An Intersectional Approach to HIV Vulnerabilities and Testing Among Heterosexual African Caribbean and Black Men in London, Ontario: Results From the weSpeak Study

Factors Associated with the Uptake of HIV Testing in Canada: Evidence from a Nationally Representative Study

In this study, we explore the factors associated with the uptake of HIV testing at the national level in Canada. Using the 2015-16 Canadian Community Health Survey and applying logistic regression analysis, we examine the associations between HIV testing and factors identified by the Andersen's behavioral model of healthcare utilization. We find that a range of predisposing, enabling, and need factors are significantly associated with HIV testing. For example, compared to the oldest respondents (i.e. 55-64), their younger counterparts (i.e. 45-54, 35-44, and 25-34) are more likely to have been tested for HIV. Compared to those in Atlantic Canada, respondents in Quebec (OR = 1.96, p < .001), Ontario (OR = 1.44, p < .001), Prairies (OR = 1.37, p < .001), British Columbia (OR = 1.99, p < .001), and the Territories (OR = 2.22, p < .001) are all more likely to have been tested for HIV. Based on these findings, we provide several important suggestions for policymakers and future research.

Does Trust Mediate the Relationship Between Experiences of Discrimination and Health Care Access and Utilization Among Minoritized Canadians During COVID-19 Pandemic?

OBJECTIVES

We sought to determine if trust in government institutions mediate the relationship between experiences of discrimination and health care utilization during the COVID-19 pandemic.

METHODS

We used data from Statistics Canada's Crowdsourcing Data: Impacts of COVID-19 on Canadians-Experiences of Discrimination. We used generalized linear latent and mixed models (Gllamm) with a binomial and logit link function as well as generalized structural equation modeling (GSEM) to determine if reported discrimination and trust were associated with difficulties in accessing health services, health care, and the likelihood of experiencing negative health impacts. We also examined if trust mediated the relationship between experiences of discrimination and these health outcomes. Our analytical sample consisted of 2568 individuals who self-identified as belonging to a visible minority group.

RESULTS

The multivariate results indicate that experiences of discrimination during COVID-19 were associated with higher odds of reporting difficulties in accessing general health services (OR = 1.99, p ≤ 0.01), receiving care (OR = 1.65, p ≤ 0.01), and higher likelihood of reporting negative health impacts (OR = 1.68, p ≤ 0.01). Our mediation analysis indicated that trust in public institutions explained a substantial portion of the association between reported discrimination and all the health outcomes, although the effects of experiencing discrimination remain significant and robust.

CONCLUSION

The findings show that building and maintaining trust is important and critical in a pandemic recovery world to build back better.

Black heterosexual men's resilience in times of HIV adversity: findings from the "weSpeak" study

BACKGROUND

In Canada, heterosexual African, Caribbean and Black (ACB) men tend to suffer a disproportionate burden of HIV. Consequently, studies have examined the underlying contributors to this disparity through the nexus of behavioral and structural factors. While findings from these studies have been helpful, their use of deficit and risk models only furthers our knowledge of why ACB men are more vulnerable to HIV infection. Thus far, there is a dearth of knowledge on how heterosexual ACB men mobilize protective assets to promote their resilience against HIV infection.

METHODS

As part of a larger Ontario-based project called weSpeak, this study examined how ACB men acquire protective assets to build their resilience to reduce their HIV vulnerability. We analyzed three focus group discussions (n = 17) and 13 in-depth interviews conducted with ACB men using NVivo and a mixed inductive-deductive thematic analyses approach.

RESULTS

The findings show that ACB men mostly relied on personal coping strategies, including sexual abstinence, to build resilience against HIV. Interpersonal resources such as family, friends, and religious communities also played an important role in constructing ACB men's resilience. ACB men bemoaned their lack of access to essential institutional resources, such as health services, that are important in managing HIV adversity.

CONCLUSION

Based on these findings, there is an urgent need for HIV policy stakeholders, including service providers, to engage the ACB community in the design of intervention programs. Additionally, addressing the socioeconomic disadvantages faced by ACB communities will increase the capacity of ACB men to develop resilience against HIV.

