Clinical HIV outcome trajectories associated with a history of child protective service out-of-home care: Longitudinal cohort findings with women living with HIV in Canada.

OBJECTIVES: Knowledge gaps exist regarding the effects of experiencing child protective services (CPS) out-of-home care (e.g. foster homes) among women with HIV. We examined whether CPS out-of-home care was associated with HIV clinical outcome trajectories among women with HIV in a longitudinal cohort study in Ontario, British Columbia, and Quebec, Canada. METHODS: At three timepoints across 5 years (2013-2018), we examined self-reported current antiretroviral therapy (ART) use and viral load (VL) detectability (>50 copies/mL). We used latent class growth analysis (LCGA) to identify trajectories of ART use and VL outcomes across study waves. LCGA identifies subgroups (classes) with similar trajectories within the sample. We assessed whether HIV outcome trajectories could be predicted by CPS history. We then conducted a mediation analysis to test whether a mental health latent construct mediated the association between CPS history and detectable VL. RESULTS: Nearly one-fifth (n = 272; 19%) of participants (n = 1422; mean age 42.8 years) reported CPS out-of-home care. Most participants (89%) were in classes that consistently used ART and had an undetectable VL. Individuals with CPS out-of-home care histories were twice as likely to have a consistently detectable VL (ß = 0.72, p = 0.02); there were no differences in ART use trajectories. In mediation analyses, we found an indirect path from CPS history to a consistently detectable VL via baseline mental health status (ß = 0.02, 95% confidence interval 0.005-0.04, p = 0.02), with a significant odds ratio (1.12, z = 2.43, p = 0.02). CONCLUSION: Among women with HIV in Canada, experiencing childhood CPS out-of-home care was associated with a reduced likelihood of achieving viral suppression, via poorer mental health.

Increased difficulty accessing food and income change during the COVID-19 pandemic among youth living in the eThekwini district, South Africa.

OBJECTIVE: To estimate the effect of income change on difficulty accessing food since the COVID-19 pandemic for South African youth and evaluate whether this effect was modified by receiving social grants. DESIGN: A cross-sectional, online survey was conducted between December 2021 and May 2022. Primary outcome was increased difficulty accessing food since the COVID-19 pandemic. Income change was categorised as 'Decreased a lot', 'Decreased slightly' and 'Unchanged or increased'. Multivariable logistic regressions were used, with an interaction term between social grant receipt and income change. SETTING: eThekwini district, South Africa. PARTICIPANTS: Youth aged 16-24 years. RESULTS: Among 1,620 participants, median age was 22 years (IQR 19-24); 861 (53 %) were women; 476 (29 %) reported increased difficulty accessing food; 297 (18 %) reported that income decreased a lot, of whom 149 (50 %) did not receive social grants. Experiencing a large income decrease was highly associated with increased difficulty accessing food during the COVID-19 pandemic (adjusted OR [aOR] 3·63, 95 % CI 2·70, 4·88). The aOR for the effect of a large income decrease on difficulty accessing food, compared to no income change, were 1·49 (95 % CI 0·98, 2·28) among participants receiving social grants, and 6·63 (95 % CI 4·39, 9·99) among participants not receiving social grants. CONCLUSIONS: While social grant support made a great difference in lowering the effect of income decrease on difficulty accessing food, it was insufficient to fully protect youth from those difficulties. In post-pandemic recovery efforts, there is a critical need to support youth through economic empowerment programming and food schemes.

'Life became harder with COVID-19': exploring the experiences of the COVID-19 pandemic among youth living in eThekwini district, South Africa.

BACKGROUND: In South Africa, pervasive age and gender inequities have been exacerbated by the COVID-19 pandemic and public health response. We aimed to explore experiences of the COVID-19 pandemic among youth in eThekwini district, South Africa. METHODS: Between December 2021-May 2022 we explored experiences of the COVID-19 pandemic on youth aged 16-24 residing in eThekwini, South Africa. We collated responses to the open-ended question "Has the COVID-19 pandemic affected you in any other way you want to tell us about?" in an online survey focused on understanding the pandemic's multi-levelled health and social effects. We used a thematic analysis to summarise the responses. RESULTS: Of 2,068 respondents, 256 (12.4%, median age = 22, 60.9% women) completed the open-ended survey question (11% in isiZulu). Results were organized into three main themes encompassing (1) COVID-19-related loss, fear, grief, and exacerbated mental and physical health concerns; (2) COVID-19-related intensified hardships, which contributed to financial, employment, food, education, and relationship insecurities for individuals and households; and (3) positive effects of the pandemic response, including the benefits of government policies and silver linings to government restrictions. CONCLUSIONS: We found that South African youth experienced significant grief and multiple losses (e.g., death, income, job, and educational) during the COVID-19 pandemic. Trauma-aware interventions that provide economic and educational opportunities must be included in post-COVID recovery efforts.

