Methods in HIV-Related Intersectional Stigma Research: Core Elements and Opportunities.

Researchers are increasingly recognizing the importance of studying and addressing intersectional stigma within the field of HIV. Yet, researchers have, arguably, struggled to operationalize intersectional stigma. To ensure that future research and methodological innovation is guided by frameworks from which this area of inquiry has arisen, we propose a series of core elements for future HIV-related intersectional stigma research. These core elements include multidimensional, multilevel, multidirectional, and action-oriented methods that sharpen focus on, and aim to transform, interlocking and reinforcing systems of oppression. We further identify opportunities for advancing HIV-related intersectional stigma research, including reducing barriers to and strengthening investments in resources, building capacity to engage in research and implementation of interventions, and creating meaningful pathways for HIV-related intersectional stigma research to produce structural change. Ultimately, the expected payoff for incorporating these core elements is a body of HIV-related intersectional stigma research that is both better aligned with the transformative potential of intersectionality and better positioned to achieve the goals of Ending the HIV Epidemic in the United States and globally. (Am J Public Health. 2022;112(S4):S413-S419. https://doi.org/10.2105/AJPH.2021.306710).

Severe Food Insecurity, Gender-Based Violence, Homelessness, and HIV Risk among Street-based Female Sex Workers in Baltimore, Maryland.

Despite established links between food insecurity and HIV outcomes, no studies have examined the role of food insecurity among female sex workers (FSW) in the United States (US). The aim of this exploratory study was to identify correlates (structural vulnerability and health factors) of severe food insecurity among street-based FSW in Baltimore, Maryland using multivariable logistic regression. In adjusted models, FSW with severe food insecurity were at greater odds of recent homelessness, physical intimate partner violence, client condom refusal, and HIV infection. Multi-sectoral approaches must take into consideration the co-occurrence of structural and health vulnerabilities to food insecurity among FSW in the US, including those that address violence, housing, and HIV.

Economic Context and HIV Vulnerability in Adolescents and Young Adults Living in Urban Slums in Kenya: A Qualitative Analysis Based on Scarcity Theory.

Urban slum adolescents and young adults have disproportionately high rates of HIV compared to rural and non-slum urban youth. Yet, few studies have examined youth's perceptions of the economic drivers of HIV. Informed by traditional and behavioral economics, we applied a scarcity theoretical framework to qualitatively examine how poverty influences sexual risk behaviors among adolescents and young adults. Focus group discussions with one hundred twenty youth in Kenyan's urban slums were transcribed, coded, and analyzed using interpretive phenomenology. Results indicated that slum youth made many sexual decisions considered rational from a traditional economics perspective, such as acquiring more sex when resources were available, maximizing wealth through sex, being price-sensitive to costs of condoms or testing services, and taking more risks when protected from adverse sexual consequences. Youth's engagement in sexual risk behaviors was also motivated by scarcity phenomena explained by behavioral economics, such as compensating for sex lost during scarce periods (risk-seeking), valuing economic gains over HIV risks (tunneling, bandwidth tax), and transacting sex as an investment strategy (internal referencing). When scarcity was alleviated, young women additionally described reducing the number of sex partners to account for non-economic preferences (slack). Prevention strategies should address the traditional and behavioral economics of the HIV epidemic.

'If you have children, you have responsibilities': motherhood, sex work and HIV in southern Tanzania.

Many female sex workers begin sex work as mothers, or because they are mothers, and others seek childbearing. Motherhood may influence women's livelihoods as sex workers and their subsequent HIV risks. We used qualitative research methods (30 in-depth interviews and three focus group discussions) and employed Connell's theory of Gender and Power to explore the intersections between motherhood, sex work, and HIV-related risk. Participants were adult women who self-reported exchanging sex for money within the past month and worked in entertainment venues in southern Tanzania. Participants had two children on average, and two-thirds had children at home. Women situated their socially stigmatised work within their respectable identities as mothers caring for their children. Being mothers affected sex workers' negotiating power in complex manners, which led to both reported increases in HIV-related risk behaviours (accepting more clients, accepting more money for no condom, anal sex), and decreases in risk behaviours (using condoms, demanding condom use, testing for HIV). Sex workers/mothers were aware of risks at work, but with children to support, their choices were constrained. Future policies and programming should consider sex workers' financial and practical needs as mothers, including those related to their children such as school fees and childcare.

