Examining the Health Care Experiences of Women Living with Human Immunodeficiency Virus (HIV) and Perceived HIV-Related Stigma

IntroductionThe increased incidence of human immunodeficiency virus (HIV) in women, particularly marginalized women, prompted research to examine women's health service experiences at a local outpatient clinic.MethodsA qualitative case study using semistructured interviews examined facilitators and barriers to health care services. Seventeen women living with HIV who accessed care at an outpatient HIV clinic in central west Ontario were interviewed. Thematic analysis was used to code health care experiences perceived as HIV-related stigma.ResultsWomen perceived HIV-related stigma when health care providers lacked basic HIV knowledge and failed to uphold the ethical principles of patient–provider relationships, resulting in women's disengagement from health care.ConclusionsWe propose a community-based participatory research framework to reform health care educational curriculum toward a culture of health care safety that is inclusive of people living with HIV.     

Envisioning Women-Centered HIV Care: Perspectives from Women Living with HIV in Canada

BackgroundWomen comprise nearly one-quarter of people living with human immunodeficiency virus (HIV) in Canada. Compared with men, women living with HIV experience inequities in HIV care and health outcomes, prompting a need for gendered and tailored approaches to HIV care.MethodPeer and academic researchers from the Canadian HIV Women's Sexual and Reproductive Health Cohort Study conducted focus groups to understand women's experience of seeking care, with the purpose of identifying key characteristics that define a women-centered approach to HIV care. Eleven focus groups were conducted with 77 women living with HIV across Quebec, Ontario, and British Columbia, Canada.ResultsWomen envisioned three central characteristics of women-centered HIV care, including i) coordinated and integrated services that address both HIV and women's health care priorities, and protect against exclusion from care due to HIV-related stigma, ii) care that recognizes and responds to structural barriers that limit women's access to care, such as violence, poverty, motherhood, HIV-related stigma, and challenges to safe disclosure, and iii) care that fosters peer support and peer leadership in its design and delivery to honor the diversity of women's experiences, overcome women's isolation, and prioritize women's ownership over the decisions that affect their lives.ConclusionDespite advances in HIV treatment and care, the current care landscape is inadequate to meet women's comprehensive care needs. A women-centered approach to HIV care, as envisioned by women living with HIV, is central to guiding policy and practice to improve care and outcomes for women living with HIV in Canada.     

A qualitative exploration of barriers to HIV prevention,treatment and support: Perspectives of transgender women and service providers

Transgender (trans) women experience barriers to access to HIV care, which result in their lower engagement in HIV prevention, treatment and support relative to cisgender people living with HIV. Studies of trans women's barriers to HIV care have predominantly focused on perspectives of trans women, while barriers are most often described at provider, organisation and/or systems levels. Comparing perspectives of trans women and service providers may promote a shared vision for achieving health equity. Thus, this qualitative study utilised focus groups and semi-structured interviews conducted 2018–2019 to understand barriers and facilitators to HIV care from the perspectives of trans women (n = 26) and service providers (n = 10). Barriers endorsed by both groups included: (a) anticipated and enacted stigma and discrimination in the provision of direct care, (b) lack of provider knowledge of HIV care needs for trans women, (c) absence of trans-specific services/organisations and (d) cisnormativity in sexual healthcare. Facilitators included: (a) provision of trans-positive trauma-informed care, (b) autonomy and choice for trans women in selecting sexual health services and (c) models for trans-affirming systems change. Each theme had significant overlap, yet nuanced perspective, between trans women and service providers. Specific recommendations to improve HIV care access for trans women are discussed. These recommendations can be used by administrators and service providers alike to work collaboratively with trans women to reduce barriers and facilitators to HIV care and ultimately to achieve health equity for trans women.     

