Sexual Orientation Differences in Health and Wellbeing Among Women Living with HIV in Canada: Findings from a National Cohort Study

Brief Report: Social Factors Associated With Trajectories of HIV-Related Stigma and Everyday Discrimination Among Women Living With HIV in Vancouver, Canada: Longitudinal Cohort Findings

INTRODUCTION

Women living with HIV (WLHIV) experience stigma rooted in social inequities. We examined associations between social factors (food insecurity, housing insecurity, violence, sexual minority identity, and substance use) and HIV-related stigma and Everyday Discrimination trajectories among WLHIV.

METHODS

This community-based open longitudinal cohort study with WLHIV living in and/or accessing HIV care in Metro Vancouver, Canada, plotted semiannual averages (2015-2019) of recent (past 6-month) HIV-related stigma and Everyday Discrimination. We examined distinct trajectories of HIV-related stigma and Everyday Discrimination using latent class growth analysis (LCGA) and baseline correlates of each trajectory using multinomial logistic regression.

FINDINGS

Among participants (HIV-related stigma sample: n = 197 participants with n = 985 observations; Everyday Discrimination sample: n = 203 participants with n = 1096 observations), LCGA identified 2 distinct HIV-related stigma and Everyday Discrimination trajectories: sustained low and consistently high. In multivariable analysis, concurrent food and housing insecurity (adjusted odds ratio [AOR]: 2.15, 95% confidence interval [CI] 1.12-4.12) and physical/sexual violence (AOR: 2.57, 95% CI: 1.22-5.42) were associated with higher odds of the consistently high (vs. sustained low) HIV-related stigma trajectory. Sexual minority identity (AOR: 2.84, 95% CI: 1.49-5.45), concurrent food and housing insecurity (AOR: 2.65, 95% CI: 1.38-5.08), and noninjection substance use (less than daily vs. none) (AOR: 2.04, 95% CI: 1.03-4.07) were associated with higher odds of the consistently high (vs. sustained low) Everyday Discrimination trajectory.

CONCLUSIONS

Social inequities were associated with consistently high HIV-related stigma and Everyday Discrimination among WLHIV. Multilevel strategies can address violence, economic insecurity, intersecting stigma, and discrimination to optimize health and rights among WLHIV.

Structural racism and violence: Routine healthcare access in a cohort of marginalized Indigenous women and Two-Spirit Peoples during the COVID-19 Pandemic

Objectives

Historical and ongoing colonial violence, racism, discrimination, criminalization, and intergenerational trauma continues to impact the health of Indigenous women (cisgender and transgender) and Two-Spirit Peoples. Previous and ongoing work clearly articulate the deeply harmful roles of colonialism and racism in continuing to systemically exclude Indigenous Peoples from accessing equitable and culturally safe healthcare. While the COVID-19 pandemic has amplified structural inequities, little attention has been paid to how the pandemic impacts healthcare access for Indigenous women and Two-Spirit Peoples living in urban settings. The aim of this study was to evaluate factors associated with experiencing difficulty accessing routine healthcare in a cohort of marginalized urban Indigenous women and Two-Spirit Peoples on the ancestral, occupied territories of the Musqueam, Squamish and Tsleil-Waututh Nations in what is now referred to as Metro Vancouver, Canada during the COVID-19 pandemic.

Methods

Data were drawn from AMPLIFY, a study of Indigenous cis and trans women and Two-Spirit Peoples in Metro Vancouver. Analyses drew on baseline and semi-annual questionnaire data collected with sex workers and women living with HIV from October 2020-August 2021. We used bivariate and multivariable logistic regression with generalized estimating equations (GEE) to model correlates of experiencing difficulty accessing a family doctor, nurse, or clinic for routine healthcare during the COVID-19 pandemic in the last 6-months.

Results

Amongst 142 marginalized Indigenous women and Two-Spirit Peoples (199 observations), 27.5% reported difficulty accessing routine healthcare. In multivariable GEE logistic regression, participants who had ever been pregnant (AOR:4.71, 95% CI:1.33-16.66) experienced negative changes in psychological and emotional well-being (AOR: 3.99, 95% CI: 1.33-11.98), lacked access to culturally safe health services (AOR:4.67, 95% CI:1.43-15.25), and had concerns regarding safety or violence in their community (AOR:2.72, 95% CI:1.06-6.94) had higher odds of experiencing recent difficulty accessing routine healthcare.

