Socioecological factors influencing women's HIV risk in the United States: qualitative findings from the women's HIV SeroIncidence study (HPTN 064)

The Impact of Human Immunodeficiency Virus on Women in the United States

Substantial improvements have been made in reducing HIV incidence rates among women in the United States. However, numerous disparities affect women's risk of HIV acquisition, in addition to affecting treatment outcomes for women living with HIV. As people with HIV continue to live longer due to antiretroviral therapy, clinicians must be cognizant of various health, financial, and social implications that can affect HIV self-management. Successfully ending the HIV epidemic will require more targeted approaches on prevention, linkage to care, and treatment while also addressing underlying factors that affect women's engagement in HIV-related services across the HIV care continuum.

Knowledge and attitude to HIV pre exposure prophylaxis among women in five sub-Saharan African countries: a multilevel model analysis of population-based survey 2021-2022

BACKGROUND

HIV Pre-Exposure Prophylaxis (HIV PrEP) may help reduce the rate of HIV infection among women in sub-Saharan Africa (SSA). This study aimed to assess women's knowledge and attitudes toward PrEP, a crucial component of HIV prevention, using nationwide data. It is the first study of its kind conducted in five SSA countries: Burkina Faso, Ghana, Côte d'Ivoire, Kenya, and Tanzania. The primary objective was to examine women's knowledge and attitudes toward PrEP for the prevention of HIV infection, as well as to explore individual- and community-level factors associated with it.

METHODS

The current study utilized the 2021/22 demographic and health survey datasets from five African nations, namely Burkina Faso, Côte d'Ivoire, Ghana, Kenya, and Tanzania. The analysis was performed using Stata 17. A weighted sample of 77,052 women of reproductive age participated in the survey. Univariate and multivariable multilevel logistic regressions were conducted to assess parameters related to knowledge and attitudes toward PrEP in these countries. In both the univariate regression and the final model, the significance of variables was determined using P values of ≤ 0.2 and < 0.05.

RESULTS

Overall, only about 13.88 (95% CI: 13.64,14.12) of women had knowledge and attitudes toward HIV PrEP. The highest (34.29%) and lowest (5.61%) values were observed for Kenya and Tanzania respectively. Higher rates of knowledge, and attitude toward HIV PrEP among women were independently associated with age 25-34 years old (AOR = 1.52, 95% CI:1.41,1.64), and 35-49 years old (AOR = 1.56, 95% CI:1.43,1.69), primary education level (AOR = 1.79,95% CI:1.65,1.95), and secondary/higher education level (AOR = 2.92, 95% CI: 2.67,3.20), richer (AOR = 1.14, 95% CI:1.02,1.27), and richest (AOR = 1.21, 95% CI:1.06,1.37), employed women (AOR = 1.82, 95% CI:1.65,1.99), had media exposure (AOR = 1.49,95% CI:1.40,1.59),knowledge of modern contraception (AOR = 2.62, 95% CI: 1.94,3.43), had at least one ANC visit (AOR = 1.99, 95% CI:1.47,2.69), gave birth at health institutions (AOR = 1.17, 95% CI: 1.02,1.37), ever had given birth (AOR = 1.53, 95% CI: 1.41,1.66), female household heads (AOR = 1.24, 95% CI:1.17,1.31), rural women (AOR = 0.83, 95% CI: 0.76,0.89). Similarly, women from communities with high ANC coverage (AOR = 1.84, 95% CI: 1.61,2.11), high community mass media exposure (AOR = 1.62, 95% CI: 1.39,1.88), and high community wealth level (AOR = 1.48, 95% CI: 1.30,1.68), and women from the high illiteracy rate community (AOR = 0.71, 95% CI: 0.61,0.82) showed statistically significant associations with the outcome variable in the final model.

CONCLUSIONS

Less than one-seventh of women exhibited knowledge of and positive attitudes toward HIV PrEP. All stakeholders involved in HIV/AIDS prevention and control have recognized the significance of the factors mentioned above. Enhancing maternal health services, such as promoting institutional delivery, contraception, antenatal care (ANC), and women's empowerment, alongside harnessing the power of media and embracing these transformative changes, will contribute to a greater understanding of and more favorable attitudes toward HIV PrEP within the population.

How does intersectionality impact the quality of healthcare services for Black women living with HIV?

Women with HIV are affected more than men by intersecting discriminations. For Black women, additional discrimination can have a detrimental effect on their HIV care. An extended literature review of primary research studies was undertaken to explore the issues and the impact of intersectionality on Black women with HIV. Electronic databases were searched for studies published since antiretroviral treatment became recognised to be effective, and eight studies met detailed inclusion and exclusion criteria. Critical appraisal led to the identification of three themes: discrimination; stigmatisation; and racism. The findings suggest that while Black women with HIV reported barriers to health care because of intersectionality, older women who felt confident in their self-identity were more able to cope with issues around this. Knowledge of the factors affecting these women will enable health professionals to deliver person-centred care.

Self-Perception of HIV Risk and Interest in Pre-Exposure Prophylaxis in a General Obstetrics and Gynecology Clinic Population

Background: Pre-exposure prophylaxis (PrEP) for HIV is underutilized, particularly among attendees of obstetrics and gynecology (Ob/Gyn) clinics. Lack of self-perception of HIV risk is a barrier to PrEP utilization, and a lack of understanding of community risk factors for HIV may contribute to that lack of self-perception of risk. Methods: Attendees of general Ob/Gyn clinics in New Orleans completed a survey assessing HIV knowledge, self-perception of HIV risk, and interest in PrEP. They reviewed a brief written educational intervention on demographic and behavioral risk factors for HIV and availability of PrEP. HIV knowledge, self-perception of HIV risk, and interest in PrEP were reassessed after the intervention. Results: One-hundred seventy individuals completed the survey. Eighty-five participants (50%) expressed initial interest in PrEP. Self-perception of risk of HIV acquisition was associated with interest in PrEP. Ten of 11 (90.9%) respondents who had high self-perceived risk of HIV were interested in PrEP, compared with 75 of 159 (47.2%) of those who had low self-perceived risk (p = 0.01). The association remained significant in a multivariate analysis. After the intervention, the number of those who perceived themselves to be at risk of HIV increased from 11 to 25 individuals (p < 0.01) and 20 of these (80%) were interested in PrEP. Knowledge of HIV risk factors increased (p < 0.01). The intervention did not significantly alter interest in PrEP. Conclusions: Self-perception of HIV risk was associated with interest in PrEP. A brief written educational intervention increased knowledge of HIV risk factors and increased self-perception of risk of HIV. The intervention did not translate to increased interest in PrEP.