Understanding the Promise: Considering the Experiences of Women Living with HIV to Maximize Effectiveness of HIV Prevention Technologies

BackgroundThe United States' response to HIV was designed primarily to meet the needs of single men without dependent children and its prevention strategies focused primarily on individual behavior change with little attention to the social, cultural, and economic factors fueling HIV risk, especially among indigent and marginalized women. In 2012, the President's Advisory Council called for an updating of the National HIV/AIDS Strategy's Implementation Plan to “achieve specific, targeted and measurable goals for reducing HIV incidence and … improving health care access and health outcomes for women living with HIV.”Outcome MeasuresWomen living with HIV and those at greatest risk of HIV generally live side by side in the same communities and under the same conditions, separated in status only by a positive HIV test and its consequences. Thus, women openly living with HIV constitute an identifiable and accessible source of first-hand information regarding the barriers that keep women out of HIV prevention and care. Their insights, rooted in lived experience, can vitally inform the development of realistic HIV prevention goals and strategies for the successful integration of HIV prevention into the services already accessed by high-risk women. Their expertise, however, is largely untapped.ConclusionsIn this article, women living with HIV summarize the substantial deficits that exist with regard to woman-focused HIV prevention efforts nationally and the policy and practice changes needed to reduce the domestic impact of the HIV epidemic on women and girls. They also outline opportunities for movement in this direction as implementation of the National HIV/AIDS Strategy proceeds.     

‘I am not a man’: Trans-specific barriers and facilitators to PrEP acceptability among transgender women

ABSTRACT

The frequent conflation of transgender (‘trans’) women with ‘men who have sex with men (MSM)’ in HIV prevention obscures trans women's unique gender identities, social and behavioural vulnerabilities, and their disproportionately high rates of HIV infection. Pre-exposure prophylaxis (PrEP) is an efficacious biomedical HIV prevention approach. However, trans women are underrepresented in PrEP research, and are often aggregated with MSM without consideration for their unique positions within sociocultural contexts. This study examined PrEP acceptability among trans women via three focus groups and nine individual interviews (total N?=?30) in San Francisco. While knowledge of PrEP was low, interest was relatively high once participants were informed. Due to past negative healthcare experiences, ability to obtain PrEP from a trans-competent provider was cited as essential to PrEP uptake and adherence. Participants noted that PrEP could address situations in which trans women experience reduced power to negotiate safer sex, including sex work. Trans-specific barriers included lack of trans-inclusive marketing of PrEP, prioritisation of hormone use, and medical mistrust due to transphobia. Findings underscore the importance of disaggregating trans women from MSM in HIV prevention strategies to mitigate disparate risk among this highly vulnerable population.     

Reluctant educators and self‐advocates: Older trans adults’ experiences of health‐care services and practitioners in seeking gender‐affirming services

BackgroundTrans‐identifying individuals experience unique barriers and challenges in negotiating health‐care systems due to the cisnormative attitudes and practices which obstruct the receipt of trans‐inclusive care. To date, there has been little exploration of older trans consumers’ experiences of contemporary health‐care services when seeking to transition medically in later life.ObjectivesQualitative findings are presented from a study of trans ageing and trans‐related health and social care needs in Wales, UK (2016‐18). The objectives are to (1) examine supportive and obstructive points of interaction with health‐care professionals, and (2) identify key learning messages for improving trans‐related health care from the perspectives of trans‐identifying adults in later life.DesignTrans‐identifying participants self‐selected to take part in two interviews—a life‐history interview and a semi‐structured interview. Interview data were analysed thematically using the framework method approach.Setting and participantsThis paper focuses on the accounts of 19 participants (50‐74 years of age) who identified as trans and were seeking to transition medically in mid‐ to later life.ResultsFindings indicate how older trans patients are positioned as reluctant educators for GPs in primary care settings and illustrate the transphobic practices and cisnormative assumptions encountered across health‐care interactions and systems that impede their journey of transitioning in later life.Discussion and conclusionsMessages from this study speak to the importance of improving professionals’ knowledge of gender identity diversity across the life course and making changes at a systemic level in redressing cisnormative assumptions and systems that reinforce inequities on the basis of gender identity.     