Concurrent sexual partnerships and HIV testing among heterosexual Black men in Ontario, Canada: findings from the weSpeak study

BACKGROUND

African, Caribbean, and Black men constitute the second-highest category of males living with HIV in Ontario, which increased from 15.4% to 17% between 2011 and 2016. Previous studies have attributed this disproportionately higher rate to multiple concurrent sexual partnerships and low rates of HIV testing. Drawing on theoretical constructs of the health belief model (HBM), this study examined the relationship between multiple concurrent sexual partnerships and the uptake of HIV testing services among heterosexual Black men in Ontario.

METHODS

Using a cross-sectional sample data of 829 individuals from four cities in Ontario, we employed the multinomial logit analysis to examine the relationship between multiple sexual partnerships and the uptake of HIV testing services among heterosexual Black men.

RESULTS

The findings show that heterosexual Black men with multiple concurrent sexual partners were more than twice (RRR = 2.306, P < 0.01) as likely to test for HIV within the past 12 months when compared to those with one partner. Furthermore, being an immigrant, having good knowledge of HIV transmission, and earning lower annual income predicted higher odds of testing while sexual debut between the ages of 16 and 20 years, no visit to a healthcare provider in the past year and difficulty accessing healthcare significantly predicted lower likelihood of testing for HIV.

CONCLUSIONS

These findings align with the theoretical constructs of the health belief model but more importantly, they suggest heterosexual Black men with concurrent sexual partners may be aware of their HIV risk and are taking measures to know their serostatus. Hence, making HIV screening services accessible and at safer spaces could increase their use of HIV screening services.

HIV-Related Intersectional Stigma and Discrimination Measurement: State of the Science

Background. Across settings, individuals from populations that are multiply stigmatized are at increased risk of HIV and experience worse HIV treatment outcomes. As evidence expands on how intersecting stigmatized identities and conditions influence HIV outcomes, researchers have used diverse quantitative approaches to measure HIV-related intersectional stigma and discrimination. To date, no clear consensus exists regarding how to best quantitatively measure and analyze intersectional stigma and discrimination. Objectives. To review and document existing quantitative measures of HIV-related intersectional stigma and discrimination to inform research, programmatic, and policy efforts. Search Methods. We searched 5 electronic databases for relevant studies. References of included articles were screened for possible inclusion. Additional articles were screened on the basis of consultations with experts in the field. Selection Criteria. We included peer-reviewed studies published between January 1, 2010, and May 12, 2021, that were HIV related and presented 1 or more quantitative measures of stigma and discrimination using an intersectional lens in measure design or analysis. Data Collection and Analysis. Systematic methods were used to screen citations and abstract data via a standardized coding form. Data were analyzed by coding categories stratified according to 2 subgroups: (1) studies incorporating a single intersectional measure and (2) studies that examined intersectional stigma through analytical approaches combining multiple measures. Main Results. Sixteen articles met the inclusion criteria, 7 of which explicitly referenced intersectionality. Ten studies were from the United States. All of the studies included participants living with HIV. Among the 4 studies incorporating a single intersectional stigma measure, 3 explored race and gender stigma and 1 explored gender and HIV stigma. Studies involving analytic approaches (n = 12) mostly examined intersectional stigma via interaction terms in multivariate regression models. Three studies employed structural equation modeling to examine interactive effects or latent constructs of intersectional stigma. Conclusions. Research on the measurement of HIV-related intersectional stigma and discrimination is currently concentrated in high-income settings and generally focuses on the intersection of 2 identities (e.g., race and gender). Efforts are needed to expand appropriate application of intersectionality in the development, adaptation, and use of measures of HIV-related intersectional stigma and discrimination. The use of context-, identity-, or condition-adaptable measures should be considered. Researchers should also carefully consider how to meaningfully engage communities in the process of measurement development. Public Health Implications. The measures and analytic approaches presented could significantly enhance public health efforts in assessing the impact of HIV-related intersectional stigma and discrimination on critical health outcomes. (Am J Public Health. 2022;112(S4):S420-S432. https://doi.org/10.2105/AJPH.2021.306639).