Individual, Social, and Structural Vulnerability for Black Women in the South: Implications for PrEP

Pre-exposure prophylaxis (PrEP) is an effective biomedical HIV prevention option, yet adoption among Black women, who are disproportionately impacted by HIV, is low. A nuanced understanding of the multi-level factors that contribute to elevated risk is necessary to better contextualize PrEP uptake. Qualitative data from Black women residing in the Southern U.S. who self-screened as HIV-negative, were collected via four focus groups (N = 27) to understand influences on HIV vulnerability and the potential role of PrEP in mitigating risk. Content analysis of transcribed data yielded multiple themes addressing: the pervasiveness of sexual partner sharing; lack of transparency regarding HIV status, disclosure, and testing; and social/cultural influences on HIV risk. Experiences with the health care system and providers were of particular concern. Findings demonstrate support for PrEP in this population and contribute to our understanding of individual, social, and structural factors to better inform PrEP promotion.

A multiplicative effect of Education and Wealth associated with HIV-related knowledge and attitudes among Ghanaian women

BACKGROUND

Knowledge and attitudes regarding HIV play a crucial role in prevention and control efforts. Understanding the factors influencing HIV-related knowledge and attitudes is essential for formulating effective interventions and policies. This study aims to investigate the possibility of an interaction between education and wealth in influencing HIV-related knowledge and attitudes among women in Ghana.

METHODS

Cross-sectional data from the Ghana Multiple Indicator Cluster Survey (MICS), a nationally representative sample, were analyzed. Statistical summaries were computed using place of residence, marital status, education level, wealth index quintile, use of insurance, functional difficulties, and exposure to modern media. Furthermore, a three-model Logistic regression analysis was conducted; Model 1 with main effects only, Model 2 with the interaction between education and wealth, and Model 3 with additional covariates. To account for the complexity of the survey data, the svyset command was executed in STATA.

RESULTS

Although most interaction terms between wealth index quintiles and education levels did not show statistical significance, a few exceptions were observed. Notably, women with primary education in the second, middle, and fourth wealth quintiles, along with those with secondary education in the second wealth quintile, exhibited a negative significant association with HIV-related attitude level. However, no significant associations were found between other factors, including age, place of residence, marital status, and health insurance, and HIV-related attitude. The study also found significant associations between socioeconomic variables and HIV-related knowledge. There was a significant positive association between higher levels of education and HIV-related knowledge level. Women in wealthier quintiles had a significant positive association with HIV-related knowledge level. Factors such as place of residence and media exposure, including radio and television were also observed to be associated with HIV-related knowledge level.

CONCLUSIONS

This study highlights the importance of socioeconomic status and media exposure in shaping HIV-related knowledge and attitudes among women in Ghana. Policy interventions should focus on reducing socioeconomic disparities, ensuring equitable access to education and healthcare services, and utilizing media platforms for effective HIV information dissemination.

Development of a predictive model for identifying women vulnerable to HIV in Chicago

INTRODUCTION

Researchers in the United States have created several models to predict persons most at risk for HIV. Many of these predictive models use data from all persons newly diagnosed with HIV, the majority of whom are men, and specifically men who have sex with men (MSM). Consequently, risk factors identified by these models are biased toward features that apply only to men or capture sexual behaviours of MSM. We sought to create a predictive model for women using cohort data from two major hospitals in Chicago with large opt-out HIV screening programs.

METHODS

We matched 48 newly diagnosed women to 192 HIV-negative women based on number of previous encounters at University of Chicago or Rush University hospitals. We examined data for each woman for the two years prior to either their HIV diagnosis or their last encounter. We assessed risk factors including demographic characteristics and clinical diagnoses taken from patient electronic medical records (EMR) using odds ratios and 95% confidence intervals. We created a multivariable logistic regression model and measured predictive power with the area under the curve (AUC). In the multivariable model, age group, race, and ethnicity were included a priori due to increased risk for HIV among specific demographic groups.

RESULTS

The following clinical diagnoses were significant at the bivariate level and were included in the model: pregnancy (OR 1.96 (1.00, 3.84)), hepatitis C (OR 5.73 (1.24, 26.51)), substance use (OR 3.12 (1.12, 8.65)) and sexually transmitted infections (STIs) chlamydia, gonorrhoea, or syphilis. We also a priori included demographic factors that are associated with HIV. Our final model had an AUC of 0.74 and included healthcare site, age group, race, ethnicity, pregnancy, hepatitis C, substance use, and STI diagnosis.

CONCLUSIONS

Our predictive model showed acceptable discrimination between those who were and were not newly diagnosed with HIV. We identified risk factors such as recent pregnancy, recent hepatitis C diagnosis, and substance use in addition to the traditionally used recent STI diagnosis that can be incorporated by health systems to detect women who are vulnerable to HIV and would benefit from preexposure prophylaxis (PrEP).

An effectiveness-implementation trial protocol to evaluate PrEP initiation among U.S. cisgender women using eHealth tools vs. standard care

Background

The United States' (U.S.) initiative to End the HIV Epidemic aims to reduce new HIV infections in areas of high HIV prevalence. Despite national efforts to reduce HIV incidence, cisgender women continue to represent approximately one out of every five new HIV diagnoses in the U.S. Taking pre-exposure prophylaxis (PrEP) is an effective HIV prevention strategy; however, PrEP initiation among cisgender women is suboptimal, with only 10% of eligible women receiving PrEP prescriptions in 2019.

Methods

We designed a trial to test the effectiveness of interventions to increase PrEP initiation, while evaluating the implementation strategy (hybrid type II trial) in seven obstetrics and gynecology (OB/GYN) clinics (two federally qualified health centers, three community-based, and two academic) in Baltimore, Maryland. A total of 42 OB/GYN providers will be enrolled and randomized (1:1:1) into one of three clinical trial arms (standard of care, patient-level intervention, or multi-level intervention). Eligible patients of enrolled providers will receive a sexual health questionnaire before their appointment through the electronic health record's (EHR) patient portal. The questionnaire will be scored in three tiers (low, moderate, and high) to assess HIV risk. Patients at low risk will be offered an HIV test only, while those who score medium or high risk will be included in the clinical trial and assigned to the clinical trial arm associated with their provider. Differences in PrEP initiation, our primary outcome, across the three arms will be analyzed using generalized linear mixed-effect models with logistic regression. We will adjust results for demographic differences observed between arms and examine PrEP initiation stratified by patient's and provider's race and ethnicity.Additionally, a comprehensive economic analysis for each intervention will be conducted.