Discussion

Findings are in line with the BC Commissioned In Plain Sight report which recommends the need for accessible, culturally safe, anti-racist, and trauma-informed routine healthcare for marginalized Indigenous cisgender and transgender women and Two-Spirit Peoples during the current and future pandemics. More community-based research is needed to understand access needs for culturally safe routine healthcare amongst marginalized Indigenous cisgender and transgender women and Two-Spirit Peoples.

Resilience during the COVID-19 pandemic among people living with HIV: A cross-sectional study

BACKGROUND

This study aims to investigate the factors shaping resilience during the COVID-19 pandemic among people living with HIV (PLWH).

METHODS

A total of 341 participants were included in this cross-sectional study. The online survey included scales of resilience, depression & anxiety, loneliness, social support, COVID-19 fear, stress, and sociodemographic information.

RESULTS

Logistic regression test results showed loneliness (OR = 2.548, 95% CI = 1.251, 5.189), social support (OR = 2.217, 95% CI = 1.148, 4.279), income (OR = 2.581, 95% CI = 1.217, 5.472), sexual orientation (OR = 2.707, 95% CI = 1.004, 7.300), age (OR = 1.044, 95% CI = 1.006, 1.083) and COVID-19 fear (OR = 0.891, 95% CI = 0.840, 0.944) were statistically significant factors associated with resilience among PLWH.

CONCLUSION

In conclusion, reducing COVID-19 fear by providing the correct information about the COVID-19 pandemic, fortifying the level of social support satisfaction, as well as minimising the level of loneliness have the potential to improve psychological resilience among PLWH.

Access to and quality of care for sexual and gender minority women living with HIV in Metro Vancouver, Canada: Results from a longitudinal cohort study

BACKGROUND

While scarce, literature suggests that women at the intersection of HIV status and gender and/or sexual minority identities experience heightened social and health disparities within health care systems.

OBJECTIVES

This study examines the association between sexual and/or gender minority identities and: (1) experiences of poor treatment by health professionals and (2) being unable to access health services among a cohort of women living with HIV in Metro Vancouver, Canada.

DESIGN

Data were drawn from a longitudinal community-based cohort of women living with HIV (Sexual Health and HIV/AIDS Women's Longitudinal Needs Assessment).

METHODS

We examined associations between sexual and/or gender minority identities and the two outcomes. We drew on explanatory variables to measure sexual minority and gender minority identities independently and a combined variable measuring sexual and/or gender minority identities. The associations between each of these three variables and each outcome were analysed using bivariate and multivariable logistic regression models with generalized estimating equations for repeated measures over time. Adjusted odds ratios and 95% confidence intervals are reported.

RESULTS

The study sample included 1460 observations on 315 participants over 4.5 years (September 2014 to February 2019). Overall, 125 (39.7%) reported poor treatment by health professionals and 102 (32.4%) reported being unable to access health care services when needed at least once over the study period. A total of 110 (34.9%) of participants reported sexual and/or gender minority identities, 106 (33.7%) reporting sexual minority identities, with 29 (9.2%) reporting gender minority identities. In multivariable analysis, adjusting for confounders, sexual minority identities, and combined sexual and/or gender minority identities were significantly associated with increased odds of experiencing poor treatment by health professionals (sexual minority adjusted odds ratio = 1.39 (0.94-2.05); sexual and/or gender minority adjusted odds ratio = 1.48 (1.00-2.18)) and being unable to access health services (sexual minority adjusted odds ratio = 1.89 (1.20-2.97); sexual and/or gender minority adjusted odds ratio = 1.91 (1.23-2.98)). In multivariable analysis, gender minority identities were not significantly associated with increased odds of experiencing poor treatment by health professionals (gender minority adjusted odds ratio = 1.38; 95% CI = 0.76-2.52) and being unable to access health services (gender minority adjusted odds ratio = 1.72; 95% CI = 0.89-3.31) possibly due to low sample size among women with gender minority identities.

CONCLUSION

Our findings suggest the need for access to inclusive, affirming, trauma-informed health care services tailored specifically for and by women living with HIV with sexual and/or gender minority identities.