Barriers and facilitators of retention in HIV care and treatment services in Iringa, Tanzania: the importance of socioeconomic and sociocultural factors.

Although an increasing number of people living with HIV (PLHIV) in sub-Saharan Africa are benefiting from the rapid scale-up of antiretroviral therapy (ART), retention in HIV care and treatment services remains a major concern. We examined socioeconomic and sociocultural barriers and potential facilitators of retention in ART in Iringa, Tanzania, a region with the second highest prevalence of HIV in the country. In 2012, 116 in-depth interviews were conducted to assess community members' perceptions, barriers and facilitators of HIV treatment in Iringa, including key informants, persons at heightened risk for infection, and HIV service-delivery users. Data were transcribed, translated, entered into Atlas.ti, coded, and analyzed for key themes. In order to provide the full range of perspectives across the community on issues that may affect retention, we report findings from all 116 participants, but draw on verbatim quotes to highlight the experiences of the 14 PLHIV who reported that they were receiving HIV care and treatment services. Despite the growing availability of HIV care and treatment services in Iringa, participants reported significant barriers to retention, including lack of knowledge and misperceptions of treatment, access problems that included difficulties in reaching distant clinics and pervasive poverty that left PLHIV unable to cope with out-of-pocket costs associated with their care, persistent stigmatization of PLHIV and frequent reliance on alternative healing systems instead of biomedical treatment. Positive perceptions of the efficacy of ART, improved ART availability in the region, improved access to care through supplemental aid, and social support were perceived to enhance treatment continuation. Our findings suggest that numerous socioeconomic and sociocultural barriers inhibit retention in HIV care and treatment services in this setting. Intervention strategies that improve ART accessibility, incorporate supplemental aid, enhance social support, reduce stigma, and develop partnerships with alternative healers are needed to improve HIV-related outcomes.

"You know that we travel a lot": Mobility narratives among female sex workers living with HIV in Tanzania and the Dominican Republic.

Female sex workers (FSW) are highly mobile, which may result in reduced access to and use of health services and increased risk for poor health outcomes, particularly for those living with HIV. Mobility includes spatial, temporal, and social elements that are not fully captured by quantitative measures. We conducted two rounds of in-depth interviews with FSW living with HIV in Iringa, Tanzania (n = 20), and Santo Domingo, Dominican Republic (n = 20), to describe mobility experiences and compare mobility narratives across settings. We integrated a thematic analysis of all interviews with a narrative analysis of a subset of 10 information-rich interviews (five in each country) with women who had recently traveled, for sex work or another reason, outside of their hometown. Across narratives, FSW living with HIV traveled locally or to seasonal destinations, for short and long periods. Social factors influencing mobility included economic drivers; risk of arrest, harassment, or violence; anonymity and/or familiarity; social relationships; and clients' mobility. Spatial, temporal, and social factors intersected in unique ways in FSW's mobility experiences, yet distinct mobility typologies were evident across settings and destinations. Together, mobility narratives of FSW living with HIV can inform quantitative research on mobility typologies in Tanzania, the Dominican Republic, and elsewhere. With the potential for economic circumstances, climate change, and other emergencies to increase people's mobility around the world, researchers and practitioners can learn from the lived experiences of FSW to inform whether and how to tailor and improve the accessibility of HIV care and treatment interventions based on spatial, temporal, and social characteristics of mobility.

HIV prevention among women in low- and middle-income countries: intervening upon contexts of heightened HIV risk.

Women's vulnerability to HIV infection is influenced by contextual factors in the risk environment that operate at multiple levels (i.e., physical, social, economic, policy). We present three case studies that illustrate combination approaches to HIV prevention among women who are at heightened risk for infection, especially sex workers, in low- and middle-income countries (LMICs). Lessons learned from these case studies are consistent with international literature promoting interventions that combine sexual risk reduction, condom promotion, and improved access to sexually transmitted infection (STI) treatment in the context of structural interventions, including policy change and empowerment of sex workers to reduce their vulnerability to HIV/STIs. We suggest avenues for future research and new intervention targets as well as a more nuanced approach to understanding the structural and social vulnerability of women to HIV infection in these settings.

Association between condom use and use of other contraceptive methods among female sex workers in Swaziland: a relationship-level analysis of condom and contraceptive use.

