Development and assessment of a hospital-led, community-partnering COVID-19 testing and prevention program for homeless and congregate living services in Toronto, Canada: a descriptive feasibility study.

BACKGROUND: Outbreaks of SARS-CoV-2 in shelters and congregate living settings are a major concern because of overcrowding and because resident populations are often at high risk for infection. The objective of this study was to describe the development, implementation and assessment of the COVID-19 Community Response Team, a program that enabled Women's College Hospital in Toronto, Ontario, to work in partnership with shelters and congregate living settings to prevent outbreaks. METHODS: The Community Response Team, associated with Women's College Hospital, an academic ambulatory hospital, carried out mobile testing for SARS-CoV-2, supported outbreak management and prevention through ongoing onsite partnership with medical staff, and conducted infection prevention and control (IPC) training to shelter staff. We conducted a descriptive analysis of the sites supported by the program between Apr. 20, 2020, and Aug. 15, 2020. We also assessed the program's feasibility (number of completed needs assessments, mobile testing events and IPC training events, and median time from referral to service delivery), adoption (number of nasopharyngeal swabs, number of pre- and post-program outbreaks and IPC uptake) and acceptability or satisfaction. RESULTS: The Community Response Team supported 32 sites. Of those, 30 completed an intake needs assessment, 24 completed mobile testing for SARS-CoV-2 and 15 received IPC support. Mobile testing resulted in the collection of 1566 nasopharyngeal swabs, of which 64 were positive for SARS-CoV-2 infection. Three sites had confirmed outbreaks. The median time from referral to needs assessment was 4 days (interquartile range [IQR] 1-13 days), and the median time to the testing day was 9 days (IQR 1-49 days). The median time from referral to IPC staff training was 14 days (IQR 4-79 days), and 100% of respondents reported being pleased or very pleased with the training. During the follow-up period, the 3 facilities with outbreaks overcame those outbreaks. Three sites supported by the Community Response Team had further single cases, but no site reported subsequent or secondary outbreaks. INTERPRETATION: The Community Response Team program led to the transfer of IPC knowledge, allowed for the management and prevention of SARS-CoV-2 outbreaks, and demonstrated feasibility. Collaborative supports between hospitals and the community housing sector may serve as models for ongoing system integration beyond the COVID-19 pandemic.

Sexual Relationship Power Equity Is Associated With Consistent Condom Use and Fewer Experiences of Recent Violence Among Women Living With HIV in Canada.

BACKGROUND: Sexual relationship power (SRP) inequities, including having a controlling partner, have not been widely examined among women living with HIV (WLWH). We measured the prevalence and key outcomes of relationship control among WLWH in Canada. METHODS: Baseline data from WLWH (≥16 years), reporting consensual sex in the last month enrolled in a Canadian community-collaborative cohort study in British Columbia, Ontario, and Quebec, included the relationship control SRP subscale by Pulerwitz (2000). Scale scores were dichotomized into medium/low (score = 1-2.82) vs. high relationship control (score = 2.82-4), and high scores indicate greater SRP equity. Cronbach's alpha assessed scale reliability. Bivariate analyses compared women with high vs. medium/low relationship control. Crude and adjusted multinomial regression examined associations between relationship control and condom use [consistent (ref), inconsistent, or never]; any sexual, physical, and/or emotional violence; and physical and/or sexual violence [never (ref), recent (≤3 months ago), and previous (>3 months ago)]. RESULTS: Overall, 473 sexually active WLWH (33% of cohort), median age = 39 (IQR = 33-46) years, 81% on antiretroviral therapy, and 78% with viral loads <50 copies/mL were included. The subscale demonstrated good reliability (Cronbach's alpha = 0.92). WLWH with high relationship control (80%) were more likely ( P < 0.05) to be in a relationship, have no children, have greater resilience, and report less sociostructural inequities. In adjusted models, high relationship control was associated with lower odds of inconsistent vs. consistent condom use [adjusted odds ratio (aOR): 0.39 (95% confidence interval: 0.18 to 0.85)], any recent violence [aOR: 0.14 (0.04-0.47)] as well as recent physical and/or sexual [aOR : 0.05 (0.02-0.17)] but not previous violence (vs. never). DISCUSSION: Prioritizing relationship equity and support for WLWH is critical for addressing violence and promoting positive health outcomes.