Discussion

We hypothesize that gathering information on sensitive sexual behaviors electronically, communicating HIV risk in an understandable and relatable format to patients and OB/GYN providers, and deploying EHR alerts will increase PrEP initiation and HIV testing.

Trial Registration

The trial is registered with ClinicalTrials.gov (NCT05412433) on 09 June 2022. https://clinicaltrials.gov/ct2/show/NCT05412433?term=NCT05412433&draw=2&rank=1.

Protocol for WeExPAnd: a prospective, mixed-methods pilot demonstration study to increase access to pre-exposure prophylaxis among women vulnerable to HIV infection in the Southern USA

INTRODUCTION

African American women (AA), particularly those living in the Southeastern USA, experience disproportionately high rates of HIV infection. Pre-exposure prophylaxis (PrEP) is a highly effective HIV prevention tool that may circumvent barriers to traditional HIV prevention tools, such as condom use; however, very little is known about how to improve PrEP access and uptake among AA women who may benefit from PrEP use. This project aims to understand how to increase PrEP access among AA women in the rural Southern USA, which may ultimately affect HIV incidence in this population.

METHODS AND ANALYSIS

The goal of the current study is to systematically adapt a patient-provider communication tool to increase PrEP uptake among AA women receiving care at a federally qualified health centre in Alabama. We will use an iterative implementation process, by assessing the feasibility, acceptability and preliminary impact of the tool on PrEP uptake, using a pilot preintervention/postintervention design (N=125). We will evaluate women's reasons for declining a referral to a PrEP provider, reasons for incomplete referrals, reasons for not initiating PrEP after a successful referral and ongoing PrEP use at 3 and 12 months after PrEP initiation among our sample. The proposed work will significantly contribute to our understanding of factors impacting PrEP uptake and use among AA women, particularly in underserved areas in the Deep South that are heavily impacted by the HIV epidemic and experience worse HIV-related health outcomes relative to other areas in the USA.

ETHICS AND DISSEMINATION

This protocol has been approved by the Institutional Review Board (IRB) at University of Alabama at Birmingham (Birmingham, AL; protocol 300004276). All participants will review a detailed informed consent form approved by the IRB and will provide written or verbal informed consent prior to enrolment. Results will be disseminated through peer-reviewed manuscripts, reports, and local, national and international presentations.

TRIAL REGISTRATION NUMBER

NCT04373551.

Using education based on the health belief model to modifications in performance of behaviors related to sexually transmitted infections in vulnerable women

BACKGROUND

Sexually transmitted infections (STIs) have always been considered as a health problem in the world. Also, vulnerable women (addicts, jail breakers, and prostitutes) are at the highest risk. According to the World Health Organization's (WHO) approach, the only effective way to prevent and control this disease is public health education, and high-risk and vulnerable groups should be prioritized in educational programs. The aim of the study was to investigate the effect of health belief model (HBM)-based education on changing the behaviors related to STIs in vulnerable women.

MATERIALS AND METHODS

The present study is an intervention (field trial) study in vulnerable women. Convenience sampling method was used in this study and the sample size was determined to be 84 subjects. Through tossing a coin, the social support center was selected as the intervention group and the drop-in center as the control group. Quantitative data analysis was performed, and descriptive and inferential statistical methods were used.

RESULTS

The mean scores of perceived threat, perceived benefits, perceived barriers, and perceived self-efficacy and changes in performance between the three measurement stages, as well as changes in the scores of perceived threat, perceived benefits, perceived barriers, and perceived self-efficacy over three measurement times were significantly different between the two groups (interaction) (P < 0.001). The mean score of performance 3 months after the intervention was significantly higher than before the intervention (P = 0.001).

CONCLUSIONS

The present study confirmed the effectiveness of the HBM in promoting behavioral modifiers that lead to STIs. Therefore, educational interventions with emphasis on understanding the threats, benefits, barriers, and self-efficacy and, ultimately, performance improvement in relation to STIs are recommended.

Exploring the Influence of Social Capital on HIV Prevention with Migrants from the Democratic Republic of Congo (DRC) Living in Durban, South Africa

Background: Research shows a growing attentiveness to the role of social and environmental influences on HIV risk behaviours. Moreover, the understanding of HIV risk behaviours has moved from an earlier consideration of individual risk, to ecological models, with the understanding that behaviours are rooted in the economic, environmental and social structure. Aim: To explore how social capital, specifically on a social bonding level, operates as a risk or protective factor for the spread of HIV among French-speaking migrants from the Democratic Republic of Congo (DRC), living in Durban, South Africa. Methods: A qualitative approach using a case study design was used to conduct the study. Data were collected through focus group discussions and individual in-depth interviews from a purposive sample of French-speaking migrants from DRC, living in Durban, South Africa. Ethical approval to conduct the study was obtained from the University of KwaZulu-Natal's Human and Social Science Research Ethics' Committee. Data were analysed thematically using Creswell's steps of data analysis. Results: This study found that social capital can act as both a protective factor in certain circumstances, and a risk factor in others. Trust, norms, reciprocity and social networks are complex elements in the refugee community and are influenced by a myriad of factors including the past and present stressors that are prevalent within this community. Conclusions: The findings confirm the complexity of issues related to HIV prevention which necessitate policy and practice interventions to mitigate consequences that may result from the higher risks of HIV transmission in this community.

Structural Barriers to HIV Prevention and Services: Perspectives of African American Women in Low-Income Communities

BACKGROUND

African American women are at a disproportionate HIV risk compared with other U.S. women. Studies show that complex structural and social determinants, rather than individual behaviors, place African American women at greater risk of HIV infection; however, little is known about women's views of what puts them at risk.

AIMS

This study sought to comprehend the perceptions of African American women living in low-income housing regarding the factors that influence both their personal sexual health behaviors and use of HIV prevention services.

METHODS

We conducted seven focus groups with 48 African American women from 10 public housing communities in a small city in the southeastern United States. We analyzed the focus group transcripts using thematic data analysis to identify salient themes and points of interest related to the study aim.