OBJECTIVES: Nonbarrier modern contraceptive users often are less likely to use condoms, particularly with more intimate sex partners. We examine whether female sex workers (FSWs) in Swaziland who use nonbarrier contraception use condoms less consistently and whether this inverse association varies by relationship type. METHODS: In 2011, we conducted a survey among 325 Swazi FSWs using respondent-driven sampling. Each woman reported on condom use during sexual activity in the past month with up to 3 partner types (new clients, regular clients, noncommercial partners). We used a generalized estimating equation model to conduct a relationship-level multivariate logistic regression analysis of correlates of consistent condom use in the past month. We tested whether relationship type modified the effect of nonbarrier modern contraception on condom use. RESULTS: Each participant reported up to 3 observations, for a total of 892 measures of condom use in the past month. Compared with sexual activity with new clients, sex with regular clients and noncommercial partners was less likely to be protected by consistent condom use (adjusted odds ratio, 0.30 [95% confidence interval, 0.19-0.47] for regular clients; adjusted odds ratio, 0.15 [95% confidence interval, 0.09-0.24] for noncommercial partners). There was no significant association between condom use and nonbarrier modern contraceptive use. CONCLUSIONS: These data highlight the need to provide condoms and condom-compatible lubricants and targeted education programs for FSWs and their male sex partners to encourage the consistent use of these commodities with all sex partners, irrespective of the use of other contraceptive methods.

Community empowerment among female sex workers is an effective HIV prevention intervention: a systematic review of the peer-reviewed evidence from low- and middle-income countries.

We conducted a systematic review and meta-analysis of community empowerment interventions for HIV prevention among sex workers in low- and middle-income countries from 1990-2010. Two coders abstracted data using standardized forms. Of 6,664 citations screened, ten studies met inclusion criteria. For HIV infection, two observational studies showed a significantly protective combined effect [odds ratio (OR): 0.84, 95% confidence interval (CI): 0.709-0.988]. For STI infection, one longitudinal study showed reduced gonorrhoea/chlamydia (OR: 0.51, 95% CI: 0.26-0.99). Observational studies showed reduced gonorrhoea (OR: 0.65, 95% CI: 0.47-0.90), but non-significant effects on chlamydia and syphilis. For condom use, one randomized controlled trial showed improvements with clients (beta: 0.3447, p = 0.002). One longitudinal study showed improvements with regular clients (OR: 1.9, 95% CI: 1.1-3.3), but no change with new clients. Observational studies showed improvements with new clients (OR: 3.04, 95% CI: 1.29-7.17), regular clients (OR: 2.20, 95% CI: 1.41-3.42), and all clients (OR: 5.87, 95% CI: 2.88-11.94), but not regular non-paying partners. Overall, community empowerment-based HIV prevention was associated with significant improvements across HIV outcomes and settings.

Descriptive and injunctive norms related to concurrent sexual partnerships in Malawi: implications for HIV prevention research and programming.

Concurrent sexual partnerships are hypothesized to be a contributing factor to Malawi's HIV epidemic. As social norms influence health behavior and have been found to influence sexual behavior, the purpose of this study was to explore two types of norms, descriptive and injunctive norms, toward concurrent sexual partnerships in Malawi. Data from 40 focus group discussions and 20 in-depth interviews conducted in five districts in Malawi, which included 318 participants aged 18-55 years, were analyzed. Participants perceived that concurrent sexual partnerships were extremely common, and believed that very few individuals in their communities were not in concurrent sexual partnerships. However, participants perceived that others in their communities heavily disapproved of concurrent sexual partnerships outside of polygamy, as polygamy was viewed as an acceptable type of partnership because it was conducted in the open. Participants asserted that there were no traditional practices that promoted concurrent sexual partnerships, and perceived that those that engaged in the behavior were for the most part stigmatized by community members. Further research is needed to obtain a thorough understanding of the way in which the perceived actions and beliefs of peers influence the beliefs, feelings and actions of individuals to strengthen HIV programming efforts in the region.

Contraception and condom use among Bolivian female sex workers: relationship-specific associations between disease prevention and family planning behaviors.

We examined data from a clinic-based survey of 1,222 Bolivian female sex workers (FSWs) to assess whether use of nonbarrier modern contraception is associated with less consistent condom use with clients and noncommercial partners. Women who were using nonbarrier modern contraception were less likely than nonusers to consistently use condoms with noncommercial partners (AOR 0.393, 95% CI 0.203-0.759, p = .005). With clients, this inverse association did not hold. Public health professionals must consider both disease prevention and pregnancy prevention needs in this vulnerable population, and messages should be tailored to encourage dual method use with all partners.