Development of the Canadian Women-Centred HIV Care Model Using the Knowledge-to-Action Framework.

In Canada, women make up 25% of the prevalent HIV cases and represent an important population of those living with HIV, as a high proportion are racialized and systemically marginalized; furthermore, many have unmet healthcare needs. Using the knowledge-to-action framework as an implementation science methodology, we developed the "Women-Centred HIV Care" (WCHC) Model to address the needs of women living with HIV. The WCHC Model is depicted in the shape of a house with trauma- and violence-aware care as the "foundation". Person-centred care with attention with attention to social determinants of health and family make up the "first" floor. Women's health (including sexual and reproductive health and rights) and mental and addiction health care are integrated with HIV care, forming the "second" floor. Peer support, leadership, and capacity building make up the "roof". To address the priorities of women living with HIV in all their diversity and across their life course, the WCHC Model should be flexible in its delivery (e.g., single provider, interdisciplinary clinic or multiple providers) and implementation settings (e.g., urban, rural).

Quality of life of older women living with HIV: comparative assessment of physical and mental health-related markers using a large Canadian Sexual and Reproductive Health Cohort Study.

Objective: This study assessed and compared physical and mental health components of quality of life (QoL) for older and younger women living with HIV (WLWH). Method: Using survey data from the Canadian HIV Women's Sexual and Reproductive Health Cohort Study, demographic, well-being, and physical and mental health-related QoL (HR-QoL) variables were compared between older (≥50 years) and younger (<50 years) WLWH. As the only significantly different QoL component, bivariate analyses and linear regression were used to assess factors associated with physical HR-QoL of older women. Results: The sample frame comprised 1,422 women (28.0% older women). Younger WLWH's mean age was 37.8 years (SD = 7.4) compared to older WLWH (55.8 years, SD = 5.3). Compared to younger WLWH, older WLWH had poorer physical HR-QoL (40.0 vs. 50.7; p < 0.001) but similar mental HR-QoL (42.7 vs. 42.1; p > 0.001). Older WLWH had lower social support (p < 0.001) with no significant differences in depressive symptoms or resilience. Resilience was associated with improved physical HR-QOL. Food insecurity, poorer mental HR-QoL and depressive symptoms were associated with poorer physical health. Discussion: Compared to younger WLWH, older WLWH had poorer physical HR-QoL, which was associated with resilience, food insecurity and mental health factors, highlighting the complex interactions of health-related social-ecological factors impacting aging WLWH.

Cost-effectiveness analysis of infant feeding modalities for virally suppressed mothers in Canada living with HIV.

OBJECTIVE: The aim of the study was to determine whether exclusive breastfeeding or exclusive formula feeding is more cost-effective when a Canadian mother with HIV is adherent to antiretroviral therapy and has full virologic suppression. DESIGN: Current Canadian guidelines recommend that mothers with HIV practice exclusive formula feeding. This contradicts the updated World Health Organization (WHO) guidelines which recommend that mothers with HIV should breastfeed for ≥12 months while receiving support for antiretroviral therapy adherence. Due to the economic and health risks and benefits associated with each modality, there remains expert disagreement on whether the WHO recommendations should be adopted in high-income countries. METHODS: A microsimulation model was developed to estimate lifetime costs and effectiveness (i.e., infant's quality-adjusted life years) of a hypothetical group of 1,000,000 initially healthy, HIV-negative infants, if the mother with HIV was on antiretroviral therapy with full virologic suppression and either exclusive breastfeeding or exclusive formula feeding. The model was developed from the economic perspective of the Ontario Ministry of Health, taking into account direct costs associated with infant feeding modality as well as related indirect costs born out of the child's lifetime health outcomes. Uncertainties related to model parameters were evaluated using one-way and probabilistic sensitivity analyses. RESULTS: In comparison to exclusive formula feeding, exclusive breastfeeding was the dominant feeding modality (i.e., less costly and more effective) yielding cost-savings of $13,812 per additional quality-adjusted life year gained. Neither one-way nor probabilistic sensitivity analyses altered the conclusions. CONCLUSIONS: Despite the risk of HIV transmission, exclusive breastfeeding was more cost-effective than exclusive formula feeding. These findings merit review of current infant feeding guidelines for mothers with HIV living in high-income countries.

Assessment of antiretroviral third agent virologic durability after initiation of first antiretroviral regimen.