Violence, policing, and systemic racism as structural barriers to substance use treatment amongst women sex workers who use drugs: Findings of a community-based cohort in Vancouver, Canada (2010-2019)

BACKGROUND

Despite a high prevalence of substance use among women sex workers (SWs), rigorous social epidemiologic data on substance use treatment experiences among SWs remains limited. Given these gaps and the disproportionate burden of criminalization borne by Indigenous SWs, we evaluated (1) structural correlates of unsuccessful attempts to access substance use treatment; and (2) the interaction between policing and Indigenous ancestry on unsuccessful attempts to access treatment among SWs who use drugs.

METHODS

Prospective data were from an open community-based cohort of women SWs (2010-2019) in Vancouver, Canada. Bivariate and multivariable logistic regression with generalized estimating equations(GEE) assessed correlates of unsuccessful attempts to access treatment. A multivariable GEE confounder model examined the interaction between Indigenous ancestry and policing on unsuccessful attempts to access treatment.

RESULTS

Amongst 645 SWs who used drugs, 32.1 % reported unsuccessful attempts to access substance use treatment during the 9.5-year study. In multivariable GEE analysis, unsuccessful substance use treatment access was associated with identifying as a sexual/gender minority (AOR: 1.90, 95 %CI:1.37-2.63), opioid use (AOR: 1.43, 95 %CI: 1.07-1.91), and exposure to homelessness (AOR: 1.72; 95 %CI:1.33-2.21), police harassment (AOR: 1.48, 95 %CI:1.03-2.13), workplace violence (AOR: 1.80, 95 %CI: 1.31-2.49) and intimate partner violence (AOR: 2.11, 95 %CI:1.50-2.97). In interaction analysis, Indigenous SWs who experienced police harassment faced the highest odds of unsuccessful attempts to access substance use treatment (AOR: 2.59, 95 %CI:1.65-4.05).

CONCLUSION

Findings suggest a need to scale-up culturally-safe, trauma-informed addictions, gender-based violence, and sex worker services, alongside dismantling of systemic racism across and beyond health and addictions services.

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.

Health of two-spirit, lesbian, gay, bisexual and transgender people experiencing poverty in Canada: a review

Two-spirit, lesbian, gay, bisexual and transgender (2SLGBTQ+) people are disproportionately represented among those experiencing poverty. Both 2SLGBTQ+ people and people experiencing poverty face poorer health outcomes and greater difficulty accessing healthcare. Evidence of intersectional impacts of 2SLGBTQ+ status and poverty on health can help to inform economic and health policy. The objective of this review is to determine what is known about the health of 2SLGBTQ+ people in Canada experiencing poverty. Following the PRISMA framework, we searched and summarized Canadian literature on 2SLGBTQ+ poverty indexed in Medline, Sociological Abstracts, PsycInfo and EconList (N = 33). 2SLGBTQ+ poverty-related literature remains sparse but is expanding as illustrated by the fact that most (31/33) studies were published in the past decade. Half the studies analysed poverty as a focal variable and half as a covariate. Intersectionality theory assists in understanding the three health-related themes identified-healthcare access, physical health and mental health and substance use-as these outcomes are shaped by intersecting social structures that result in unique forms of discrimination. Those at the intersection of poverty and 2SLGBTQ+ status face poorer health outcomes than other 2SLGBTQ+ people in Canada. Discrimination was an overarching finding that explained persistent associations between 2SLGBTQ+ status, poverty and health. Research that directly interrogated the experiences of 2SLGBTQ+ populations experiencing poverty was sparse. In particular, there is a need to conduct research on underrepresented 2SLGBTQ+ sub-groups who are disproportionately impacted by poverty, including transgender, bisexual and two-spirit populations.

Prevalence and Correlates of HIV Stigma Among Women Living with HIV in Metro Vancouver, Canada

This study elucidated the prevalence and correlates of four types of HIV stigma among women living with HIV (WLWH). Data were drawn from 2 years (September 1/15 to August 31/17) of follow-up from a longitudinal community-based open cohort of 215 cisgender or transgender WLWH who lived and/or accessed care in Metro Vancouver, Canada (2014-present). Bivariate and multivariable cumulative logistic regression using generalized estimating equations for repeated measures were used to examine correlates of HIV stigma, including: (1) anticipated; (2) enacted; (3) internalized; and (4) perceived stigma. In multivariable analysis, disclosure of HIV status without consent was significantly associated with heightened: anticipated; enacted; and perceived stigma. Verbal and/or physical violence related to HIV status was significantly associated with heightened enacted, internalized and perceived stigma. Negative physical effects/symptoms of HIV was significantly associated with all stigma outcomes. Results suggest a need to support safe disclosure of HIV status and address social and structural violence against WLWH.

