoL, and three main profiles of self-reported FQoL among MLHIV were established: high FQoL (33%), moderate FQoL (58%), and low FQoL (9%). Among the mothers' characteristics, education, physical functioning, social support, and resilience increased FQoL, while anxiety and irritability decreased FQoL. Among the children's characteristics, resilience followed the FQoL profile. A trend was observed toward children's greater awareness of the mother's HIV status in high and low FQoL profiles. Additionally, irritability tended to be higher within the lower FQoL profile. FQoL profiles can be used to identify families needing special care, particularly for family interventions with both parents and children. Other relevant indicators must be studied (e.g., closeness and support between family members, availability and accessibility of care, family structure, father-child relationships, and medical condition of the mother) and longitudinal research conducted to estimate the direction of causality between FQoL profile and individual family member characteristics.

[Not Available]

OBJECTIVE

Studies targeting children born with HIV have principally focused on the period preceding the announcement of the diagnosis to the child. The objective of the present study was to explore intrafamilial communication dynamics following the announcement of the diagnosis.

METHODOLOGY

Twenty-nine youths (10 to 18 years of age) living with HIV since birth participated in individual semistructured interviews about the following: 1) serostatus disclosure, 2) family relations and 3) sexual education within the family. The testimonials underwent a content analysis.

RESULTS

The youths learned of their HIV-positive diagnosis at the average age of 11 years. The dynamic established after the announcement appears to be regulated by silence: the exchanges that follow mainly involve questions related to medication and prevention of sexual transmission of the virus. This silence preserves the familial equilibrium by performing three functions: protecting the mother from a feeling of guilt regarding transmission, assuring family harmony and feeling normal compared with others. The adolescent's diagnosis is generally not revealed to the extended family, thus preserving their integration within the family by protecting them from rejection, betrayal and judgement.

DISCUSSION

The functions of silence and the secret serve as important stabilizers within the family. However, they contribute to the isolation of the adolescents in the form of emotional support that they still need. Suggestions for intervention are presented.