Information on the virologic durability of modern antiretroviral regimens is important to clinicians. We aimed to describe virologic durability of first-line integrase strand transfer inhibitor (INSTI)-, nonnucleoside reverse transcriptase inhibitor (NNRTI)-, or protease inhibitor (PI)-based antiretroviral regimens. This was a retrospective study of antiretroviral-naïve patients that initiated first-line antiretroviral regimens with two nucleoside reverse transcriptase inhibitors and an INSTI, NNRTI, or PI between January 2006 and June 2016. The outcome was time to virologic failure, which was assessed by Kaplan-Meier survival analysis and Cox regression models. There were 780 patients (median age = 37 years [interquartile range (IQR) = 30-45], 93.3% male, 56.2% Caucasian, median HIV duration = 1.8 years [IQR = 0.4-5.4], baseline log10 viral load [VL]=4.6 [IQR = 4.1-5.1], and baseline CD4+ cell count = 320 cells/µl [IQR = 217-440]). In total, 189/780 were on a third agent INSTI, 339/780 on a third agent NNRTI, and 252/780 on a third agent PI. Kaplan-Meier survival probability revealed longer time to virologic failure for INSTI, followed by NNRTI then PI (p < 0.001). Multivariable Cox regression revealed that being on an INSTI regimen (aHR = 0.27; 95%CI = 0.18-0.41) or NNRTI regimen (aHR = 0.64; 95%CI = 0.47-0.87) versus PI regimen, frequent VL testing (per year), (aHR = 0.64; 95%CI = 0.47-0.87), and duration of ART (aHR = 0.22; 95%CI = 0.17-0.30) (years) were inversely associated with time to virologic failure, and log10 of baseline VL (aHR = 1.94; 95%CI = 1.58-2.39 per log10) increased risk. Virologic failure was delayed and virologic durability prolonged for INSTI- compared to NNRTI- and PI-based regimens, supporting current antiretroviral therapy guidelines.

Understanding the Fertility Desires and Intentions among HIV-Positive Men Living in Ontario: Survey Instrument Development and Validation.

Men with HIV have highlighted the importance of understanding their fertility desires. However, most research has focused on women. We aimed (1) to develop a survey instrument to assess fertility desires and intentions among HIV-positive men and (2) to assess its face, content, and construct validity, as well as test-retest reliability and internal consistency. Principal component analysis was used for construct validity analysis in a sample of 60 men with HIV. The test-retest reliability and internal consistency were assessed using Spearman correlation and Cronbach α, respectively. The initial and the final version of the questionnaire consisted of 10 domains and 14 constructs. We found a one-component model for the 3 constructs analyzed and Cronbach α values were ≥.70. Test-retest statistic was stable with Spearman correlation >0.70. In conclusion, a reliable and valid questionnaire was developed for determining the fertility desires and intentions of men with HIV.

South Asian immigrant women's suggestions for culturally-tailored HIV education and prevention programs.

Using a community-based, socialist feminist qualitative study, and an emergent research design, we explored the unique individual experiences of South Asian immigrant women living with HIV in the Greater Toronto Area (GTA) of Ontario, Canada. We assessed both the HIV risk context and the strategies for HIV education and prevention as expressed by study participants. Grounded in Connell's social theory of gender, a thematic analysis of semi-structured interviews with 12 women yielded six themes related to the power and impact of stigmatization, community's denial of HIV, infidelity, manifested in resistance to discussing sex and condom use, non-disclosure, and lack of HIV knowledge. This study validated the legitimacy of listening to the voices of South Asian immigrant women living with HIV, who communicated 20 recommendations for researchers, educators, community organizations, and service providers to culturally-tailor HIV education programs.

Geographic differences in the experiences of HIV-related stigma for women living with HIV in northern and rural communities of Ontario, Canada.