Immigrant generational status and the uptake of HIV screening services among heterosexual men of African descent in Canada: Evidence from the weSpeak study

Objective

Canada became a preferred destination for many non-European and non-American migrants since the introduction of favorable immigration policies in the late 1960 s. Blackimmigrants from the African and Caribbean regions however are a known vulnerable population to HIV infection in Canada. Even though first-generation immigrants might differ from subsequent generations in terms of culture and beliefs which are important for health outcomes and behaviors, research examining disparities in their use of preventative healthcare is limited. This study aimed to examine generational disparities in the uptake of HIV screening services among a sample of heterosexual Black men in Ontario, Canada.

Methods

We used data from a cross-sectional survey sample (n = 829) that was collected from heterosexual Black men in four Ontarian cities (Toronto, Ottawa, London and Windsor) between March 2018 and February 2019. We used the negative log-log link function of the binomial family to examine the independent relationship between immigration status and the uptake of HIV testing and the cumulative effect of other predictor variables on HIV testing in nested models.

Results

Findings from multivariate analysis show second-generation immigrants were significantly less likely to test for HIV compared with their first-generation immigrant counterparts. After controlling for theoretically relevant variables, the second-generation immigrants were 53% less likely to test for HIV. We further observed that participants with good knowledge of HIV transmission (OR=1.05; p > 0.05) and those who were older were more likely to test for HIV. Those with masculine tendencies (OR=0.98; p > 0.05) and those who reported not having sexual partner were less likely to test (OR=0.57; p > 0.01). Religion emerged as a significant predictor of HIV testing as Christians (OR=1.62; p > 0.05) and other believers (OR=1.59; p > 0.05) were more likely to test for HIV when compared to their Muslim counterparts.

Conclusion

HIV prevention policies may need not only prioritize first-generation immigrants, but the wellbeing of their descendants as well. This could be achieved by implementing programs that will enhance second-generation immigrants’ use of HIV screening services. Additionally, HIV educational programs would be of relevance and especially so as respondents with good knowledge of HIV transmission consistently demonstrated higher likelihood of testing for their HIV status.

Understanding the factors associated with HIV and STIs diagnosis among Black heterosexual men in Ottawa and Windsor, Ontario

Background: The African, Caribbean and Black (ACB) men living in Canada share a heightened risk of infection by Human Immunodeficiency Virus and other sexually transmitted illnesses (STIs) and the associated risky behaviours such as suboptimal use of family planning services such as condom use. The African, Caribbean and Black (ACB) heterosexual men living in Canada are disproportionately exposed to HIV and other sexually transmitted infections. The present paper aims to assess the relationship between knowledge, attitude and use of condom with diagnosis of HIV and STIs among ACB heterosexual men in Ontario.

Design and Methods: This was a cross-sectional study on 430 participants consisting of black heterosexual men living two communities, Ottawa and Windsor in Ontario. The outcome variables were ever being diagnosed with HIV (Yes/No) and other STIs (Yes/No). Data were analysed using descriptive, and logistic regression techniques.

Results: Findings indicated that 70.20% did not have good knowledge of HIV, 68.10% had positive attitude towards condom use, and 62.82% were not regular condom user. Men who reported experiencing difficulty in accessing healthcare services had significantly higher odds of reporting HIV and STI diagnosis. Men with positive attitude towards condom use had lower odds of both HIV (odds ratio= 0.48, 95%CI=0.30,0.76) and STI diagnosis (odds ratio= 0.27, 95%CI=0.08,0.90). Similarly, condom users also had lower odds of both HIV and (odds ratio= 0.21, 95%CI=0.09,0.49) STI diagnosis (odds ratio= 0.62, 95%CI=0.39,0.99).

Conclusions: A large proportion of the sample with positive attitude to condom use was not a reflection of the large sample who did not have correct knowledge of HIV. Several factors were also found to be associated with heightened odds of being diagnosed with HIV and other STIs. The most notable of these factors were experiences of difficulty in accessing healthcare and utilisation of condoms.

Intersections of race, gender and the drug economy: Placing drugs in HIV discussions in Brazil

While much research now demonstrates how social inequalities can drive HIV transmission, relatively little attention is given to the spatialized 'intersections' of race, class, and gender. Using this approach, this article considers an understudied phenomenon in Brazilian HIV discussions, the importance of the drug economy in shaping intimacy in favelas. Drawing on interviews with young women in Rio de Janeiro, it documents the intimate relations between young women and male drug workers to situate HIV vulnerability at the juncture of three social-spatial changes: (1) the rise of a drug economy that provides some racialized men, marginalized from mainstream society, with opportunities for work; (2) the precarious economic position of racialized women; and (3) the gendered dynamics including violence that can shape intimate relations. The paper shows how these relationships are contested by women who can cast their partners as living a 'wrong life.'