RESULTS

Women identified factors related to the health care system (trustworthiness of the health care system), the external environment (racism, classism, patriarchal structures, and violence/crime), as well as predisposing (health beliefs, stigma, and gender norms), enabling (agency to negotiate gendered power), and need (perceived HIV risk and perceptions of partner characteristics) features of individuals in the population.

CONCLUSION

African American women living in public housing are especially vulnerable to HIV infection due to intersectional discrimination based on racism, classism, gender power dynamics, and community conditions. Our findings confirm the need to develop HIV intervention programming addressing intersectional identities of those making up the communities they plan to address, and being informed by those living in the communities they plan to act on.

A Retrospective Cohort Study of Women and Men Living with HIV, Attending an HIV Clinic in Australia

OBJECTIVES

To compare women with men presenting with HIV to a public health HIV clinic, to identify the special characteristics and health care needs of women living with HIV in the Barwon South West region in Victoria.

METHODS

A retrospective cohort study of 35 women and 135 men living with HIV who attended the clinic between 2009 and 2020. Gender differences were assessed using nonparametric analyses.

RESULTS

The women were diagnosed with HIV younger than the men (mean 29.5 years vs. 36.7 years) and more were born in Africa (28.6% vs. 5.2%). More men than women presented with sexually transmittable infections (38.5% vs. 14.3%) at the time of diagnosis, and were diagnosed through a sexual health screen (37% vs. 17%). The proportions of men and women who used alcohol and other drugs (recent to their diagnosis) were similar (68.1% vs. 48.6%), and there was no difference in proportions presenting with AIDS-defining illnesses (p = 0.425), or CD4 cell count (advanced: ≤200 cells, relatively well: ≥201 cells, p = 0.241), but the women had a lower viral load (p < 0.001).

CONCLUSIONS

In this study of 170 people living with HIV, nearly one-half of the men with known HIV history were diagnosed through sexual health screens, but women's HIV was mostly detected through targeted screening. Results highlight gender disparity in access to sexual health screening and assessment, including low awareness of sexual health risks for women, and endorse the view that HIV is a heterosexual sexually transmittable infection in women.

Neuroinflammation in HIV-associated depression: evidence and future perspectives

People living with HIV face a high risk of mental illness, especially depression. We do not yet know the precise neurobiological mechanisms underlying HIV-associated depression. Depression severity in the general population has been linked to acute and chronic markers of systemic inflammation. Given the associations between depression and peripheral inflammation, and since HIV infection in the brain elicits a neuroinflammatory response, it is possible that neuroinflammation contributes to the high prevalence of depression amongst people living with HIV. The purpose of this review was to synthesise existing evidence for associations between inflammation, depression, and HIV. While there is strong evidence for independent associations between these three conditions, few preclinical or clinical studies have attempted to characterise their interrelationship, representing a major gap in the literature. This review identifies key areas of debate in the field and offers perspectives for future investigations of the pathophysiology of HIV-associated depression. Reproducing findings across diverse populations will be crucial in obtaining robust and generalisable results to elucidate the precise role of neuroinflammation in this pathophysiology.

Hearing From Men Living With HIV: Experiences With HIV Testing, Treatment, and Viral Load Suppression in Four High-Prevalence Countries in Sub-Saharan Africa

Engaging men in HIV services remains a challenge across sub-Saharan Africa. There is a critical need to better understand facilitators of men's successful engagement with HIV services and assess if there are similarities across contexts. We conducted in-depth interviews and focus group discussions with 92 men living with HIV (MLHIV) across Malawi, Uganda, South Africa, and Eswatini, most of whom had been diagnosed with HIV within the last 5 years. We coded interviews for themes using a constant-comparative approach. We contextualized our findings within a socioecological framework. HIV testing was primarily motivated by illness (individual level), though illness was sometimes accompanied by prompting and support from healthcare providers and/or intimate partners. Once diagnosed, nearly all participants reported immediate linkage to care, initiation of antiretroviral therapy (ART), and subsequent ART adherence. ART initiation and adherence were facilitated by men's sense of agency and ownership over their health (individual level), social support from intimate partners, friends, and family (interpersonal/network level), supportive-directive counseling from healthcare providers (institutional/health systems level), and male-friendly services, i.e., rapid, respectful, private (institutional/health systems level). Health literacy regarding viral suppression (individual level), strengthened by patient-provider communication (institutional/health systems level), was highest in Uganda, where most men could discuss viral load testing experiences, report their viral load status (most reported suppressed), and demonstrate an understanding of treatment as prevention. Elsewhere, few participants understood what viral load suppression was and even fewer knew their viral load status. Our findings reveal socioecological-level facilitators of men's progress across the HIV-care continuum. Programs may want to leverage facilitators of ART initiation and adherence that span socioecological levels—e.g., healthcare ownership and agency, social support, supportive-directive counseling—and apply them to each end of the continuum to encourage early HIV testing/diagnosis and improve health literacy to help men understand and achieve viral load suppression.

Intimate partner violence, HIV-risk behaviors, and HIV screening among heterosexually active persons at increased risk for infection

ABSTRACTIntimate partner violence (IPV) can increase a person's risk of HIV and other sexually transmitted infections (STIs), and may affect access to sexual health services. We assessed the prevalence of HIV screening and IPV among heterosexually-active persons using data from the 2016 National HIV Behavioral Surveillance. Participants were eligible if they were 18-60 years old, could complete the interview in English or Spanish, and reported having sex with an opposite sex partner in the previous 12 months. People who reported neither injection drug use within the past 12 months nor prior HIV diagnosis, and persons with valid responses to questions regarding HIV screening and physical/sexual IPV within the past 12 months were included (N = 7,777). Overall, 17% reported IPV in the previous 12 months and 19% had never had HIV screening. Abused persons were more likely to have been screened for HIV and to report high risk behaviors than non-abused persons. There was no difference in the proportion being offered HIV screening by their health care provider in the previous year. Findings suggest an integrated approach to violence prevention and sexual health may help increase awareness about clinical best practices and reduce risk for HIV/STIs among at-risk communities.