INTRODUCTION: In Canada, individuals living in northern and rural regions report more barriers to health service access. For people living with HIV, these barriers may be exacerbated by experiences of HIV-related stigma, and women living with HIV can be disproportionately affected because of intersections of multiple forms of oppression, including racism, sexism and classism. To further understand the impact of geography on the wellbeing of women living with HIV, this study assessed geographic differences in HIV-related stigma experiences among women in the Canadian HIV Women's Sexual & Reproductive Health Cohort Study (CHIWOS). METHODS: CHIWOS is a multisite cohort study of women living with HIV in Canada that operates under community-based participatory research methodology along with GIPA (greater involvement of people with HIV/AIDS) and MIWA (meaningful involvement of women living with HIV/AIDS) principles. This analysis compared peer research associate-administered questionnaire data between participants in northern and southern Ontario, Canada, and between participants in rural and non-rural Ontario. Northern regions were defined by healthcare delivery jurisdiction. The primary outcome was the 10-item shortened HIV Stigma Scale score. Multivariable linear regression models assessed the association between rural and northern regions and stigma score. RESULTS: Sixteen women were excluded due to incomplete HIV Stigma Scale data. Of 701 women included in the analysis, 66 (9.4%) were from northern regions and 24 (3.4%) were from rural regions. Mean stigma scores were 23.9 (standard deviation (SD) 8.0) overall, 26.7 (SD 8.8) in northern regions, 23.6 (SD 7.9) in southern regions, 28.3 (SD 10.1) in rural regions, and 23.8 (SD 7.8) in non-rural regions. In multivariable analyses, northern and rural regions of residence were associated with a 3.05 (95% confidence interval (CI): 0.77, 5.32) and 4.83 (95% CI: 1.37, 8.28) point increase in stigma score, respectively. CONCLUSIONS: Living in both northern and rural regions of Ontario was associated with higher HIV Stigma Scale scores. These geographic discrepancies in experiences of HIV-related stigma highlight the need for region-specific programs to reduce HIV-related stigma and to support people living with HIV who are affected by HIV-related stigma, particularly those living in geographically isolated regions. Prior qualitative studies have documented the important impact of HIV-related stigma, and this study supports these observations with quantitative data from a population that is often under-represented in HIV research.

Factors Associated with the Separate and Concurrent Experiences of Food and Housing Insecurity Among Women Living with HIV in Canada.

People living with HIV are disproportionately affected by food and housing insecurity. We assessed factors associated with experiencing food and/or housing insecurity among women living with HIV (WLHIV) in Canada. In our sample of WLHIV (N = 1403) 65% reported an income less than $20,000 per year. Most (78.69%) participants reported food and/or housing insecurity: 27.16% reported experiencing food insecurity alone, 14.26% reported housing insecurity alone, and 37.28% reported experiencing food and housing insecurity concurrently. In adjusted multivariable logistic regression analyses, experiencing concurrent food and housing insecurity was associated with: lower income, Black ethnicity versus White, province of residence, current injection drug use, lower resilience, HIV-related stigma, and racial discrimination. Findings underscore the urgent need for health professionals to assess for food and housing insecurity, to address the root causes of poverty, and for federal policy to allocate resources to ameliorate economic insecurity for WLHIV in Canada.

Health System Features That Enhance Access to Comprehensive Primary Care for Women Living with HIV in High-Income Settings: A Systematic Mixed Studies Review.

Women living with HIV in high-income settings continue to experience modifiable barriers to care. We sought to determine the features of care that facilitate access to comprehensive primary care, inclusive of HIV, comorbidity, and sexual and reproductive healthcare. Using a systematic mixed studies review design, we reviewed qualitative, mixed methods, and quantitative studies identified in Ovid MEDLINE, EMBASE, and CINAHL databases (January 2000 to August 2017). Eligibility criteria included women living with HIV; high-income countries; primary care; and healthcare accessibility. We performed a thematic synthesis using NVivo. After screening 3466 records, we retained 44 articles and identified 13 themes. Drawing on a social-ecological framework on engagement in HIV care, we situated the themes across three levels of the healthcare system: care providers, clinical care environments, and social and institutional factors. At the care provider level, features enhancing access to comprehensive primary care included positive patient-provider relationships and availability of peer support, case managers, and/or nurse navigators. Within clinical care environments, facilitators to care were appointment reminder systems, nonidentifying clinic signs, women and family spaces, transportation services, and coordination of care to meet women's HIV, comorbidity, and sexual and reproductive healthcare needs. Finally, social and institutional factors included healthcare insurance, patient and physician education, and dispelling HIV-related stigma. This review highlights several features of care that are particularly relevant to the care-seeking experience of women living with HIV. Improving their health through comprehensive care requires a variety of strategies at the provider, clinic, and greater social and institutional levels.

HIV-related stigma, racial discrimination, and gender discrimination: Pathways to physical and mental health-related quality of life among a national cohort of women living with HIV.