Factors Associated with Condom Knowledge, Attitude, and Use among Black Heterosexual Men in Ontario, Canada

African, Caribbean, and Black (ACB) men living in Canada share a heightened risk of HIV infection and the associated risk factors such as suboptimal use of family planning services such as condom use. In this study, we assessed the factors associated with knowledge, attitude, and condom use among ACB men in Ontario. Methods. This was a cross-sectional study that surveyed heterosexual ACB men regardless of their residency status living in Ontario (n = 430). This is a part of a larger mixed methods study informed by critical race theory, intersectionality, and community-based participatory research (CBPR). Outcome variables were knowledge of condom use, attitude towards condom use, and actual use of condom during the last 12 months. Results. Of 430 participants, 77.70% has good knowledge of condom use as a protection against HIV transmission, 31.77% had positive attitude towards condom use, and 62.43% reported using condom regularly with casual partners during the last 12 months. Men who were currently married had more positive attitude towards condom use compared with their unmarried counterparts (odds ratio = 1.46, 95% CI = 1.20, 1.78). Canadian residents were found to have higher odds of having correct knowledge of condom (odds ratio = 1.31, 95% CI = 1.11, 1.55), and positive attitude towards condom use (odds ratio = 1.44, 95%CI = 1.09, 1.92). Men who visited sexual health clinics showed a positive association with having correct knowledge of condom (odds ratio = 1.78, 95% CI = 1.30, 2.44) and reported experiences of difficulty in accessing sexual health. This showed a negative association towards condom use (odds ratio = 0.45, 95% CI = 0.21, 0.97]. Conclusion. A considerable percentage of heterosexual ACB men did not have correct knowledge regarding the protective effect of condom use against HIV and positive attitude towards the use of condom. Several sociodemographic and healthcare-related factors were significantly associated with knowledge, attitude, and use of condom.

Testing, Inequities and Vulnerability of Adolescents to Sexually Transmitted Infections

Sexually transmitted infections (STIs) should form part of the comprehensive healthcare agenda for adolescents and young people (A&Y) and testing plays a strategic role in STI prevention. However, little attention has been paid to the social and programmatic obstacles to this practice among A&Y. The aim of this study is to describe the prevalence of testing for syphilis and HIV reported by a group of A&Y, analyzing its relationship with variables potentially indicative of inequities related to vulnerability to STIs. This was a cross-sectional survey applied to students at public high schools in three cities in the state of São Paulo, Brazil. The responses of 369 young people who reported having started sexual life were analyzed. The analysis included description of the frequencies of demographic and socioeconomic variables and their associations with testing for syphilis and HIV through the chi-square test. The concentration index (CI) was also calculated, with construction of the respective concentration curve for the associated variables. Positive associations were found between occurrence of testing and living in homes with up to three inhabitants, living in a marital situation with a regular or committed partnership, previous use of primary care services and previous use of hospitals or emergency services. The concentration curve for testing STIs showed significant contributions from the associated variables. The findings indicated that situations of inequity need to be addressed in order to reduce A&Y's vulnerability to STIs.

Sexual Debut Among Heterosexual Men of African and Caribbean Descent: Are the Youth Initiating Sex Earlier than the Older Generation?

Although age at first sex is considered a measure of sexual risk and vulnerability for HIV infection, there is a dearth of literature on age at sexual debut in the Canadian context. This study examined time variations to first sex among heterosexual African, Caribbean, and Black (ACB) men in four Ontarian cities. A population-based retrospective survey (n = 879) on timing to first sexual intercourse was conducted between 2018 and 2019 among self-identified heterosexual ACB men 16 years or older and residing in London, Ottawa, Toronto or Windsor. We used the lognormal survival analysis technique to examine variations in time to first sexual intercourse among age cohorts and between cities. The findings showed a generational shift in the pattern of sexual initiation, with younger heterosexual ACB men initiating sexual intercourse earlier compared with those currently older than 50 years. We observed those between 16 and 19 years, 20 and 29 years, and 30 and 39 years of age to have significantly higher risk ratios of TR = 0.852, TR = 0.869, and TR = 0.855, respectively. At city level, the results show marked spatial variations, with youth in cities of Toronto, Ottawa, and London at the highest risk of early sexual debut relative to those in Windsor. Early initiation of first sexual intercourse among heterosexual ACB youth was observed with those in the larger cities being at a relatively higher risk. There is the need for programs aimed at delaying sexual debut among youth in general. It is, however, important to recognize the relative risk of those in the larger cities.