Socioeconomic Status and Psychosocial Resources Mediate Racial/Ethnic Differences in Psychological Health Among Gay and Bisexual Men: A Longitudinal Analysis Using Structural Equation Modeling

A large body of research demonstrates disparities in psychological health attributed to sexual minority identity, racial/ethnic minority identity, and socioeconomic status (SES). Fewer studies have explicated the role of these multiple attributes on psychological health and explored the role of SES and psychosocial resources in determining outcomes. We analyzed data from Project STRIDE, a longitudinal survey involving a diverse sample of gay and bisexual adult men (n = 198). Using structural equation modeling, we tested hypothesized direct and indirect effects of race/ethnicity, SES, and three psychosocial mediational variables (collective self-efficacy, everyday discrimination, internalized homophobia) on two outcome variables-psychological and social well-being-assessed at 1-year follow-up. Our model indicated that: (1) race/ethnicity and SES were significantly associated with each other and with each psychosocial mediator; (2) higher SES was directly and indirectly associated with both measures of well-being; and (3) collective self-esteem and everyday discrimination mediated the association between SES and both measures of well-being. The model also indicated that racial/ethnic associations with psychological mediators and outcomes are evident in the context of SES, but these effects might be suppressed when the model does not consider SES. Findings highlight the critical role of SES and race/ethnicity in determining the psychological and social well-being of sexual minority men. Specification of mediating variables-collective self-efficacy, everyday discrimination, internalized homophobia-indicates potential intervention targets to improve psychological and social health in sexual minority men. Associations between race/ethnicity and SES support the need for intersectional frameworks in addressing the health of sexual minority men.

Effects of clean intermittent self-catheterization on late bladder dysfunction after radical hysterectomy in cervical cancer

OBJECTIVE

To identify the benefits of clean intermittent self-catheterization in women who have late bladder dysfunction caused by radical hysterectomy in cervical cancer.

METHODS

Thirty women who underwent radical hysterectomy with late bladder dysfunction were recruited. A nursing intervention program focusing on clean intermittent self-catheterization and a drinking plan was implemented. We recorded urinary times during the day and night, post-voiding residual urine volume, positive catheter specimen of urine rate, and quality of life instruments for patients with cervical cancer .

RESULTS

All patients were able to satisfactorily manage clean intermittent self-catheterization following video-based operational training. Bladder function was significantly increased after 3-month intervention compared with before the intervention. Urinary times during the day and night, and post-voiding residual urine volume were greatly decreased post-intervention compared with pre-intervention. The rate of a positive catheter specimen of urine test significantly decreased over time. There was significant improvement in quality of life in five dimensions between weeks 1 and 12 following the intervention.

CONCLUSIONS

Patients are able to learn the technique of clean intermittent self-catheterization without any difficulty. This technique is effective together with a drinking plan to decrease late bladder dysfunction caused by radical hysterectomy in cervical cancer.

Factors associated with HPV and other self-reported STI coinfections among sexually active Brazilian young adults: cross-sectional nationwide study

OBJECTIVES

To analyse factors associated with genital human papillomavirus (HPV) and other self-reported sexually transmitted infection (STI) coinfections among women and men aged 16-25 years from Brazil.

DESIGN

A cross-sectional, nationwide, multicentre study.

SETTING

119 primary healthcare centres between September 2016 and November 2017.

PARTICIPANTS

6388 sexually active young adults were enrolled by trained health professionals.

PRIMARY OUTCOME MEASURE

Genital HPV and other self-reported STI coinfections.

RESULTS

Of 3512 participants with valid data for genital HPV and (STI)-positive status, 276 (9.60%, 95% CI 7.82% to 11.36%) had HPV/STI coinfection. Among men, HPV/STI coinfection was more prevalent than HPV infection alone. Among HPV-positive participants, the percentage of subjects who reported having another STI was highest for gonorrhoea at 4.24% (95% CI 2.67% to 5.81%), followed by syphilis, herpes and HIV. Smoking, drug use and ever having a same-sex sexual experience were risk factors that were uniquely associated with HPV/STI coinfection compared with HPV infection alone.