Mental health service use and shortages among a cohort of women living with HIV in Canada.

BACKGROUND: The prevalence of mental health conditions among women with HIV in Canada ranges between 29.5% and 57.4%, highlighting the need for accessible mental health care. We aimed to (1) describe the availability and use of mental health services among women with HIV and (2) identify characteristics associated with reporting that shortages of these services presented a problem in their care. METHODS: Baseline data from the Canadian HIV Women's Sexual and Reproductive Health Cohort Study were analysed. Self-reported availability and use of mental health services were examined using descriptive statistics. Participants indicated whether a lack of mental health support was a problem in their care. Logistic regression models were constructed to determine associations between sociodemographic, clinical, and psychosocial characteristics and reported problematic shortages. RESULTS: Of 1422 women, 26.7% (n = 380) used mental health services in the last year, which most accessed through their HIV clinic. Thirty-eight percent (n = 541) reported that a shortage of mental health support was a problem in their care. Among this subset, 22.1% (n = 119) used services at their HIV clinic, 26.5% (n = 143) reported available services but did not use them, and 51.4% (n = 277) either indicated that these services were unavailable, did not know if such services were available, or were unengaged in HIV care. Factors associated with reporting problematic shortages included rural residence [adjusted odds ratio (aOR): 1.69, 95% confidence interval (CI): 1.03-2.77], higher education level (aOR: 1.43, 95% CI: 1.02-2.02), and higher HIV stigma score (aOR: 1.03, 95% CI: 1.02-1.03). Conversely, African/Caribbean/Black identity (aOR: 0.37, 95% CI: 0.26-0.54), history of recreational drug use (aOR: 0.56, 95% CI: 0.39-0.81), and Quebec residence (aOR: 0.69, 95% CI: 0.50-0.96) were associated with lower odds of reporting service shortages. CONCLUSION: Our findings highlight the HIV clinic as the primary location of mental health service use. However, existing services may not be sufficient to reach all patients or meet specific needs. Furthermore, the low uptake among those reporting a shortage suggests a lack of connection to services or patient knowledge about their availability. Characteristics associated with reporting shortages reflect geographic and socioeconomic disparities that must be accounted for in future service design.

Using Latent Profile Analysis to Identify Associations Between Gestational Chemical Mixtures and Child Neurodevelopment.

BACKGROUND: Unsupervised machine learning techniques have become increasingly popular for studying associations between gestational exposure mixtures and human health. Latent profile analysis is one method that has not been fully explored. METHODS: We estimated associations between gestational chemical mixtures and child neurodevelopment using latent profile analysis. Using data from the Maternal-Infant Research on Environmental Chemicals (MIREC) research platform, a longitudinal cohort of pregnant Canadian women and their children, we generated latent profiles from 27 gestational exposure biomarkers. We then examined the associations between these profiles and child Verbal IQ, Performance IQ, and Full-Scale IQ, measured with the Wechsler Preschool and Primary Scale of Intelligence, Third Edition (WPPSI-III). We validated our findings using k-means clustering. RESULTS: Latent profile analysis detected five latent profiles of exposure: a reference profile containing 61% of the study participants, a high monoethyl phthalate (MEP) profile with moderately low persistent organic pollutants (POPs) containing 26%, a high POP profile containing 6%, a low POP profile containing 4%, and a smoking chemicals profile containing 3%. We observed negative associations between both the smoking chemicals and high MEP profiles and all IQ scores and between the high POP profile and Full-Scale and Verbal IQ scores. We also found a positive association between the low POP profile and Full-Scale and Performance IQ scores. All associations had wide 95% confidence intervals. CONCLUSIONS: Latent profile analysis is a promising technique for identifying patterns of chemical exposure and is worthy of further study for its use in examining complicated exposure mixtures.