The conflation of gender and sex: Gaps and opportunities in HIV data among transgender women and MSM

ABSTRACT

Historically, HIV studies have conflated men who have sex with men (MSM) with transgender (trans) women, explicitly excluded trans individuals, or included sample sizes of trans people that are too small to reach meaningful conclusions. Despite the heavy burden of HIV among trans women, conflation of this population with MSM has limited the information available on the social and behavioural factors that increase HIV vulnerability among trans women and how these factors may differ from MSM. Using data sets from quantitative studies among MSM (n?=?645) and trans women (n?=?89), as well as qualitative in-depth interviews with 30 trans women in Baltimore, we explore what these data tell us about similarities and differences in HIV vulnerability between the two groups and where they leave gaps in our understanding. We conclude with implications for data collection and intervention development.     

Comparing Substance Use and School-Based Stressors Among Black and Latinx Transgender Youth and Peers With Shared Minoritized Identities

PurposeThe aim of this study is to compare substance use and school-based stressors among Black and Latinx transgender youth (trans BLY), White transgender youth (trans WY), and Black and Latinx cisgender youth (cis BLY) and identify associations between substance use and stressors among trans BLY.MethodsWe analyzed 2015–2017 Biennial California Healthy Kids Survey data with a weighted sample of the state’s secondary school population. The analytic sample included 9th and 11th grade trans BLY, trans WY, and cis BLY. Past 30-day and lifetime substance use (cigarettes, e-cigarettes/vaping, marijuana, and alcohol) and school-based stressors (victimization, race-, gender-, and sexuality-based harassment) were compared between cohorts via logistic regression. For trans BLY, associations between substance use and stressors were assessed via logistic regression.ResultsThe analytic sample (n = 19,780) included 252 trans BLY, 104 trans WY, and 19,424 cis BLY. Among trans BLY, estimated prevalence of 30-day (and lifetime) use of cigarettes, e-cigarette/vaping, marijuana, and alcohol were 13% (23%), 19% (39%), 27% (42%), and 29% (48%), respectively. Trans BLY had similar odds of 30-day and lifetime use of all substances compared to trans WY but higher odds of use compared to cis BLY. For trans BLY, race- and gender-based harassment and higher victimization levels were associated with higher odds of 30-day and lifetime use of all substances. Sexuality-based harassment was associated with higher odds of 30-day and lifetime marijuana and alcohol use.DiscussionTrans BLY have high prevalence of substance use, comparable with trans WY but higher than cis BLY. Substance use among trans BLY is associated with school-based stressors.     

Gender,migration and perceptions of HIV risk in Mexico

Abstract

This study examines the role that duty plays in men’s and women’s perceptions of HIV-related risk in Mexico, and how gender and migration influence these perceptions. We draw on qualitative data from the 2014 Study of Health and Migration in Mexico (SHMM), which included 24 in-depth interviews with migrant men and non-migrant women living in a medium-sized city in Guanajuato, Mexico. While men report migrating out of responsibility to provide for their families, this sense of duty also had implications for their sexual health behaviours. Duty permeates how residents in this migrant-sending community described their perceptions of HIV risk, with men and women drawing consistently on three aspects of duty: fidelity, gendered sexual expectations, and the burden of HIV prevention. We argue that a strong sense of duty can prompt gender role expansion for migrant men and limit gender role expansion for non-migrant women.     

Disparities in Sexually Transmitted Infection/HIV Testing,Contraception, and Emergency Contraception Care Among Adolescent Sexual Minority Women Who Are Racial/Ethnic Minorities