CONCLUSIONS

The results identified a low prevalence of self-reported STIs, but in participants with at least one STI, the prevalence of HPV was high. These results reinforce the importance of implementing strategies to prevent risky behaviours among Brazilian young adults.

Factors Associated with Sexual Risks and Risk of STIs, HIV and Other Blood-Borne Viruses Among Women Using Heroin and Other Drugs: A Systematic Literature Review

This systematic literature review identified factors associated with sexual risks related to sexually transmitted infections (STI), HIV and other blood-borne viruses (BBV) among women using heroin and other drugs. The search strategy included five databases (PubMed, EMBASE, PsycNET, Web of Science, Scopus), and PsycEXTRA for grey literature. Out of the 12,135 publications screened, 30 peer-reviewed articles were included. Most publications were cross-sectional (n = 25), quantitative (n = 23) and included 11,305 women. Factors identified were: (1) socio-demographics; (2) gender roles and violence against women; (3) substance use; (4) transactional sex; (5) partner characteristics, partner's drug use, and context of sex; (6) preferences, negotiation and availability of condoms; (7) HIV status and STIs; (8) number of sexual partners; (9) love and trust; (10) reproductive health and motherhood; and (11) risk awareness and perception of control. Overall, this review highlights important implications for future research and practice, and provides evidence for developing STI/BBV preventive strategies.

Perceptions of intersectional stigma among diverse women living with HIV in the United States

Attitudes and behavior that devalue individuals based upon their HIV status (HIV-related stigma) are barriers to HIV prevention, treatment, and wellbeing among women living with HIV. Other coexisting forms of stigma (e.g., racism, sexism) may worsen the effects of HIV-related stigma, and may contribute to persistent racial and gendered disparities in HIV prevention and treatment. Few studies examine perceptions of intersectional stigma among women living with HIV. From June to December 2015, we conducted 76 qualitative interviews with diverse women living with HIV from varied socioeconomic backgrounds enrolled in the Women's Interagency HIV Study (WIHS) in Birmingham, Alabama; Jackson, Mississippi; Atlanta, Georgia; and San Francisco, California. Interview guides facilitated discussions around stigma and discrimination involving multiple interrelated identities. Interviews were audio-recorded, transcribed verbatim, and coded using thematic analysis. Interviewees shared perceptions of various forms of stigma and discrimination, most commonly related to their gender, race, and income level, but also incarceration histories and weight. Women perceived these interrelated forms of social marginalization as coming from multiple sources: their communities, interpersonal interactions, and within systems and structures. Our findings highlight the complexity of social processes of marginalization, which profoundly shape life experiences, opportunities, and healthcare access and uptake among women living with HIV. This study highlights the need for public health strategies to consider community, interpersonal, and structural dimensions across intersecting, interdependent identities to promote the wellbeing among women living with HIV and to reduce social structural and health disparities.

'In the North you can't be openly gay': Contextualising sexual practices among sexually and gender diverse persons in Northern Canada

Scant research has addressed health and well-being among lesbian, gay, bisexual, transgender, and queer (LGBTQ) persons in the Arctic. The Northwest Territories (NWT) has among Canada's highest rates of sexually transmitted infections (STIs). LGBTQ persons in NWT are at the nexus of LGBTQ and Arctic health disparities. Yet little is known of their sexual health needs. This qualitative study explored the sexual health needs of LGBTQ persons in the NWT. We conducted semi-structured, in-depth interviews with 51 participants, including 16 LGBTQ youth aged 15-24, 21 LGBTQ adults aged 25 and above, and 14 key informants who worked with LGBTQ persons. Social-ecological approaches to understanding sexual health guided this study. Participants discussed how structural contexts such as heteronormativity in sexual health education and a lack of access to safer sex tools constrained their ability to practice safer sex. Social contexts of intersectional stigma resulted in shame, concealing identities, and fear of accessing safer sex materials. Myriad factors influenced partner communication about safer sex practices, including honesty, consent, and relationship power. Findings suggest the need for comprehensive sexuality education and interventions that address syndemics of substance use, stigma, and low self-esteem to advance sexual health among LGBTQ persons in Northern Canada.