Practices, support and stigma related to infant feeding and postpartum engagement in care among women living with HIV in Canada.

Background: Breastfeeding is not recommended for women living with HIV (WLWH) in Canada. We described the prevalence of breastfeeding and explored experiences of care, support, and stigma related to infant feeding. Setting: Quebec, Ontario, and British Columbia (Canada). Methods: Data were obtained from the HIV Women's Sexual and Reproductive Health Cohort Study (CHIWOS) surveys, conducted between 2013 and 2018. Results: Breastfeeding was reported by 73.5% of the 786 women who delivered before HIV diagnosis and 7.3% of the 289 women who delivered after HIV diagnosis. Among them, earlier year of delivery, delivery outside of Canada, and African, Caribbean, Black ethnicity were independently associated with increased odds of breastfeeding. Among WLWH who had a live birth during the last year, 77% (40/52) felt that they had received support regarding infant feeding practices, and 77% (23/30) were concerned that not breastfeeding could lead to them being identified as WLWH. Among 71 women within one year postpartum at any one of the study waves, 89% reported having an undetectable viral load. Conclusion: Breastfeeding experiences were common among WLWH, most often prior to HIV diagnosis. Fear of unintentional HIV status disclosure when not breastfeeding and challenges to maintain an undetectable HIV viral load are important issues to address during postpartum care.

Associations between psychosocial factors and antiretroviral therapy outcomes differ by gender and sexual orientation among people living with HIV in British Columbia, Canada.

Little is known about how the co-occurrence of psychosocial factors affect sub-populations of people living with HIV (PLWH). We used cross-sectional data from 999 PLWH, aged ≥19, accessing antiretroviral therapy (ART) in British Columbia, Canada (2007-2010) to examine associations between psychosocial factors and ART-related outcomes separately for trans/cis inclusive women; heterosexual men; and gay, bisexual, and other men who have sex with men (gbMSM). Multivariable logistic regression examined associations between psychosocial factors (0-3): any violence in the past 6 months, depressive symptoms in the past week, and current street drug use (heroin, crack, meth or speedball) with sub-optimal adherence (outcome 1: average annual ART adherence <95% from interview until end of follow-up, death, or December 31st, 2018) and ever viral rebound (outcome 2) adjusting for potential confounders. Of 999 PLWH (264 women, 382 heterosexual men, and 353 gbMSM), women and heterosexual men had significantly higher median counts than gbMSM. Overall, higher counts were associated with sub-optimal adherence (adjusted odds ratio [aOR] = 1.26/1-unit increase, 95%CI = 1.07-1.49). All effect estimates were of a greater magnitude among gbMSM, but not significant for women or heterosexual men, highlighting the need for population (e.g., gender and sexual orientation)-centered care and research.

Examining gender and sexual orientation differences in physical intimate partner violence experienced and perpetrated by youth living in eThekwini district South Africa during the COVID-19 pandemic.

BACKGROUND: Young women and Lesbian, Gay, Bisexual, Trans, Non-binary/no gender, or Questioning (LGBTQ+) youth in South Africa face some of the highest global levels of intimate partner violence (IPV). Given limited evidence in the wake of the COVID-19 pandemic, which has fuelled IPV globally, we aimed to describe and compare experiences and perpetration of IPV of youth aged 16-24 by sexual orientation and gender identity (SOGI). METHODS: During the study period (December 2021-May 2022), youth aged 16-24 from eThekwini district, South Africa completed an online survey to understand multilevel impacts of the pandemic on youth. Participants were asked about experiences and perpetration of physical IPV since the start of the COVID-19 pandemic (March 2020). Descriptive statistics and adjusted logistic regressions compared the likelihood of experiencing and/or perpetrating physical IPV between cisgender and transgender inclusive heterosexual men; heterosexual women; gay, bisexual, or questioning men [GBQM]; lesbian, gay, bisexual, or questioning women [LGBQW]; or gender/sexual non-conforming youth [non-conforming]. RESULTS: Of 1,588 youth (mean age = 21.7 [SD = 2.3]; 71.7% Black) with non-missing SOGI and physical IPV data, 238 (15.0%) were LGBTQ+ (40.3% LGBQW and 36.1% non-conforming). Overall, 14.6% of respondents experienced physical IPV and 9.8% perpetrated physical IPV since the start of the pandemic, which differed by SOGI (12.3% of heterosexual men, 13.9% of heterosexual women, 22.0% of GBQM, 18.2% of LGBQW, and 25.0% of non-conforming youth experienced and 10.3% of heterosexual men; 7.7% of heterosexual women; 10.0% of GBQM; 18.2% of LGBQW; and 16.7% of non-conforming youth perpetrated). In adjusted models, compared to heterosexual women, non-conforming youth had increased odds of experiencing (adjusted odds ratio [aOR] = 2.36; 95%CI, 1.26-4.39) physical IPV and compared to heterosexual men, non-conforming youth had greater odds of perpetrating physical IPV (aOR = 2.19; 95%CI, 1.07-4.48) during the pandemic. CONCLUSION: Over one in six youth in our study experienced and one in ten perpetrated physical IPV since the onset of the COVID-19 pandemic, with gender and sexual non-conforming youth experiencing and perpetrating IPV at significantly greater rates than cisgender/heterosexual peers. Our findings highlight the need for gender transformative efforts that move beyond the gender binary to support healthy relationships and IPV prevention for LGBTQ + youth in South Africa and globally.