PurposeSexual minority women and racial/ethnic minority women in the United States are at increased risk for sexually transmitted infections (STIs) and unintended pregnancy. Yet, we know little about STI/HIV testing and contraceptive care among women who have sex with women only and women who have sex with both women and men, and who are racial/ethnic minorities. This study examined receipt of STI/HIV testing and contraceptive care among sexually active adolescent women by sex of sexual contact(s) and race/ethnicity.MethodsOur sample included 2,149 sexually active adolescent women from the National Survey of Family Growth (2011–2019). We examined receipt of sexual and reproductive health (SRH) services by sex of sexual contact(s) and race/ethnicity: STI and HIV testing, contraceptive counseling, contraceptive method, emergency contraception (EC) counseling, and EC method.ResultsService receipt was low for all adolescent women, with disparities by sex of sexual contact(s) and by race/ethnicity. Women who have sex with women only had the lowest rates across all services; women who have sex with both women and men had higher rates of STI and HIV testing and EC counseling than women who have sex with men only. Non-Hispanic Black women had higher rates of STI and HIV testing than non-Hispanic White peers, and non-Hispanic Black and Hispanic women had lower rates of contraception method receipt than their non-Hispanic White peers. Racial/ethnic disparities persisted when results were stratified by sex of sexual contact(s).DiscussionThere is an unmet need for improved SRH service delivery for all adolescent women and for services that are not biased by sex of sexual contact(s) and race/ethnicity.     

Gender differences among persons with HIV admitted to a university reference center in São Paulo, Brazil

The number of women living with HIV has increased in Brazil, demanding special attention to women's needs. To evaluate gender differences at an HIV reference center in S?o Paulo, 1,072 patient medical records from 1998 and 2002 were reviewed. As compared to male counterparts, women tended to be younger and have less schooling, and higher proportions of women were married and heterosexual. Thirty-six percent of women had undergone HIV testing because of an HIV+ partner. In contrast, 43% of men had undergone testing because of AIDS symptoms. At admission, 55% of men and 38% of women had an AIDS diagnosis. Women presented higher CD4+ cell counts and a higher proportion of undetectable HIV viral loads. No difference in access to antiretroviral therapy was seen after stratification for clinical status. Although the observed gender differences in socio-demographic characteristics emphasize women's social vulnerability to HIV, as compared to men, women in this cohort sought specialized care at earlier stages of infection. Knowledge about particular gender characteristics at admission to a reference center may contribute to organizing services delivery, improving care, and maximizing benefits.     

Psychosocial Problems and Coping Patterns of HIV Seropositive Wives of Men with HIV/AIDS

Abstract

The sociocultural milieu provides HIV positive women with fewer resources and more role responsibilities. The present research aimed at studying the psychosocial problems encountered in living, post HIV infection, and the coping patterns adopted by HIV seropositive wives of men with HIV/AIDS. In the background of an exploratory research design, thirty (n = 30) HIV positive women, attending Counseling Clinics in Bangalore (South India), selected through purposive sampling, were assessed using an interview schedule and a standardized coping scale. Majority of the respondents were the primary caregivers for their infected spouse and/or children. Content analysis of the problems revealed increased financial difficulties; problems in child care and support; compromised help-seeking due to stigma; problems in sexual interactions and communication in their marital relationship; role strain in caregiving; gender discriminatory and inadequate care; and increased concerns about parenting efficacy, post HIV infection. Escape avoidance was the most preferred coping strategy adopted by them. Situating the illness in a socio-familial context is indicated, and implications for social work and mental health practice follow from the findings.     

Intersections and evolution of ‘Butch-trans’ categories in Puerto Rico: Needs and barriers of an invisible population

ABSTRACT

Public health research among transgender populations globally has primarily focused on HIV/AIDS. However, trans men remain outside of this conceptual framework, with distinct but overlapping social contexts and needs. In Puerto Rico (PR), the trans men population has remained largely hidden within the ‘butch’ lesbian community. The objective of this article is to document the identity construction of trans men and ‘buchas’ (local term to refer to butch lesbians) in PR and its relation to their bodily practices and overall health. We conducted an exploratory qualitative study with 29 trans men and buchas based on ethnographic observation, focus groups, audio-recorded in-depth interviews, and critical discourse analysis. Findings emphasise two domains to be addressed by health policies and initiatives: (1) bodily representations and gender performance, and (2) the meanings of female biological processes. This small-scale ethnographic study represents an initial step towards understanding the social context of this ‘invisible’ community and significant implications for their health and well-being. We provide several recommendations to address public health concerns of this understudied, marginalised community.     