Findings from Encontros: a multilevel STI/HIV intervention to increase condom use, reduce STI, and change the social environment among sex workers in Brazil.

BACKGROUND: Sexually transmitted infection (STI)/HIV prevention programs, which do not modify social structural contexts that contribute to risk of STI/HIV may fail to bring about improvements in health, particularly among groups who experience discrimination and exclusion from public life. We conducted a multilevel intervention with sex workers, including improved clinical care and community-mobilizing strategies to modify social structural factors that shape sexual behavior, to improve condom use and reduce incident STI. METHODS: We followed 420 sex workers participating in the Encontros intervention in Corumbá, Brazil, between 2003 and 2005. We estimated the effect of the intervention on incident chlamydia and gonorrhea infections and condom use using generalized estimating equations and inverse probability weighting by comparing those who actively engaged in the intervention activities (exposed) with those who were less engaged (unexposed). We also determined the association of participation on reported social cohesion and participation in networks. RESULTS: Exposed participants had significantly higher odds of reporting consistent condom use with regular clients (odds ratio [OR]: 1.9, 95% confidence interval:1.1-3.3) and nonsignificantly increased odds with both new clients (OR: 1.6, 0.9-2.8) and nonpaying partners (OR: 1.5, 0.9-1.5). The odds of an incident STI were nonsignificantly reduced for exposed participants compared with unexposed (OR: 0.46, 0.2-1.3). Participation was significantly associated with increased perceived cohesion and participation in networks. CONCLUSION: This prospective study provides evidence that multilevel interventions with mobilizing strategies to modify aspects of the social environment can improve condom use, reduce STIs, and increase social cohesion and participation in networks among sex workers.

Facilitators and barriers to implementing provider-initiated HIV counselling and testing at the clinic-level in Ekurhuleni District, South Africa.

BACKGROUND: HIV testing is the entry point into the HIV care continuum and critical for HIV epidemic control. Facility-based HIV testing services (HTS) reach individuals who are already seeking clinical care and engaging with the medical care system. For this reason, individuals diagnosed with HIV during facility-based HIV testing are more likely to continue into HIV care. To increase the number of PLHIV who are diagnosed and initiated on ART, in 2015, the South African Department of Health instituted Provider-Initiated Counselling and Testing (PICT) policy-encouraging healthcare providers to recommend HIV testing, but this strategy remains under-utilized. We aimed to identify key constraints to the normalization of PICT implementation in 10 Ekurhuleni District healthcare facilities in South Africa. METHODS: In-depth interviews were conducted with 40 healthcare workers (28 clinicians and 12 lay counsellors). Health care workers were purposefully selected to participate in the interviews, stratified by health facility and work category. Interviews were audio-recorded, transcribed, and translated for analysis. Thematic analysis was guided by the normalization process theory (NPT). NPT theory explains how practices are routinely embedded within organizational contexts. We used NVivo 10 software for qualitative data management. RESULTS: Both clinicians and lay counsellors exhibited a clear understanding of the PICT policy- acknowledging its purpose and value. The identified barrier to normalization of PICT among clinicians was offering HIV testing based on suspicion of HIV despite understanding that PICT involves offering testing to all clients. Additionally, clinicians perceived PICT as incongruent with their clinical roles and perceived it to be lay counsellors' responsibility. The main facilitator was the participation of all healthcare workers, specifically the presence of lay counsellors, although they also faced barriers such as a lack of workspace and under-appreciation. CONCLUSIONS: Use of NPT helped identify barriers that prevent the normalization of PITC and its integration into routine patient care. These barriers can be modified by low-cost interventions that promote congruence of PICT to the roles of clinicians and integrate the role of lay counsellors within the patient flow in the facility.

The role of structure versus individual agency in churches' responses to HIV/AIDS: a case study of Baltimore City churches.

This paper examines the activities of churches in Baltimore, Maryland, concerning the issues of sexuality, whether they potentially stigmatize persons with or at risk for HIV/AIDS, and to what extent individual agency versus institutional forces influence churches in this regard. In-depth interviews were conducted with 20 leaders from 16 churches and analyzed using a grounded theory methodology. Although many churches were involved in HIV/AIDS-related activities, the content of such initiatives was sometimes limited due to organizational constraints. Church leaders varied, however, in the extent to which they responded in accordance with or resisted these constraints, highlighting the importance of individual agency influencing churches' responses to HIV/AIDS.