Relationship impacts of the COVID-19 pandemic and lockdown restrictions on young women and men in Durban and Soweto, South Africa.

To deepen our understanding of the impact of the COVID-19 pandemic on intimate and/or sexual relationships, we conducted a qualitative study among 26 South African women and men aged 21-30 years in Durban and Soweto between September 2020 and March 2021. Overall, 13 women and 12 men who had been in an intimate and/or sexual relationship since the start of the COVID-19 pandemic were asked about the impact of COVID-19 on their relationships with their current or most recent primary partners. Data were analysed using reflexive thematic analysis. The three most common impacts of the COVID-19 pandemic on relationships were on (i) communication and connection; (ii) strained relationships; and (iii) job and economic loss. Both women and men discussed how COVID-19-related lockdowns provided opportunities to foster better communication, connection and support to one another. However, too little or too much time together strained relationships. Finally, income loss among young men meant that some young women became the primary income earner, changing relationship power dynamics. Findings highlight the importance of young people's relationships and the need for action to support young people in building positive relationships in challenging times.

'I still desire to have a child': a qualitative analysis of intersectional HIV- and childlessness-related stigma in rural southwestern Uganda.

This study explored the intersecting forms of stigma experienced by HIV-serodifferent couples with unmet reproductive goals in rural Uganda. The parent mixed-methods study, which included 131 HIV-exposed women with plans for pregnancy, offered comprehensive HIV prevention counselling and care over a nine-month period. In-depth interviews were conducted with 37 women and seven male partners to explore care experiences and the use of safer conception strategies. This secondary analysis explored how challenges conceiving informed pregnancy plans and HIV prevention behaviours. The following themes were developed (1) partnership conflicts arise from HIV- and infertility-related forms of stigma, contributing to gender-based violence, partnership dissolution and the pursuit of new partners; (2) cultural and gender norms pressure men and women to conceive and maintain partnerships, which is complicated by the stigma directed towards serodifferent couples; (3) frustration with low partner participation in safer conception strategies led to the decreased use of these methods of HIV prevention; (4) health care provider support promotes continued hope of conception and helps overcome stigma. In HIV-affected partnerships, these intersecting forms of stigma may impact HIV prevention. Seeking to fulfil their reproductive needs, partners may increase HIV transmission opportunities as they engage in condomless sex with additional partners and decrease adherence to prevention strategies. Future research programmes should consider the integration of fertility counselling with reproductive and sexual health care.

'HIV made me fabulous': a qualitative analysis of embodied storytelling in film to address stigma, further understandings of U=U and advance gender equity.