A Systematic Review of Neighborhood-Level Influences on HIV Vulnerability

A better understanding of the social-structural factors that influence HIV vulnerability is crucial to achieve the goal of ending the HIV epidemic by 2030. Given the role of neighborhoods in HIV outcomes, synthesis of findings from such research is key to inform efforts toward HIV eradication. We conducted a systematic review to examine the relationship between neighborhood-level factors (e.g., poverty) and HIV vulnerability (via sexual behaviors and substance use). We searched six electronic databases for studies published from January 1, 2007 through November 30, 2017 (PROSPERO CRD42018084384). We also mapped the studies' geographic distribution to determine whether they aligned with high HIV prevalence areas and/or the "Ending the HIV Epidemic: A Plan for the United States". Fifty-five articles met inclusion criteria. Neighborhood disadvantage, whether measured objectively or subjectively, is one of the most robust correlates of HIV vulnerability. Tests of associations more consistently documented a relationship between neighborhood-level factors and drug use than sexual risk behaviors. There was limited geographic distribution of the studies, with a paucity of research in several counties and states where HIV incidence/prevalence is a concern. Neighborhood influences on HIV vulnerability are the consequence of centuries-old laws, policies and practices that maintain racialized inequities (e.g., racial residential segregation, inequitable urban housing policies). We will not eradicate HIV without multi-level, neighborhood-based approaches to undo these injustices. Our findings inform future research, interventions and policies.

Using an Intersectional Framework to Understand the Challenges of Adopting Pre-exposure Prophylaxis (PrEP) Among Young Adult Black Women

INTRODUCTION

There is limited functional knowledge and utilization of pre-exposure prophylaxis (PrEP) among young adult Black cisgender women (YBW).

METHODS

We conducted four focus groups with YBW using an intersectional framework to explore multiple levels of factors that impede YBW awareness, interest, and utilization of PrEP in conjunction with their sexual and reproductive healthcare needs.

RESULTS

Influences at the cultural-environmental level included a lack of information and resources to access to PrEP and medical mistrust in the healthcare system. At the social normative level, influences included attitudes towards the long-term effects on sexual and reproductive health and self-efficacy to follow the PrEP regimen. At the proximal intrapersonal level, influences included anticipated HIV stigma from family and peers along with the fear of rejection from their main partners.

CONCLUSIONS

Translation of these results indicated that interventions to increase PrEP utilization and adherence among YBW will require multi-level strategies to address barriers to integrating HIV prevention into sexual and reproductive healthcare.

Gender dimensions of the impact of HIV/AIDS on stunting in children under five years in Zimbabwe

Background

HIV/AIDS can have a disastrous effect on household food and nutrition security outcomes such as stunting in children under 5. However, stunting and HIV/AIDS are highly gendered phenomena that need to be explored in order to get an in-depth understanding of the interrelationship. This study was therefore aimed at investigating gender dimensions of the impact of HIV/AIDS on stunting in children under 5 years in Zimbabwe.

Methods

The study uses a large scale nationally representative cross-sectional dataset of 13,854 Zimbabwean households for the year 2019. To test hypothesis 1, the study employs binary choice models (Probit and Logit) since the outcome variable household HIV/AIDS status is dichotomous. To test hypothesis 2 and 3, the study employs the Propensity Score Matching (PSM) approach to circumvent the self-selection problem in the creation of treatment and control groups for households affected by HIV/AIDS and those that are not.

Results

The results revealed that household HIV/AIDS status is independent of the gender of household head. On the other hand, the results for the PSM estimates show that the probability of the household having a stunted child under 5 years is higher for households with an HIV positive member compared to those without. In addition, female headed households with an HIV positive member are more likely to have a stunted child under 5 years compared to male headed households under similar circumstances.

Conclusion

Overall, the results provide evidence of a higher risk of stunting among children from households affected by HIV/AIDS. The study offers three major findings. Firstly, the study finds no significant association between gender of the household head and household HIV/AIDS status. Secondly, households that have at least one HIV positive member are more likely to have a stunted child under 5 years. Lastly, female headed households with at least one HIV positive member are more likely to have a stunted child under 5 years compared to male headed household with similar HIV/AIDS status. The findings have important policy implications towards improved integration of HIV/AIDS status, household head gender and child nutrition services in affected households.

Applying a Nursing Perspective to Address the Challenges Experienced by Cisgender Women in the HIV Status Neutral Care Continuum: A Review of the Literature

ABSTRACT

The field of HIV research has grown over the past 40 years, but there remains an urgent need to address challenges that cisgender women living in the United States experience in the HIV neutral status care continuum, particularly among women such as Black women, who continue to be disproportionately burdened by HIV due to multiple levels of systemic oppression. We used a social ecological framework to provide a detailed review of the risk factors that drive the women's HIV epidemic. By presenting examples of effective approaches, best clinical practices, and identifying existing research gaps in three major categories (behavioral, biomedical, and structural), we provide an overview of the current state of research on HIV prevention among women. To illustrate a nursing viewpoint and take into account the diverse life experiences of women, we provide guidance to strengthen current HIV prevention programs. Future research should examine combined approaches for HIV prevention, and policies should be tailored to ensure that women receive effective services that are evidence-based and which they perceive as important to their lives.

A Review of Recent HIV Prevention Interventions and Future Considerations for Nursing Science

ABSTRACT

As our knowledge of HIV evolved over the decades, so have the approaches taken to prevent its transmission. Public health scholars and practitioners have engaged in four key strategies for HIV prevention: behavioral-, technological-, biomedical-, and structural/community-level interventions. We reviewed recent literature in these areas to provide an overview of current advances in HIV prevention science in the United States. Building on classical approaches, current HIV prevention models leverage intimate partners, families, social media, emerging technologies, medication therapy, and policy modifications to effect change. Although much progress has been made, additional work is needed to achieve the national goal of ending the HIV epidemic by 2030. Nurses are in a prime position to advance HIV prevention science in partnership with transdisciplinary experts from other fields (e.g., psychology, informatics, and social work). Future considerations for nursing science include leveraging transdisciplinary collaborations and consider social and structural challenges for individual-level interventions.

HIV Related Knowledge, HIV Testing Decision-Making, and Perceptions of Alcohol Use as a Risk Factor for HIV among Black and African American Women

The HIV/AIDS epidemic disproportionately affects Black and African American women in the United States. This study examined the extent of HIV related knowledge, HIV testing decision-making, and perceptions of alcohol use as a risk factor for HIV among Black and African American women in urban and suburban communities. Seven focus groups were conducted with 37 women aged 18 to 49 residing in the Commonwealth of Massachusetts. Women participating in focus groups had a wide breadth of HIV related knowledge. Findings suggest the influence of interpersonal relationships and provider-patient interactions on HIV testing, the need for building community capacity and leveraging community resources towards HIV prevention, and the influence of alcohol outlet density on HIV vulnerability and exposure in communities of color. Comprehensive multifaceted evidence informed interventions that are culturally relevant and gender responsive are needed to reduce HIV/AIDS disparities.