Mobility for sex work and recent experiences of gender-based violence among female sex workers in Iringa, Tanzania: A longitudinal analysis.

Female sex workers are highly mobile, which may influence their risk of experiencing physical and sexual violence. However, there remains a paucity of research, particularly longitudinal, from Sub-Saharan Africa exploring mobility and gender-based violence among female sex workers. To address this gap, this study examined the longitudinal relationship between work-related mobility and recent experience of physical or sexual gender-based violence from a client or partner among female sex workers in Iringa, Tanzania. A secondary data analysis was conducted using baseline and 18-month follow-up data from Project Shikamana, a community empowerment-based combination HIV prevention intervention. Responses from 387 female sex workers aged 18 years and older participating in both baseline and follow-up were analyzed. Unadjusted and adjusted Poisson regression models with robust variance estimations, accounting for clustering of female sex workers' responses over time, were fit. Final models adjusted for socio-demographic characteristics and aspects of participants' living situations and work environments. Recent physical or sexual violence from a client or partner was common (baseline: 40%; follow-up: 29%). Twenty-six percent of female sex workers at baseline, and 11% at follow-up, had recently traveled outside of Iringa for sex work. In the final adjusted longitudinal model, female sex workers recently mobile for sex work had a 25% increased risk of any recent experience of physical or sexual gender-based violence when compared with their non-mobile counterparts (adjusted incidence rate ratio: 1.25; 95% CI: 1.03-1.53; p<0.05). Interventions must identify ways-such as mobile support services, linkages and referrals to health and other social services while traveling, or the use of mobile or digital technology-to address mobile female sex workers' unique needs while traveling. Future quantitative and qualitative research is needed to understand the context of female sex workers' mobility and how and why mobility influences risk environments and experiences of gender-based violence.

Understanding high fertility desires and intentions among a sample of urban women living with HIV in the United States.

To assess childbearing motivations, fertility desires and intentions, and their relationship with key factors, we conducted a cross-sectional survey among 181 HIV-infected women of reproductive age (15-44 years) receiving clinical care at two urban health clinics. Fertility desires (59%) and intentions (66% of those who desired a child) were high among this predominately African American sample of women, while the proportion with accurate knowledge of mother-to-child transmission (MTCT) was low (15%). Multivariate regression analyses identified factors significantly associated with the intention to have a child. Notably, age and parity did not remain significant in the adjusted model. The discrepancies between expressed desires and intentions for future childbearing, and the strong role of perceived partner desire for childbearing emphasize the need for universal reproductive counseling to help women living with HIV navigate their reproductive decisions and facilitate safe pregnancies and healthy children.

Strategies to promote the meaningful involvement of sex workers in HIV prevention and care.

PURPOSE OF REVIEW: We review the recent evidence regarding strategies for engaging sex workers in HIV prevention and care programs. We searched Pub Med on 19 March 2019 using terms 'Sex Work' And 'HIV infections'. Our search was limited to articles published since 2017. RECENT FINDINGS: Community empowerment approaches where sex workers work collaboratively to address their specific priorities and concerns, including those beyond HIV, are those most likely to meaningfully engage sex workers. Community-driven programs that combine structural, behavioral and biomedical approaches can facilitate improved HIV outcomes by tackling barriers to uptake and retention of services along all steps in the prevention and care cascades. Microplanning, network-based recruitment and mobile-phone interventions can also help reach and support sex workers to mobilize and to engage with a range of services. Sex worker-led groups and initiatives including economic strengthening and community drug refill groups can both build social cohesion and address structural barriers to HIV outcomes including financial insecurity. Interventions which focus narrowly on increasing uptake of specific steps in prevention and care cascades outside the context of broader community empowerment responses are likely to be less effective. SUMMARY: Comprehensive, community-driven approaches where sex workers mobilize to address their structural, behavioral and biomedical priorities work across HIV prevention and treatment cascades to increase uptake of and engagement with prevention and care technologies and promote broader health and human rights. These interventions need to be adequately supported and taken to scale.

Work-related mobility and experiences of gender-based violence among female sex workers in Iringa, Tanzania: a cross-sectional analysis of baseline data from Project Shikamana.