BACKGROUND: Even with the Undetectable equals Untransmittable campaign (U=U) campaign, women living with HIV continue to experience intersecting forms of stigma. We explored how the somatic experiences of viewing a film about U=U and women could help individuals gain deeper understandings of HIV and alter learned prejudices. METHODS: HIV Made Me Fabulous is a film that utilises embodied storytelling to tell the story of a trans woman living through social and historical traumas of HIV. Four online film screenings and focus group discussions took place between June 2020 and June 2021, with participants attending from Canada, Australia, South Africa, Kenya, Zimbabwe and India. Two sessions were held with women living with HIV (n =16) and two with HIV-negative individuals (n =12). Transcripts were analysed via thematic analysis using Lafrenière and Cox's framework to assess its impact. RESULTS: Participants experienced strong, diverse emotional responses and sometimes physical effects from viewing the film. These somatic experiences furthered engagement with key messages in the film, including U=U, intersectional identities, and impacts of patriarchal systems. Women living with HIV commented on unique gendered risks experienced during disclosure, and the pressures of reaching an undetectable viral load. Women also commented how the film resulted in deeper reflection of their deservingness of pleasure. Regardless of HIV status, participants expressed motivation towards influencing change that included addressing biases and sharing U=U with others. CONCLUSIONS: Embodied storytelling in film is an effective method to counter both intra- and inter-personal HIV-related stigma by provoking responses that enhance compassion for oneself and others.

Sexual and Relationship Benefits of a Safer Conception Intervention Among Men with HIV Who Seek to Have Children with Serodifferent Partners in Uganda.

Many men with HIV (MWH) in Uganda desire children, yet seldom receive reproductive counseling related to HIV care. Because men are under engaged in safer conception programming, they miss opportunities to reap the benefits of these programs. The objective of this sub-analysis was to explore the relationship and intimacy benefits of integrating safer conception counseling and strategies into HIV care, an emergent theme from exit interviews with men who participated in a pilot safer conception program and their partners. Twenty interviews were conducted with MWH who desired a child in the next year with an HIV-uninfected/status unknown female partner, and separate interviews were conducted with female partners (n = 20); of the 40 interviews, 28 were completed by both members of a couple. Interviews explored experiences participating in The Healthy Families program, which offered MWH safer conception counseling and access to specific strategies. Data were analyzed using thematic analysis. Three major subthemes or "pathways" to the relationship and intimacy benefits associated with participation in the program emerged: (1) improved dyadic communication; (2) joint decision-making and power equity in the context of reproduction; and (3) increased sexual and relational intimacy, driven by reduced fear of HIV transmission and relationship dissolution. These data suggest that the intervention not only helped couples realize their reproductive goals; it also improved relationship dynamics and facilitated intimacy, strengthening partnerships and reducing fears of separation. Directly addressing these benefits with MWH and their partners may increase engagement with HIV prevention strategies for conception.

Understanding the Effect of a Healthcare Provider-Led Family Planning Support Intervention on Contraception use and Pregnancy Desires among Postpartum Women Living with HIV in Southwestern Uganda.

Modern contraceptive prevalence among women living with HIV (WLWH) in Uganda is still low at 45%, and up to a third of women are likely to discontinue the method within the first year of initiation. This increases risks of unplanned pregnancies, perinatal HIV transmission and pregnancy complications. We aim to explore and explain the mechanism of effect of a family planning support intervention investigated in a randomized controlled trial conducted between October 2016 and June 2018 among 320 postpartum WLWH at a referral hospital in Southwestern Uganda that led to improved uptake, decreased contraception discontinuation and lowered pregnancy rates. Thirty WLWH and 10 of their primary sexual partners who participated in this trial were purposively selected and interviewed in the local language; interviews were digitally recorded. Translated transcripts were generated and coded. Coded data were iteratively reviewed and sorted to derive descriptive categories using an inductive content analytic approach. Up to 83% of women wanted to avoid pregnancy within the first year postpartum. Qualitative data showed that contraception uptake and use were influenced by: 1) Participant awareness and understanding of different methods available; 2) Participant perception of offered health services; 3) Healthcare provider (HCP) socio-cultural sensitivity to individual experiences and (mis)conceptions surrounding contraception; 4) Having tactile engagement, follow-up reminders and a reference to prompt action or discussions with partners. Supportive and culturally sensitive HCPs and systems facilitated information sharing leading to increased patient awareness and understanding of the contraceptive methods, and improved health user experience, care engagement, confidence and willingness to take up and continue using modern contraceptive methods.

Client and Provider Experiences in Uganda Suggest Demand for and Highlight the Importance of Addressing HIV Stigma and Gender Norms Within Safer Conception Care.