How Perceived Structural Racism and Discrimination and Medical Mistrust in the Health System Influences Participation in HIV Health Services for Black Women Living in the United States South: A Qualitative, Descriptive Study

There are racial and geographic disparities for HIV in the United States; Black women have nearly 20 times the risk of White women in being infected with HIV, and lifetime HIV risk is greatest for people living in the southern United States. These disparities, layered with the structural racism and discrimination that is more prominent in the south, is a public health issue. The purpose of this article is to share Black women's perspectives of how perceived structural racism and discrimination, and medical mistrust in the health care system contribute to their participation in health services. In this formative study, we conducted seven focus groups among women living in 10 low-income housing communities. Results indicate that there are barriers to the utilization of health services that are grounded in personal experiences and historical mistrust for the health care system. Understanding these barriers is critical to combating the HIV epidemic for this population.

Modeling upstream socioeconomic inequities and syndemic conditions among mothers over time

OBJECTIVES

Mothers in lower social locations are particularly vulnerable to the syndemic conditions of substance abuse, violence, and HIV/AIDS (SAVA), yet few studies have examined the impact of upstream socioeconomic inequities as salient determinants of syndemic conditions in their lives. The purpose of this study was to investigate the influence of Temporary Assistance for Needy Families (TANF) receipt, TANF sanctions, and economic hardship (EH) on SAVA syndemic conditions that included indicators of substance use, HIV risk-taking behaviors, and intimate partner violence among mothers over time.

METHODS

Using data from the Fragile Families and Child Wellbeing Study (n = 4,898), we investigated the longitudinal measurement invariance of a proposed measure of syndemic conditions among mothers over five waves and performed path analysis to investigate the relationships between TANF use, TANF sanctions, and EH with syndemic conditions.

RESULTS

Analyses revealed the presence of SAVA syndemic conditions and EH predicted increased SAVA in subsequent waves. Relationships between reported race of the mother and the sanctioning of TANF benefits and increased SAVA were also noted.

CONCLUSIONS

This study has implications regarding race, welfare policy and sanctioning practices, and the socioeconomic determinants of health that drive syndemic conditions among mothers in the United States.

Prevalence and correlates of transactional sex among women of low socioeconomic status in Portland, OR

BACKGROUND

Women who report transactional sex are at increased risk for HIV and other sexually transmitted infections (STIs). However, in the United States, social, behavioral, and trauma-related vulnerabilities associated with transactional sex are understudied and data on access to biomedical HIV prevention among women who report transactional sex are limited.

METHODS

In 2016, we conducted a population-based, cross-sectional survey of women of low socioeconomic status recruited via respondent-driven sampling in Portland, Oregon. We calculated the prevalence and, assessed the correlates of, transactional sex using generalized linear models accounting for sampling design. We also compared health outcomes, HIV screening, and knowledge and uptake of HIV pre-exposure prophylaxis (PrEP) between women who did and did not report transactional sex.

RESULTS

Of 334 women, 13.6% reported transactional sex (95% confidence interval [CI]: 6.8, 20.5%). Women who reported transactional sex were older, more likely to identify as black, to identify as lesbian or bisexual, to experience childhood trauma and recent sexual violence, and to have been homeless. Six percent (95% CI: 1.8, 10.5%) of women with no adverse childhood experiences (ACEs) reported transactional sex compared to 23.8% (95% CI: 13.0, 34.6%) of women who reported eleven ACEs (P <  0.001). Transactional sex was strongly associated with combination methamphetamine and opiate use as well as condomless sex. Women who reported transactional sex were more likely to report being diagnosed with a bacterial STI and hepatitis C; however, HIV screening and pre-exposure prophylaxis knowledge and use were low.

CONCLUSIONS

In a sample of women of low socioeconomic status in Portland, Oregon, transactional sex was characterized by marginalized identities, homelessness, childhood trauma, sexual violence, substance use, and sexual vulnerability to HIV/STI. Multi-level interventions that address these social, behavioral, and trauma-related factors and increase access to biomedical HIV prevention are critical to the sexual health of women who engage in transactional sex.

A Prospective Study of Exposure to Gender-Based Violence and Risk of Sexually Transmitted Infection Acquisition in the Women's Interagency HIV Study, 1995-2018

Background: Our objectives were to estimate the association of gender-based violence (GBV) experience with the risk of sexually transmitted infection (STI) acquisition in HIV-seropositive and HIV-seronegative women, to compare the STI risks associated with recent and lifetime GBV exposures, and to quantify whether these associations differ by HIV status. Methods: We conducted a multicenter, prospective cohort study in the Women's Interagency HIV Study, 1994-2018. Poisson models were fitted using generalized estimating equations to estimate the association of past 6-month GBV experience (physical, sexual, or intimate partner psychological violence) with subsequent self-reported STI diagnosis (gonorrhea, syphilis, chlamydia, pelvic inflammatory disease, or trichomoniasis). Results: Data from 2868 women who reported recent sexual activity comprised 12,069 person-years. Higher STI risk was observed among HIV-seropositive women (incidence rate [IR] 5.5 per 100 person-years) compared with HIV-seronegative women (IR 4.3 per 100 person-years). Recent GBV experience was associated with a 1.28-fold (95% confidence interval [CI] 0.99, 1.65) risk after adjustment for HIV status and relevant demographic, socioeconomic, and sexual risk variables. Other important risk factors for STI acquisition included unstable housing (adjusted incidence rate ratio [AIRR] 1.81, 95% CI 1.32-2.46), unemployment (AIRR 1.42, 95% CI 1.14-1.76), transactional sex (AIRR 2.06, 95% CI 1.52-2.80), and drug use (AIRR 1.44, 95% CI 1.19-1.75). Recent physical violence contributed the highest risk of STI acquisition among HIV-seronegative women (AIRR 2.27, 95% CI 1.18-4.35), whereas lifetime GBV experience contributed the highest risk among HIV-seropositive women (AIRR 1.59, 95% CI 1.20-2.10). Conclusions: GBV prevention remains an important public health goal with direct relevance to women's sexual health.

