Interpersonal violence and other social-structural barriers associated with needing HIV treatment support for women living with HIV

Medical-Legal Partnerships: a promising approach for addressing health-harming legal needs among people with HIV

Introduction

People with HIV (PWH), particularly those at the intersection of sexual and gender identities, face enduring obstacles to accessing HIV care, including structural stigma, structural racism and discrimination, housing instability, and limited access to health insurance. To address these challenges, Medical-Legal Partnerships (MLPs) in HIV care offer an innovative approach that integrates medical and legal services. By targeting health-harming legal needs (HHLN), MLPs aim to enhance the HIV care continuum outcomes for PWH.

Methods

This study examines the benefits and challenges of MLPs within organizations serving PWH through the social-ecological model. MLP providers (n=111) identified organizational-level challenges such as funding limitations, resource integration issues, and staffing constraints.

Results

MLPs demonstrated numerous benefits, including patient impact and benefits, comprehensive service provision, enhanced staff support and capacity, and potential for policy influence.

Discussion

These results underscore the feasibility of MLPs while offering valuable insights into their efficacy and challenges, guiding the implementation of MLPs to address health-harming legal needs, including discrimination, and thereby improving HIV care outcomes.

Impact of COVID-19 on women living with HIV who are survivors of intimate partner violence

BACKGROUND

Women living with HIV (WLWH) experience higher rates of intimate partner violence (IPV) compared to women without HIV, but there has been minimal research to date on the impact of the COVID-19 pandemic on the lived experiences of WLWH who are IPV survivors.

METHODS

This is a secondary analysis of COVID-19 impact using baseline data from an ongoing, prospective, micro-longitudinal cohort study of HIV care engagement among WLWH who have experienced lifetime IPV. We measured the impact of COVID-19 along key domains (i.e., physical health, day-to-day life, sexual/relationship behavior, substance use, HIV care, mental health, financial status, and having conflict with partners). Using independent t-tests or Fisher's exact tests, and Pearson's chi-squared tests, we compared women with and without ongoing IPV across sociodemographic characteristics, psychiatric disorders, substance use, and COVID-19 impact domains. We then built separate multivariate linear regression models for each of the different COVID-19 impact domains; ongoing IPV exposure was the primary explanatory variable of interest.

RESULTS

Enrolled participants (n = 84) comprised a group of women (mean age 53.6y; SD = 9.9) who were living with HIV for a mean 23.3 years (SD = 10), all of whom had experienced lifetime IPV. Among 49 women who were currently partnered, 79.6% (n = 39) reported ongoing IPV. There were no statistically significant differences between those experiencing ongoing IPV and those who were not (or not partnered) in terms of demographic characteristics, substance use, or mental health. In multivariate models, ongoing IPV exposure was not associated with any COVID-19 impact domain. Anxiety and depression, however, were associated with COVID-19-related physical health, HIV care, and relationship conflict. Hispanic ethnicity was significantly associated with COVID-19-related physical health. More severe cocaine and opioid use were also significantly associated with COVID-19-related impact on day-to-day life.

CONCLUSIONS

Among this sample of WLWH who are all lifetime IPV-survivors, nearly half had ongoing IPV exposure. The COVID-19 public health emergency period affected WLWH in varied ways, but impacts were most profound for women experiencing concurrent mental health and substance use problems. Findings have important implications for future interventions to improve women's health and social outcomes.

HIV disclosure without consent linked to increased violence against women living with HIV in a Canadian setting

Our study examined the association between HIV disclosure without consent and verbal and/or physical violence due to HIV status among women living with HIV (WLWH). This study draws on baseline data of a sample (N = 316) from SHAWNA, a longitudinal community-based open cohort with WLWH in Metro Vancouver, Canada (2010-2019). Bivariate and multivariable logistic regression was used to investigate factors associated with physical and/or verbal violence due to HIV status. Adjusted odds ratios (AOR) and 95% confidence intervals [95%CIs] are reported. In total, 46.5% experienced non-consensual disclosure of HIV status without consent and 34.2% experienced physical and/or verbal violence related to HIV status in their lifetime. In multivariable analysis, HIV disclosure without consent was associated with increased odds of experiencing HIV-related physical and/or verbal violence (AOR: 7.46[4.21-13.21]). Lifetime exposure to homelessness was also associated with increased odds of physical and/or verbal violence due to HIV status (AOR: 2.15[1.03-4.49]). This research underscores the reality of HIV stigmatization and criminalization and suggests a critical need to remove HIV disclosure from the reach of criminal law and ensure women's rights to confidentiality. Governments and organizations must work to identify and address the drivers of various levels of stigma and gender-based violence and invest in inclusive, trauma-informed, culturally safe support and care programs and policies designed in collaboration with WLWH.