Safer conception counseling supports HIV-serodifferent couples to meet reproductive goals while minimizing HIV transmission risk, but has not been integrated into routine HIV care. We piloted a novel safer conception program in an established public-sector HIV clinic in Uganda to inform future implementation. In-depth interviews and counseling observations explored experiences of program clients and healthcare providers to assess program acceptability, appropriateness, and feasibility. Fifteen index clients (8 women, 7 men), 10 pregnancy partners, and 10 providers completed interviews; 15 participants were living with HIV. Ten observations were conducted. We identified four emergent themes: (1) High demand for safer conception services integrated within routine HIV care, (2) Evolving messages of antiretroviral treatment as prevention contribute to confusion about HIV prevention options, (3) Gender and sexual relationship power inequities shape safer conception care, and (4) HIV-related stigma impacts safer conception care uptake. These findings confirm the need for safer conception care and suggest important implementation considerations.

Intention to Receive a COVID-19 Vaccine by HIV Status Among a Population-Based Sample of Women and Gender Diverse Individuals in British Columbia, Canada.

COVID-19 vaccination is recommended for people living with HIV (PLWH), among whom social inequities and co-morbidities may drive risks of COVID-19 infection and outcome severity. Among a provincial (British Columbia) sample, we determined the prevalence of COVID-19 vaccine intention by HIV status and assessed socio-demographic, vaccine hesitancy, and psychological predictors of vaccine intention. Individuals (25-69 years) recruited from province-wide research cohorts and the general public completed an online survey examining COVID-19 impacts (August/2020-March/2021). In an analysis restricted to women and gender diverse participants (n = 5588), we compared intention to receive a recommended COVID-19 vaccine (Very likely/Likely vs Neutral/Unlikely/Very Unlikely) by self-reported HIV status. Logistic regression models assessed the independent effect of HIV status and other factors on COVID-19 vaccine intention. Of 5588 participants, 69 (1.2%) were living with HIV, of whom 79.7% were on antiretroviral therapy. In bivariate analyses, intention to vaccinate was significantly lower among PLWH compared to participants not living with HIV (65.2% vs 79.6%; OR 0.44; 95%CI 0.32-0.60). However, this association was not statistically significant after adjustment for ethnicity, income, education, and essential worker status (aOR 0.85; 95%CI 0.48-1.55). Among PLWH, those with greater vaccine confidence, positive attitudes towards the COVID-19 vaccine, and more strongly influenced by direct and indirect social norms to vaccinate had significantly higher odds of vaccine intention. Tailored messaging is needed to build vaccine confidence, address questions about vaccine benefits, and support informed vaccination decision-making to promote COVID-19 vaccine uptake among women and gender diverse people living with HIV.

"I feel like it is asking if he is a stalker but I also feel like it is asking if he cares": exploring young South African women and men's perceptions of the Sexual Relationship Power Scale.

BACKGROUND: Gender inequity and the subsequent health impacts disproportionately affect communities in the Global South. However, most gender equity measures, such as Pulerwitz' (2000) Sexual Relationship Power Scale (SRPS), are developed and validated in the Global North and then applied in Global South settings without investigation of context applicability or validity. This study examines the SRPS' validity evidence, comprehensiveness, and contemporary relevance for young South African women and men. METHODS: Between 2019 and 2021, 38 cognitive interviews (CIs) were conducted among previous participants of a South African youth cohort study 'AYAZAZI' (2015-2017) to explore youth's perceptions of the SRPS. The SRPS measures women's perceptions of their partner's controlling behaviours, and men's perceptions of their own controlling behaviours. Using CIs, participants responded to a 13-item adaptation of the SRPS for use among South African youth (strongly agree-strongly disagree), and then were asked to think-aloud their reasoning for responses, their understanding and perceived relevance of each item, and made overall suggestions for scale adaptations. An item appraisal coding process was applied, whereby Cognitive Coding assessed the types of cognitive problems youth had with understanding the items, and Question Feature Coding assessed which item features caused problems for participant understandings. Finally, youth recommendations for scale adaptations were summarized. RESULTS: Overall, 21 women and 17 men aged 21-30 participated in CIs in Durban and Soweto, South Africa. Cognitive Coding revealed 1. Comprehension issues, and 2. Judgements related to items' applicability to lived experiences and identities (e.g., being unmarried). Question Feature Coding revealed items' 1. Lack of clarity or vagueness in wording and 2. Logical problems in assumptions leading to multiple interpretations (e.g., item 'my partner always need to know where I am' interpreted as both controlling and caring behaviour). Multiple, overlapping issues revealed how many items failed to "fit" within the present-day living realities of South African youth. Youth recommended several item adaptations and additions, including strength-based items, to existing measures of gender equity and relationship power. CONCLUSION: Given identified issues, several adaptations including revising items to be more inclusive, contemporary, context specific, relational, and strength-based are needed to validly measure gender equity and power dynamics within the relationships of South African youth.