Longitudinal predictors of male sexual partner risk among Black and Latina women in their late thirties: ethnic/racial identity commitment as a protective factor

This study aimed to investigate predictors of male sexual partner risk among Latinas and Black women in their late thirties. We used multiple regression analysis to examine factors associated with male sexual partner risk among 296 women who participated in two waves of the Harlem Longitudinal Development Study (New York, 2011-2013 and 2014-2016). Women who experienced childhood sexual abuse had higher risk partners than those who did not [b = 0.16, 95% confidence interval (CI) = 0.06, 0.28]. Earlier marijuana use was a risk factor for partner risk in the late thirties (b = 0.12, 95% CI = 0.04, 0.27). Higher levels of ethnic/racial identity commitment mitigated this risk (b = - 0.15, 95% CI = - 0.26, - 0.04). Ethnic/racial identity commitment can be protective against male sexual partner risk among Latina and Black women who use marijuana. Further research should explore the protective role of different dimensions of ethnic/racial identity against sexually transmitted infections, including HIV.

Strategies for increasing impact, engagement, and accessibility in HIV prevention programs: suggestions from women in urban high HIV burden counties in the Eastern United States (HPTN 064)

BACKGROUND

Merely having the tools to end HIV is insufficient. Effectively ending the epidemic necessitates addressing barriers that impede engagement in biomedical and behavioral prevention and wide scale implementation and utilization of existing interventions. This qualitative study identifies suggestions for increasing access to, engagement in, and impact of HIV prevention among women living in cities in high HIV burden counties in the eastern US.

METHODS

Data analyzed for the current study were collected via a qualitative sub-study within the HIV Prevention Trials Network Study 064 (HPTN 064), a multisite observational cohort study designed to estimate HIV incidence among women residing in communities with elevated HIV prevalence who also reported personal or partner characteristics associated with increased risk of HIV acquisition. Focus group and interview participants in the qualitative sub-study (N = 288) were from four cities in the eastern US.

RESULTS

Thematic analyses revealed four themes describing women's most frequently stated ideas for improving prevention efforts: 1) Promote Multilevel Empowerment, 2) Create Engaging Program Content, 3) Build "Market Demand", and 4) Ensure Accessibility. We conducted additional analyses to identify contradictory patterns in the data, which revealed an additional three themes: 1) Address Structural Risk Factors, 2) Increase Engagement via Pleasure Promotion, 3) Expand Awareness of and Access to Prevention Resources.

CONCLUSIONS

Findings may be useful for enhancing women's engagement in and uptake of behavioral and biomedical HIV prevention resources, improving policy, and addressing multilevel risk factors.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT00995176 , prospectively registered.

Antenatal HIV screening: results from the National Perinatal Survey, France, 2016

Background

Universal antenatal HIV screening programmes are an effective method of preventing mother-to-child transmission.

Aims

To assess the coverage and yield of the French programme on a nationally representative sample of pregnant women, and predictive factors for being unscreened or missing information on the performance/ result of a HIV test.

Methods

Data came from the medical records of women included in the cross-sectional 2016 French National Perinatal Survey. We calculated odds ratios (OR) to identify factors for being unscreened for HIV and for missing information by multivariable analyses.

Results

Of 13,210 women, 12,782 (96.8%) were screened for HIV and 134 (1.0%) were not; information was missing for 294 (2.2%). HIV infection was newly diagnosed in 19/12,769 (0.15%) women screened. The OR for being unscreened was significantly higher in women in legally registered partnerships (OR: 1.3; 95% CI: 1.1–1.6), with 1–2 years of post-secondary schooling (OR: 1.6; 95% CI: 1.2–2.1), part-time employment (OR: 1.4; 95% CI: 1.1–1.8), inadequate antenatal care (OR: 1.9; 95% CI: 1.5–2.4) and receiving care from > 1 provider (OR: 1.8; 95% CI: 1.1–2.8). The OR of missing information was higher in multiparous women (OR: 1.4; 95% CI: 1.2–1.5) and women cared for by general practitioners (OR: 1.4; 95% CI: 1.1–1.9).

Conclusions

The French antenatal HIV screening programme is effective in detecting HIV among pregnant women. However, a few women are still not screened and awareness of the factors that predict this could contribute to improved screening levels.

Navigating new sexual partnerships in midlife: a socioecological perspective on factors shaping STI risk perceptions and practices

OBJECTIVE

Despite increases in STIs among those over 40, little is known about the social context of STI transmission among people experiencing relationship transition in midlife, and few sexual health promotion initiatives are targeted at this group. This study sought to identify factors shaping STI risk perceptions and practices among midlife individuals either contemplating or having sex with new partners following the end of a long-term relationship.

METHODS

Participants were purposively selected from respondents to Britain's third National Survey of Sexual Attitudes and Lifestyles, using three eligibility criteria: aged 40-59, reported experience of the end of a marital or cohabiting relationship with an opposite-sex partner in the past 5 years, and willingness to participate in a qualitative interview. Qualitative data were generated via face-to-face interviews with 10 women and 9 men and analysed inductively using thematic analysis, with themes then organised using a socioecological framework.

RESULTS

Participants' accounts of new sexual partnerships in midlife indicate that STI risk perceptions and practices are shaped by factors operating at multiple levels across the socioecological arena (individual, partnership, peers and communities, societal). Constraints on, and resources for, the navigation of sexual safety include self-perceived STI risk rooted in past rather than present circumstances; legacies of mistrust within former relationships; intersecting gender-age dynamics in negotiation of risk prevention strategies with new partners; peers and younger relatives' influences on understandings of sexual risk and safety; postrelationship change in social networks that increase or mitigate vulnerability to sexual risk; age-related barriers to accessing condoms; and disconnection from safer sex messaging and services culturally coded as for the young.

CONCLUSIONS

Improving sexual health among midlife adults requires age-sensitive interventions designed to address multilevel constraints, and harness positive influences, on the navigation of sexual safety at this stage of life.