Barriers and facilitators to engagement in care and medication adherence for women living with HIV in the Southern United States

Women living in the South have the second highest rate of HIV and the lowest rate of viral suppression among women in all regions in the United States (U.S.). Viral suppression is achieved by successfully linking women to HIV care and supporting adherence to antiretroviral therapy (ART). We aimed to qualitatively explore perceived barriers and facilitators to HIV care engagement and ART adherence among women living with HIV in the South. Participants (N = 40) were recruited across a broad geographic area of the South, assisted by a location-specific Community/Clinician Advisory Board (CCAB). Qualitative research methods were used to generate in-depth descriptions of women's experiences in accessing HIV care and adhering to ART. Intrapersonal qualities expressed through resilience and self-efficacy were amongst the most prominent themes for both engagement in care and adherence to medications. Structural barriers such as transportation and distance to care continued to be a barrier to engagement, while medication delivery facilitated adherence. Conclusion: Our findings highlight the complexity and interrelated nature of factors impacting care and adherence. Multilevel interventions that incorporate structural factors in addition to individual-level behavioral change are needed to facilitate engagement in care and adherence to ART.

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.

Pathways From Recent Incarceration to Antiretroviral Therapy Adherence: Opportunities for Interventions to Support Women Living With HIV Post Release From Correctional Facilities

ABSTRACT

Women living with HIV are increasingly incarcerated and experience suboptimal HIV health outcomes post release from incarceration. Drawing on cohort data with cisgender and trans women living with HIV (Sexual Health and HIV/AIDS: Women's Longitudinal Needs Assessment), we used path analysis to investigate pathways from recent incarceration to optimal antiretroviral therapy (ART) adherence. We tested direct effects between recent incarceration, mediating variables, and ART adherence, along with indirect effects between incarceration and ART adherence through each mediator. We assessed model fit using chi-square, root-mean-square error of approximation (RMSEA), and comparative fit index (CFI). Our hypothesized model fit well to the data (χ2(1)=1.100; p=.2943; CFI = 1.000; RMSEA = 0.007). Recent experiences of homelessness, criminalized substance use, and gender-based violence each fully mediated the pathway between recent incarceration and optimal ART adherence. Findings highlight the need for safe and supportive housing, supports for criminalized substance use, and trauma and violence-informed care and practice post release from incarceration.

In the midst of plenty: Experiences of food insecurity amongst women living with HIV in Vancouver, Canada

Globally, people living with HIV (PLWH) are disproportionately affected by food insecurity. Yet there is limited understanding of the impacts of food insecurity among cisgender and transgender women living with HIV (WLWH) in high-income countries. Thus, it is critical to examine the lived experiences of WLWH and food insecurity to inform policy and service provision. As part of the community-based SHAWNA (Sexual Health and HIV/AIDS: Women's Longitudinal Needs Assessment) study, we conducted 64 semistructured qualitative interviews with WLWH in Vancouver, Canada (2015-2017). Drawing on a socio-ecological framework, this analysis explores the lived experiences of navigating food security and health among WLWH in Metro Vancouver. Our findings indicate that WLWH relied heavily on food banks and other food-related supportive services. Despite the abundance of programs, access to nutritious foods remained difficult, and women often relied on processed foods that were more affordable and readily available. For many, food insecurity was exacerbated by unresponsive food services regulations that did not reflect the actual needs of food service users in terms of opening hours and locations, and a lack of nutritious food. Additionally, the absence of trauma-aware, women-centred and culturally responsive services, as well as, spatial and material barriers related to the recent loss of funding for HIV-specific support services, impeded food security among WLWH. Our findings emphasise that recognizing and addressing the social and structural disparities that exist for WLWH in high-income setting are essential for addressing food insecurity and ultimately optimal health among this population.