Barriers To Accessing Contraception and Cervical and Breast Cancer Screening During COVID-19: A Prospective Cohort Study.

OBJECTIVE: This study sought to examine how access to contraception and cervical and breast cancer screening in British Columbia, Canada, has been affected by the COVID-19 pandemic. METHODS: From August 2020 to March 2021, 3691 female residents of British Columbia (age 25-69 y) participated in this study. We used generalized estimating equations to analyze the proportion of females accessing contraception and the proportion having difficulty accessing contraception across the different phases of pandemic control measures, and logistic regression to analyze attendance at cervical and breast cancer screening. We added sociodemographic and biological variables individually into the models. Self-reported barriers to accessing contraception and attending screening were summarized. RESULTS: During phases with the highest pandemic controls, self-reported access to contraception was lower (OR 0.94; 95% CI 0.90-0.98; P = 0.005) and difficulty with access was higher (OR 2.74; 95% CI 1.54-4.88; P = 0.001). A higher proportion of adults aged 25-34 years reported difficulty accessing contraception than those aged 35-39 years (P < 0.0001), and participants identifying as Indigenous had higher odds of access difficulties (OR 5.56; 95% CI 2.44-12.50; P < 0.001). Of those who required screening during the COVID-19 pandemic, 62% and 54.5% did not attend at least one of their cervical or breast screening appointments, respectively. Those with a history of breast cancer had significantly higher odds of self-reporting having attended their mammogram appointment compared with those without a history of breast cancer (OR 5.62; 95% CI 2.69-13.72; P < 0.001). The most common barriers to screening were difficulty getting an appointment and appointments being considered non-urgent. CONCLUSIONS: The COVID-19 pandemic has uniquely affected access to contraception and cancer screening participation for various subgroups. Self-reported data present potential avenues for mitigating barriers.

Factors associated with contraceptive use among women living with HIV in Canada: a controlled, cross-sectional study.

BACKGROUND: Multiple contraindications to combined hormonal contraceptives (CHC) use exist. The impact of these factors on contraceptive choice, particularly among women living with HIV (WLWH), is not well understood. We measured and compared the prevalence of contraceptive use and contraindications among WLWH and women not living with HIV (controls). METHODS: We examined cross-sectional survey and medical chart data from 83 WLWH and 62 controls, aged 16-49 and sexually active, from 2013-2017. We compared the age-adjusted prevalence and types of contraceptives used in the last month and the proportion of women with CHC contraindications, including drug interactions, medical comorbidities, and smoking at ≥ 35 years old. All WLWH received care at an interdisciplinary, women-centred HIV clinic. RESULTS: Compared to controls, WLWH were older (median [IQR)] 39 [34-43] vs 31 [23-41] years; p = 0.003), had less post-secondary education (37% vs 73%; p < 0.001), and more often had household income < $15,000/year (49% vs 30%; p = 0.006). WLWH trended to higher contraceptive prevalence than controls (80% vs 63%; p = 0.06 adjusted for age). Overall hormonal contraceptive use was similar. However, despite controlling for age, WLWH used CHC less (4% vs 18%; p = 0.006) than controls, and had more frequently undergone tubal ligation (12% vs 2%; p = 0.03). WLWH also experienced more CHC contraindications (54% vs 13%; p = 0.0001), including smoking at ≥ 35 years old (30% vs 6%; p = 0.0003) or a CHC-related drug interaction (all antiretroviral related) (25% vs 0%; p = 0.0001). CONCLUSIONS: WLWH attending our interdisciplinary clinic used hormonal contraception at similar rates as controls, though with different types. Differences may reflect different distributions of CHC contraindications. CHC contraindications present barriers to accessing the full range of contraceptive choices for WLWH. Guidelines and education for care providers and WLWH regarding contraceptive choices and drug interactions are needed, especially when care is provided without the benefit of an interdisciplinary women-centered healthcare team.