The Effects of Trauma, Violence, and Stress on Sexual Health Outcomes Among Female Clinic Clients in a Small Northeastern U.S. Urban Center

Background: Threats to sexual health can emerge across one's life span and are influenced by individual and interpersonal experiences, as well as certain environmental exposures. Although previous research has recognized the importance of ecological frameworks to understand the complexity of health and behaviors in marginalized communities, there continues to be a dearth of research that truly utilizes this perspective to gain insight into the multifaceted factors that can concurrently influence threats to sexual health among women. Methods: A sample of 279 ethnoracially diverse women were recruited from a U.S. northeastern small urban center health clinic to participate in a parent study on trauma and immunity. A hierarchical block analysis was conducted to investigate associations between women's experiences of trauma, stress and violence (i.e., childhood trauma (CHT), intimate partner violence (IPV), neighborhood stressors), and sexual health outcomes and behaviors (i.e., lifetime sexually transmitted infection [STI] diagnosis, concurrent partnerships, and lifetime sex trading). Results: In the full hierarchical model, IPV and life stress trauma were associated with lifetime sex trading and partner concurrency. Also in the full model, sexual CHT was associated with lifetime STI acquisition and partner concurrency, while emotional CHT was associated with lifetime sex trading. Lastly, as neighborhood disorder increased, so did the number of lifetime sex trading partners. Conclusion: Sexual health assessments in clinical and community settings require a holistic, comprehensive, and meaningful approach to inform person-centered health promotion intervention. Prevention and treatment interventions require a focus on parents and families, and should assist adolescents and young adults to adopt therapies for healing from these experiences of trauma, violence, and stress. Interventions to enhance sexual health promotion must also include the following: advocacy for safe environments, social policy that addresses lifelong impacts of CHT, and fiscal policy that addresses economic vulnerability among women and threatens sexual health. Further recommendations are discussed.

Perceived Value of Microenterprise for Low-Income Women Living with HIV in Alabama

We characterized the potential benefits and risks of participating in a microenterprise program targeting low-income women living with HIV (WLWH) in Alabama; and described potential mechanisms through which microenterprise programs could influence sexual risk behaviors and engagement in HIV care. Fourteen stakeholders and 46 WLWH (89% African American) participated in the qualitative study. Data were collected using in-depth interviews (stakeholders) and focus group discussions (WLWH). NVivo qualitative software was used for the management and analysis of the data. The data revealed four main mechanisms through which microenterprise programs could potentially improve health outcomes: (1) social support and encouragement from other women, (2) improvement in self-esteem, (3) creating structure in the women's lives, and (4) financial strengthening. Potential risks included unwanted disclosure of HV status, stigma and loss of insurance benefits. Microenterprise programs have the potential to be acceptable and may contribute to improved health and social outcomes among low-income WLWH in Alabama.

Epidemiology of HIV, syphilis, and hepatitis B and C among manual cane cutters in low-income regions of Brazil

Background

In recent decades the epidemic of asymptomatic sexually transmitted infections has extended deep into Brazil, including small towns and rural areas. The purpose of this study was to investigate the epidemiology of HIV, syphilis, and hepatitis B (HBV) and hepatitis C viruses (HCV), and to evaluate immunization coverage against hepatitis B in a group of rural workers in Brazil.

Methods

In 2016, a cross-sectional study was conducted with 937 manual sugarcane cutters of the Midwest and Northeast Regions of Brazil. All individuals were interviewed and screened for HIV, syphilis, HBV and HCV. Correlating factors with lifetime HBV infection were investigated using logistic regression. Positive Predictive Values, Negative Predictive Values, sensitivity and specificity were also calculated relative to vaccination against Hepatitis B, comparing anti-HBs titers to vaccination reports.

Results

Most reported previous hospitalization (55%), occupational injuries (54%), sharing of personal items (45.8%), alcohol consumption (77.2%), multiple sexual partners in previous 12 months (39.8%), and no condom use during sexual intercourse in last 12 months (46.5%). Only 0.2% reported using injection drugs. Anti-HIV-1 was detected in three individuals (0.3%). Serological markers of lifetime syphilis (treponemal test) were detected in 2.5% (95% CI: 1.6–3.6) of participants, and active syphilis (treponemal test and VDRL) present in 1.2%. No samples were positive for anti-HCV. The prevalence of lifetime HBV infection (current or past infection) was 15.9%, and 0.7% (95% CI 0.4 to 1.5) were HBsAg-positive. Previous hospitalization (OR 1.53, CI 1.05–2.24, p < 0.01) and multiple sexual partners in the last 12 months (OR 1.80, CI 1.25–2.60, p < 0.01) were predictors for lifetime HBV infection. Although 46.7% (95% CI 43.4–49.9) of individuals reported having been vaccinated against hepatitis B, only 20.6% (95% CI 18.1–23.3) showed serological evidence of previous hepatitis B vaccination (positive for anti-HBs alone).

Conclusions

The high prevalence of syphilis and HBV compared to the general population and the high frequency of risk behaviors show the potential for sexual and parenteral dissemination of these agents in this rural population. In addition, the low frequency of hepatitis B vaccinated individuals suggests a need for improved vaccination services.

Optimizing Delivery of HIV Preexposure Prophylaxis for Women in the United States

Preexposure prophylaxis (PrEP) is a highly effective HIV prevention method; however, it is underutilized among women who are at risk for acquisition of HIV. Women comprise one in five HIV diagnoses in the United States, and significant racial disparities in new HIV diagnoses persist. The rate of new HIV diagnoses among black and African American women in 2015 was 16 times greater than that of white women. These disparities highlight the importance of HIV prevention strategies for women, including the use of PrEP. PrEP is the first highly effective HIV prevention method available to women that is entirely within their control. However, because so few women who may benefit from PrEP are aware of it, few women's healthcare providers offer PrEP to their patients, PrEP has not yet achieved its potential to reduce HIV infections in women. This article describes individual and systemic barriers for women related to the uptake of PrEP services; explains how providers can identify women at risk for HIV; reviews how to provide PrEP to women; and outlines client-centered models for HIV prevention services. Better access to culturally acceptable and affordable medical and social services may offer support to women for consistent and ongoing use of PrEP. This discussion may be used to inform HIV prevention activities for women and guide interventions to decrease racial/ethnic disparities in rates of HIV infection among US women.

Information Poverty and Reproductive Healthcare: Assessing the Reasons for Inequity between Income Groups

It is commonly known that in the United States women who are low income do not access reproductive healthcare services and information with the same reliability and regularity of women who are higher income. A qualitative research approach was undertaken to assess the root cause of this disparity. In-depth semistructured interviews were conducted with 15 women divided among socioeconomic lines. The primary barriers to care for women who are low income are clinical staff attitudes, knowledge of care available and needed, and cost or lack of insurance. This study adds to the current understanding of the barriers to reproductive healthcare for women of different socioeconomic statuses.