What role can gender-transformative programming for men play in increasing men’s HIV testing and engagement in HIV care and treatment in South Africa?

Men are less likely than women to test for HIV and engage in HIV care and treatment. We conducted in-depth interviews with men participating in One Man Can (OMC) – a rights-based gender equality and health programme intervention conducted in rural Limpopo and Eastern Cape, South Africa – to explore masculinity-related barriers to HIV testing/care/treatment and how participation in OMC impacted on these. Men who participated in OMC reported an increased capability to overcome masculinity-related barriers to testing/care/treatment. They also reported increased ability to express vulnerability and discuss HIV openly with others, which led to greater willingness to be tested for HIV and receive HIV care and treatment for those who were living with HIV. Interventions that challenge masculine norms and promote gender equality (i.e. gender-transformative interventions) represent a promising new approach to address men’s barriers to testing, care and treatment.     

Barriers to gender-equitable HIV testing: going beyond routine screening for pregnant women in Nova Scotia,Canada

Background  

Women and men face different gender-based health inequities in relation to HIV, including HIV testing as well as different challenges in accessing HIV care, treatment and support programs and services when testing HIV-positive. In this article, we discuss the findings of a mixed methods study exploring the various individual and structural barriers and facilitators to HIV counselling and testing experienced among a sample of adult women and men living in Nova Scotia, Canada.     

HIV Discrimination and the Health of Women Living with HIV

ABSTRACT

Women living with HIV are especially vulnerable to discrimination because of the stigma associated with the disease, as well as their race, gender and class status. To investigate the association between self-reported HIV discrimination and health outcomes among African-American and white women living with HIV, 366 women living with HIV were recruited from HIV/AIDS clinics in Georgia and Alabama. In this cross-sectional study, participants completed an interview that assessed self-reported HIV discrimination and depressive symptomatology, suicidal ideation, self-esteem, stress, quality of life, sexual health and HIV/AIDS related health care seeking. Nearly a sixth of the sample reported experiencing HIV discrimination. Women reporting HIV discrimination had higher mean scores for stress, suicidal ideation, depressive symptoms, number of unprotected sexual episodes; they had lower mean scores for self-esteem, and quality of life, and were more likely to have not sought medical care for HIV/AIDS. In race-specific analyses, none of the relationships between HIV discrimination and health outcomes were significant for white women. African-American women who reported HIV discrimination had higher mean scores for stress, suicidal ideation, depressive symptoms, number of unprotected sexual episodes; they had lower mean scores for self-esteem, and quality of life, and were more likely not to have sought medical care for HIV/AIDS. The findings indicated that HIV discrimination adversely affects women's mental, sexual and physical health. However, separate race-specific analyses indicated that compared to white women, African-American women were markedly more likely to experience the adverse affects of HIV discrimination. Eradication of HIV discrimination remains an important public health priority.     

In the name of brevity: The problem with binary HIV risk categories

ABSTRACT

According to the ‘Consolidated Guidelines on HIV Prevention, Diagnosis, Treatment and Care for Key Populations’ there are five groups of people at elevated risk of HIV, including ‘transgender women or transgender men who have receptive anal sex with men'. Although cost effectiveness strategies and best practice lessons recommend targeting specific populations for HIV prevention, existing risk categories lack specificity, and may in fact cause further confusion. Existing categories of risk often perpetuate notions of gender and sexuality that can erroneously exclude, alienate, and stigmatise those who are at the highest risk and thus should be prioritised. We review the troubled history of the MSM category and the problematic conflation of trans feminine individuals and MSM in much of the existing HIV literature, and how this practice has stymied progress in slowing the HIV epidemic in the most at-risk groups, including those who do not fit neatly into binary notions of gender and sex. We draw from examples in the field, specifically among trans feminine people in Beirut and San Francisco, to illustrate the lived experiences of individuals whose identities may not fit into Euro-Atlantic constructs of HIV prevention categories.     