BACKGROUND: There are many reasons why individuals cannot use combined hormonal contraceptives (CHC). The impact of these reasons on contraceptive choice for women living with HIV (WLWH) are poorly understood. We measured and compared the prevalence of contraceptive choice and factors that may preclude their use in WLWH. METHODS: We examined survey and medical chart data from 83 WLWH and 62 controls (women not living with HIV), aged 16­49 and sexually active, from 2013 to 2017. We compared the prevalence and types of contraceptives used in the last month and the proportion of women with factors that would not allow the use of CHC, including drug interactions, medical conditions, and smoking at ≥ 35 years old. All WLWH received care at a women-centred HIV clinic. RESULTS: Compared to controls, WLWH were older, had less post-secondary education, and more often had household income < $15,000/year. WLWH were more likely to use contraception than controls. Overall hormonal contraceptive use was similar. However, even when accounting for age, WLWH used CHC less than controls, and had more frequently undergone tubal ligation. WLWH also had more reasons that would preclude the use of CHC contraindications including smoking at ≥ 35 years old or a CHC-related drug interaction. CONCLUSIONS: WLWH attending our interdisciplinary clinic used combined hormonal contraception at similar rates as controls, though with different types. Differences may reflect the fact that WLWH more often have factors that do not allow the safe use of CHC. Guidelines and education for care providers and WLWH regarding contraceptive choices and drug interactions are needed.

Food insecurity and depression: a cross-sectional study of a multi-site urban youth cohort in Durban and Soweto, South Africa.

OBJECTIVE: To assess the prevalence of food insecurity and the independent association between depression and food insecurity among youth living in two urban settings in South Africa. METHODS: Baseline cross-sectional survey data was analysed from a prospective cohort study conducted between 2014 and 2016 among youth (aged 16-24 years) in Soweto and Durban. Interviewer-administered questionnaires collecting socio-demographic, sexual and reproductive health and mental health data were conducted. Household food insecurity was measured using the 3-item Household Hunger Scale, with food insecure participants defined as having 'moderate' or 'severe hunger' compared to 'no hunger'. Depression was assessed using the 10-item Center for Epidemiological Studies Depression (CES-D 10) Scale (range 0-30, probable depression ≥ 10). Multivariable logistic regression models were used to estimate the association between depression and food insecurity. RESULTS: There were 422 participants. Median age was 19 years (interquartile range [IQR] 18-21) and 60% were women. Overall, 18% were food insecure and 42% had probable depression. After adjustment for socio-demographic variables (age, gender, female-headed household, household size and school enrolment), participants with probable depression had higher odds of being food insecure than non-depressed participants (2.79, 95%CI 1.57-4.94). CONCLUSION: Nearly one-fifth of youth in this study were food insecure. Those with probable depression had increased odds of food insecurity. Interventions are needed to address food insecurity among urban youth in South Africa, combining nutritional support and better access to quality food with mental health support.

Mental health among transgender women living with HIV in Canada: findings from a national community-based research study.

Antiretroviral therapy adherence among transgender (trans) women living with HIV (WLWH) is negatively impacted by depression and post-traumatic stress disorder (PTSD). Yet, little is known about factors associated with depression or PTSD among trans WLWH. Using cross-sectional data from a national community-based study of 1422 WLWH (n = 53 trans women), we characterized the prevalence of depressive and PTSD symptoms among trans WLWH and examined associations between factors (e.g., Trans stigma) and depressive and PTSD symptoms. Nearly half of participants reported clinically significant PTSD (45.3%) and depressive symptoms (45.3%) [mean Post-traumatic Stress Disorder Civilian Checklist Version-C score 13.8 (SD = 5.8); mean Center for Epidemiological Studies - Depression score 9.4 (SD = 8.0)]. Univariate linear regression analyses showed that <95% adherence, higher internalized HIV-related stigma, frequency of past-month hazardous alcohol use, and current injection drug use were significantly associated with both higher PTSD and depressive symptom scores, and higher resilience and social support with lower scores. A history of violence in adulthood was associated with higher depressive symptoms scores, whereas sexual relationship power and less difficulty meeting housing costs were associated with lower scores. Findings suggest a need for multi-level interventions to reduce barriers to mental wellbeing while fostering resilience and social support.