Social inequities compromise health-related quality of life (HR-QoL) among women living with HIV (WLWH). Little is known about health impacts of intersecting stigma based on HIV status, race and gender among WLWH or potential mechanisms to promote HR-QoL. We tested pathways from multiple types of stigma (HIV-related, racial, gender) to physical and mental HR-QoL utilizing baseline survey data from a national cohort of WLWH in Canada (2013-2015). Structural equation modeling was conducted using maximum likelihood estimation methods to test the direct effects of HIV-related stigma, racial discrimination, and gender discrimination on HR-QoL and indirect effects via social support and economic insecurity, adjusting for socio-demographic factors. Among 1425 WLWH (median age: 43years [IQR=35-50]), HIV-related stigma and gender discrimination had significant direct effects on mental HR-QoL. Social support mediated the relationship between HIV-related stigma and mental HR-QoL, accounting for 22.7% of the effect. Social support accounted for 41.4% of the effect of gender discrimination on mental HR-QoL. Economic insecurity accounted for 14.3% of the effect of HIV-related stigma, and 42.4% of the effect of racial discrimination, on physical HR-QoL. Fit indices suggest good model fit (χ2[1]=3.319, p=0.069; CFI=0.998; RMSEA=0.042 (90% CI: 0-0.069); SRMR=0.004). Findings reveal complex relationships between intersecting stigma and HR-QoL. Strategies that address intersecting stigma and economic insecurity among WLWH may prevent the harmful impacts of HIV-related stigma and gender discrimination on physical HR-QoL. Increasing social support may mitigate the impacts of stigma on mental health. Findings can inform multi-level interventions to promote health and wellbeing among WLWH.

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

BACKGROUND: Women 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. METHOD: Peer 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. RESULTS: Women 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. CONCLUSION: Despite 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.

Increased mortality among Indigenous persons in a multisite cohort of people living with HIV in Canada.

OBJECTIVE: Compare all-cause mortality between Indigenous participants and participants of other ethnicities living with HIV initiating combination antiretroviral therapy (cART) in an interprovincial multi-site cohort. METHODS: The Canadian Observational Cohort is a collaboration of 8 cohorts of treatment-naïve persons with HIV initiating cART after January 1, 2000. Participants were followed from the cART initiation date until death or last viral load (VL) test date on or before December 31, 2012. Cox proportional hazard models were used to estimate the effect of ethnicity on time until death after adjusting for age, gender, injection drug use, being a man who has sex with men, hepatitis C, province of origin, baseline VL and CD4 count, year of cART initiation and class of antiretroviral medication. RESULTS: The study sample consisted of 7080 participants (497 Indigenous, 2471 Caucasian, 787 African/Caribbean/Black (ACB), 629 other, and 2696 unknown ethnicity). Most Indigenous persons were from British Columbia (BC) (83%), with smaller numbers from Ontario (13%) and Québec (4%). During the study period, 714 (10%) participants died. The five-year survival probability was lower for Indigenous persons (0.77) than for Caucasian (0.94), ACB (0.98), other ethnicities (0.96) and unknown ethnicities (0.85) (p < 0.0001). In an adjusted proportional hazard model for which missing data were imputed, Indigenous persons were more likely to die than Caucasian participants (hazard ratio = 2.69, p < 0.0001). CONCLUSION: The mortality rate for Indigenous persons was higher than for other ethnicities and is largely reflective of the BC population. Addressing treatment challenges and identifying HIV- and non-HIV-related causes for mortality among Indigenous persons is required to optimize their clinical management.

Access to fertility services in Canada for HIV-positive individuals and couples: a comparison between 2007 and 2014.