Income Inequality,HIV Stigma,and Preventing HIV Disease Progression in Rural Communities

Antiretroviral therapies (ART) suppress HIV replication, thereby preventing HIV disease progression and potentially preventing HIV transmission. However, there remain significant health disparities among people living with HIV, particularly for women living in impoverished rural areas. A significant contributing factor to HIV-related disparities is a stigma. And yet, the relative contributions of stigma, gender, socio-economics, and geography in relation to health outcomes are understudied. We examined the associations of internalized stigma and enacted stigma with community-level income inequality and HIV viral suppression—the hallmark of successful ART—among 124 men and 74 women receiving care from a publicly funded HIV clinic serving rural areas with high-HIV prevalence in the southeastern US. Participants provided informed consent, completed computerized interviews, and provided access to their medical records. Gini index was collected at the census tract level to estimate community-level income inequality. Individual-level and multilevel models controlled for point distance that patients lived from the clinic and quality of life, and included participant gender as a moderator. We found that for women, income inequality, internalized stigma, and enacted stigma were significantly associated with HIV suppression. For men, there were no significant associations between viral suppression and model variables. The null findings for men are consistent with gender-based health disparities and suggest the need for gender-tailored prevention interventions to improve the health of people living with HIV in rural areas. Results confirm and help to explain previous research on the impact of HIV stigma and income inequality among people living with HIV in rural settings.

     

Identity management and sense of belonging to gay community among young rural Thai same-sex attracted men: implications for HIV prevention and treatment

Young Thai men who have sex with men continue to have high HIV prevalence and incidence in spite of much investment in community-based prevention approaches. To make HIV services more appropriate for same-sex attracted young men in Thailand, it needs to be considered how target groups view themselves and manage their identities. This paper derives from a qualitative study of 25 same-sex attracted rural young Thai men. It identifies five tactics men employed to manage the discrepancy between their preferences and parental/societal expectations regarding gender and sexuality, and discusses how the young men viewed themselves in the wider context of Thai society, including whether they felt part of a separate gay community. Participants usually did not adopt a gay social identity and were reluctant to join in gay community activities beyond dating. Hence, they would likely experience barriers in accessing gay community-based HIV services. HIV services targeting young same-sex attracted Thai men need to be diversified if they are to be more inclusive, appropriate and effective.     

Prevalence of health conditions and predictors of mortality in oldest old Mexican Americans and non-Hispanic whites

BackgroundThe oldest old represent a unique group of older adults. This group is rapidly growing worldwide and yet there are gaps in the knowledge related to their health condition. Ethnic differences in disease prevalence and mortality must be understood to better care for the oldest old.ObjectiveTo compare prevalence of common health conditions and predictors of mortality in oldest old Mexican Americans and non-Hispanic whites.MethodsThis study included 568 community-dwelling Mexican Americans (MA) aged 85 years and older from the Hispanic Established Population for the Epidemiological Study of the Elderly 2004–2005 and 933 non-Hispanic whites (NHW) of the same age from the Health and Retirement Study 2004. Measures included sociodemographic variables, self-reported medical conditions, activities of daily living (ADLs), and instrumental activities of daily living. Logistic regression analysis was used to examine 2-year mortality in both populations.ResultsHeart attack was significantly more prevalent in oldest old NHW compared with MA, regardless of gender. Conversely, diabetes was significantly more prevalent among MA men and women compared with their NHW counterparts. Compared with NHW men, MA men had significantly higher prevalence of cognitive impairment and hypertension. Additionally, prevalence of hip fracture was significantly higher for MA women compared with NHW women. Significant differences in ADL disability were observed only between both groups of women, whereas significant differences in instrumental activities of daily living disability were observed only between men. MA men and women had higher prevalence of obesity compared with NHW. Predictors of 2-year mortality for both ethnic groups included older age, male gender, and ADL disability. Cognitive impairment was a mortality predictor only for NHW. Similarly, lung disease was a predictor only for MA.ConclusionHealth-related conditions that affect the oldest old vary by gender and ethnicity and entail careful evaluation and monitoring in the clinical setting. Better care requires inclusion of such differences as part of the comprehensive evaluation of the oldest old adults.