OBJECTIVES: To examine how work-related mobility among female sex workers (FSWs) is associated with gender-based violence (GBV) in Iringa, Tanzania. DESIGN: Cross-sectional analyses were conducted on baseline data gathered between October 2015 and April 2016 from FSWs participating in Project Shikamana, a community empowerment-based combination HIV prevention intervention. SETTING: Participants were recruited for the baseline study using venue-based time-location sampling in two communities in Iringa, Tanzania. PARTICIPANTS: FSWs were eligible for participation if they were 18 years or older and had exchanged sex for money within the past month. Four-hundred ninety-six FSWs participated in the baseline survey. PRIMARY AND SECONDARY OUTCOME MEASURES: Any recent experience of GBV was examined by recent work-related mobility among FSWs. Any recent experience of GBV was also disaggregated by severity for analyses. All bivariate and multivariate binary and multinomial logistic regressions adjusted for intraclass correlations among women recruited from the same venues. RESULTS: Forty per cent of participants experienced recent physical or sexual violence, and 30% recently experienced severe physical or sexual violence. Thirty-three per cent of participants recently exchanged sex for money outside of their district or region, and 12% were both intraregionally and inter-regionally mobile for sex work. Intraregionally and inter-regionally mobile FSWs had 1.9 times greater odds of reporting recent GBV (adjusted OR: 1.89; 95% CI: 1.06 to 3.38; p=0.031) compared with non-mobile FSWs and a 2.5 times higher relative risk for recent experience of severe GBV relative to no recent GBV (relative risk ratio: 2.51; 95% CI: 1.33 to 4.74; p=0.005). CONCLUSIONS: Mobility for sex work may increase FSWs' exposure to GBV, particularly more severe GBV. The vulnerability of mobile FSWs to violence, particularly severe forms, demands inclusive services that are accessible to mobile FSWs.

Female sex workers' experiences with intended pregnancy and antenatal care services in southern Tanzania.

Understanding the pregnancy experiences of female sex workers (FSWs), especially in the context of high rates of HIV and sexually transmitted infections (STIs), is essential to tailoring services to meet their needs. This study explores FSWs' experiences with intended pregnancy and access to antenatal care and HIV testing in two regions of Tanzania. Thirty in-depth interviews and three focus group discussions were conducted. FSWs sought to become pregnant to gain respect as mothers, to avoid stigma, and/or to solidify relationships, sometimes posing risks to their own and their partners' health. Pregnant FSWs generally sought antenatal care (ANC) services but rarely disclosed their occupation, complicating provision of appropriate care. Accessing ANC services presented particular challenges, with health care workers sometimes denying all clinic services to women who were not accompanied by husbands. Several participants reported being denied care until delivery. The difficulties participants reported in accessing health care services as both sex workers and unmarried women have potential social and health consequences in light of the high levels of HIV and STIs among FSWs in sub-Saharan Africa.

Multi-level factors affecting entry into and engagement in the HIV continuum of care in Iringa, Tanzania.

Progression through the HIV continuum of care, from HIV testing to lifelong retention in antiretroviral therapy (ART) care and treatment programs, is critical to the success of HIV treatment and prevention efforts. However, significant losses occur at each stage of the continuum and little is known about contextual factors contributing to disengagement at these stages. This study sought to explore multi-level barriers and facilitators influencing entry into and engagement in the continuum of care in Iringa, Tanzania. We used a mixed-methods study design including facility-based assessments and interviews with providers and clients of HIV testing and treatment services; interviews, focus group discussions and observations with community-based providers and clients of HIV care and support services; and longitudinal interviews with men and women living with HIV to understand their trajectories in care. Data were analyzed using narrative analysis to identify key themes across levels and stages in the continuum of care. Participants identified multiple compounding barriers to progression through the continuum of care at the individual, facility, community and structural levels. Key barriers included the reluctance to engage in HIV services while healthy, rigid clinic policies, disrespectful treatment from service providers, stock-outs of supplies, stigma and discrimination, alternate healing systems, distance to health facilities and poverty. Social support from family, friends or support groups, home-based care providers, income generating opportunities and community mobilization activities facilitated engagement throughout the HIV continuum. Findings highlight the complex, multi-dimensional dynamics that individuals experience throughout the continuum of care and underscore the importance of a holistic and multi-level perspective to understand this process. Addressing barriers at each level is important to promoting increased engagement throughout the continuum.