In the modern era of HIV care, a multitude of clinical needs have emerged; one such need is the growing sub-specialty of HIV and reproductive health. In 2007, a study surveying Canadian fertility clinics found limited access to fertility services for HIV-positive patients. Given the extensive efforts made to address this lack of services, a follow-up assessment was warranted. This study aimed to compare the access to Canadian fertility clinics and services for HIV-positive individuals and couples in 2014 and 2007. Surveys were sent to medical or laboratory directors of assisted reproductive technology (ART) clinics in 2014 and results were compared to those sent in 2007. Main outcome measures included: the proportion of fertility clinics willing to provide ART to people with HIV, the specific services offered, and whether the 2012 Canadian HIV Pregnancy Planning Guidelines were implemented to inform practice. Across Canadian provinces, 20/34 (59%) clinics completed the survey. Ninety-five percent (19/20) of clinics accepted HIV-positive patients for consultation. Only 50% (10/20) of clinics in four provinces offered a full range of ART (defined as including in vitro fertilization [IVF]). Ten clinics (50%) in five provinces were aware that guidelines exist; half (n = 5) having read them and four reporting implementation of all the guidelines' recommendations in their practice. Compared to 2007, more clinics had implemented separate facilities (p = 0.028) to treat HIV-positive individuals, offered IVF (p = 0.013) for HIV-positive female partners, sperm washing (p = 0.033) for HIV-positive male partners, and risk reduction techniques to couples with HIV-positive men and women (p = 0.006). Access to fertility clinics for people with HIV has improved over time but is still regionally dependent and access to full ART remains limited. These findings suggest the need for advocacy targeted towards geographical-specific areas and optimizing access to comprehensive services.

Engagement in and continuity of HIV care among African and Caribbean Black women living with HIV in Ontario, Canada.

Engagement in care is a key component of the HIV care cascade, yet there are knowledge gaps regarding how to assess HIV care engagement. This study aimed to develop a tool to assess HIV care engagement and to assess associations between HIV care engagement and quality of life (QOL) among African, Caribbean and Black (ACB) women living with HIV (WLWH). We conducted a cross-sectional survey with ACB WLWH across Ontario, Canada. We developed the 'HIV Engagement in and Continuity of Care Scale' (HECCS). We conducted exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) to test the scale's factor structure. We conducted structural equation modeling (SEM) with maximum likelihood estimation to examine the associations between the HECCS and QOL. EFA yielded four factors: access to care, care by doctor/health professionals, control of HIV care, and appointment timekeeping. The CFA of the HECCS demonstrated good model fit: χ2 (DF: 1; n = 173) = 1.175, p = 0.278; CFI: 0.998; Tucker-Lewis Index (TLI): 0.990; RMSEA: 0.032. The HECCS was associated with increased QOL. The model fit the data well: χ2 (DF: 31, n = 173) = 51.19, p = 0.013; CFI = 0.955; TLI = 0.934; RMSEA = 0.062. Engagement in and continuity of care is multifaceted. We recommend interventions to promote the institutional capacity to better engage ACB WLWH in HIV care.

The Association Between HIV Disclosure Status and Perceived Barriers to Care Faced by Women Living with HIV in Latin America, China, Central/Eastern Europe, and Western Europe/Canada.

Generally, women are less likely than men to disclose their HIV status. This analysis examined the relationship between HIV disclosure and (1) perceived barriers to care and (2) quality of life (QoL) for women with HIV. The ELLA (EpidemioLogical study to investigate the popuLation and disease characteristics, barriers to care, and quAlity of life for women living with HIV) study enrolled HIV-positive women aged ≥18 years. Women completed the 12-item Barriers to Care Scale (BACS) questionnaire. QoL was assessed using the Health Status Assessment. BACS and QoL were stratified by dichotomized HIV disclosure status (to anyone outside the healthcare system). Multilevel logistic regression analysis was used to identify factors associated with disclosure. Of 1945 patients enrolled from Latin America, China, Central/Eastern Europe, and Western Europe/Canada between July 2012 and September 2013, 1929 were included in the analysis (disclosed, n = 1724; nondisclosed, n = 205). Overall, 55% of patients lived with a husband/partner, 53% were employed, and 88% were receiving antiretroviral therapy. Patients who were with a serodiscordant partner were more likely to disclose (p = 0.0003). China had a disproportionately higher percentage of participants who did not disclose at all (nearly 30% vs. <15% for other regions). Mean BACS severity scores for medical/psychological service barriers and most personal resource barriers were significantly lower for the disclosed group compared with the nondisclosed group (p ≤ 0.02 for all). Compared with the disclosed group, the nondisclosed group reported statistically significantly higher (p ≤ 0.03) BACS item severity scores for 8 of the 12 potential barriers to care. The disclosed group reported better QoL. Overall, HIV nondisclosure was associated with more severe barriers to accessing healthcare by women with HIV.

Barriers to access to care reported by women living with HIV across 27 countries.