"I went in there, had a bit of an issue with those folks": everyday challenges of heterosexual African, Caribbean and black (ACB) men in accessing HIV/AIDS services in London, Ontario

BACKGROUND

In Canada, heterosexual African, Caribbean, and Black (ACB) men's heightened risk of HIV infection has been linked to behavioral characteristics, including practices of hegemonic masculinity that discourage the use of HIV preventive services. However, this framing is bereft of the role of structural factors that may be contributing to new HIV infections. This paper examined the underlying factors limiting access to health services among heterosexual ACB men in London, Ontario Canada.

METHODS

A convenient sampling technique was used to recruit thirty-seven (n = 37) self-identified heterosexual ACB men and service providers. Four focus groups (FG) were conducted; three with ACB participants of similar age category (i.e., 16-24; 25-38; 39+), and one with service providers. The FGs focused on the barriers to using health services and interrogated the ease of access to HIV intervention programs by ACB men respectively. Recurring themes from the FGs were probed further using in-depth interviews (n = 13). FGs and in-depth interviews complemented each other in reducing uneven power dynamics, fact checking, and allowing for detail discussion of the topic under study. Data analyses were done in NVivo using a mixed inductive-deductive thematic analyses approach.

RESULTS

Most ACB men lacked information on HIV and were unaware of their increased risk of infection. Contrary to the notion that behavioral characteristics keep ACB men away from health services, we found that most ACB men were unaware of the availability of these services. Those that had some knowledge about the services reported that they were not appropriately tailored to their needs. In addition, stereotypes and stigma about the etiology of HIV among Blacks, and systemic neglect served as significant barriers to ACB men's use of services.

CONCLUSION

The findings suggest that, to enhance preventive health service use among heterosexual ACB men, there is the need to remove structural barriers. Engaging ACB men in the design and implementation of policies may be useful at improving access to HIV information, testing, and treatment services. Increased information dissemination to ACB men would create awareness of the availability of HIV services. Finally, service providers should be conscious of ACB men's concern about experiences of discrimination and racism at service centers.

Correlates of Casual Sex Amidst Vulnerability to HIV Among ACB Heterosexual Men in Ottawa and Windsor, Ontario Canada

Heterosexual exposure is the second highest means of HIV transmission; and African, Caribbean, and Black (ACB) men face greater risks. Black men can reduce the disproportionately high HIV prevalence in their communities by changing their socially misconstrued masculine role. We analysed factors predisposing heterosexual ACB men to risky sexual behaviour, particularly multiple casual sex partnerships in Ottawa and Windsor, Ontario, Canada. We employed quantitative datasets from a broader mixed methods study within hierarchical logistic regression model to determine the association between psychosocial factors and casual sex partnerships. The model controlled for city level clustering effect and sociodemographic factors. Precisely 55.0% (n = 52) of men in Windsor and 70.2% (n = 99) in Ottawa had one or more casual sex partners within the past year. Some of them (Windsor, 32.1% [n = 18], and Ottawa, 34.3% [n = 36]) used condom always. HIV knowledge (OR = 0.80, p < 0.01, CI = 0.67/0.95) and pro-Black community attitudes (OR = 0.72, p < 0.05, CI = 0.56/0.94) decreased the odds of casual sex partnerships, while traditional masculinity scores (OR = 1.21, p < 0.05, CI = 1.01/1.46) increased it. The behavioural factors jointly predicted casual sex more than sociodemographic variables and city of residence. We conclude that heterosexual ACB men are predisposed to casual sex partnerships at differing magnitude across cities, and this may constitute a risk factor for HIV exposure. Hence, propagation of HIV knowledge, community attitudes and reconstruction of masculine ideology among ACB men, with due attention to geopolitical differences in city of residence, are recommended.