Increased access to successful antiretroviral therapy (ART) is necessary in order to achieve an AIDS-free generation. Importantly, slightly over half of the people living with HIV are women. Small studies have described many barriers to accessing treatment and care among women living with HIV. This cross-sectional, non-interventional, epidemiological study assessed the prevalence of barriers to accessing care for women living with HIV across 27 countries, divided into four global regions. HIV-positive women attending routine clinical visits were offered the opportunity to participate in the study. Data describing the study sites and demographic characteristics of the participating women were collected. Participating women filled out questionnaires including the Barriers to Care Scale (BACS) questionnaire, on which they reported the extent to which they found each of the 12 potential barriers to accessing health care problematic. A total of 1931 women living with HIV were included in the study: 760 from Western Europe and Canada (WEC), 532 from Central and Eastern Europe (CEE), 519 from Latin America (LA), and 120 from China. The mean age of participating women was 40.1 ± 11.4 years. A total of 88.2% were currently taking ART. A total of 81.8% obtained HIV treatment under a government health plan. The most prevalent barrier to care was community HIV/AIDS stigma. Community HIV/AIDS knowledge, lack of supportive/understanding work environments, lack of employment opportunities, and personal financial resources were also highly prevalent barriers to accessing care. These findings indicate that, more than 30 years after the start of the AIDS epidemic, stigma is still a major issue for women living with HIV. Continued efforts are needed to improve community education on HIV/AIDS in order to maximize access to health care among women living with HIV.

An economic evaluation of conception strategies for heterosexual serodiscordant couples where the male partner is HIV-positive.

BACKGROUND: To conduct an economic evaluation of the three commonly used interventions that reduce sexual HIV transmission when an HIV-negative female aims to conceive with an HIV-positive male on combination antiretroviral therapy (condomless sex restricted to timed ovulation [CS], sperm washing with intrauterine insemination [SW] and condomless sex restricted to timed ovulation with pre-exposure prophylaxis [CS-PrEP]). As SW and CS-PrEP are only privately available for pregnancy planning for this population in Canada, this study was conducted to inform policy decisions concerning potential public health insurance coverage, as well as to inform fertility counselling in settings with adequate combination antiretroviral therapy access globally. METHODS: We developed a cohort Markov model with a lifetime horizon and used the perspective of Ontario's Ministry of Health (MOH). Input parameters were drawn from literature, the MOH's Schedule of Benefits and a time trade-off questionnaire designed for this study. Outcome measures included quality-adjusted life-years and incremental cost-effectiveness. Costs and benefits were discounted at annual rates of 3%. Costs were reported in Canadian 2013 dollars and an exchange rate of 1 USD to 1.066 CND was applied where necessary. Sensitivity analysis assessed the uncertainty of model parameters. RESULTS: The base case analysis found that CS-PrEP and SW were each more costly and less effective at conception than CS. The results were robust in the sensitivity analysis and suggest that CS is the dominant conception strategy in this population. CONCLUSIONS: Neither CS-PrEP nor SW represent better value for money relative to CS as a conception option for HIV-discordant couples with positive male partners. Based on these findings, CS-PrEP and SW cannot be recommended for public-funding in developed countries.

A review of reproductive health research, guidelines and related gaps for women living with HIV.

The study of pregnancy and motherhood in women living with HIV (WLWH) has concentrated on the health of the unborn baby and the prevention of mother-to-child transmission, whereas consideration of the broader aspects of women's reproductive health has been largely overlooked. The rights of WLWH with respect to their reproductive health should be exactly the same as non-HIV-positive women, however, inequalities exist due to discrimination and also because the treatment guidelines used in the care of women are often based on insufficient evidence. The purpose of this article is to review the available literature on reproductive health issues for WLWH and to identify gaps requiring further investigation. Our review indicates that further research is warranted into a number of aspects of reproductive health among WLWH. Currently, access to the relevant reproductive health resources and services, such as advice on contraception and fertility services, for WLWH is far from optimal in many developed countries and most developing countries. More data are needed on the most appropriate family planning options with the consideration of drug interactions between contraceptives and antiretroviral therapy and the risk of HIV transmission. Also, more research is needed to improve understanding of the maternal health challenges facing WLWH. Similarly, our understanding of the impact of HIV on the physical and emotional health of pregnant women and new mothers is far from complete. Answering these questions and countering these inequalities will help to ensure the reproductive health and child-bearing intentions of WLWH become an integral part of HIV medicine.