Social and Structural Barriers to Primary Care Access Among Women Living With HIV in Metro Vancouver, Canada: A Longitudinal Cohort Study.

ABSTRACT: This study examines correlates of being unable to access primary care in the past 6 months among cisgender (cis) and trans women living with HIV (WLWH). Data were drawn from a longitudinal community-based cohort study of WLWH (ages 14+) in Metro Vancouver, Canada (2014-2017). Of 291 participants contributing 914 observations, 15.5% reported being unable to access primary care at baseline. In multivariable analysis, increased odds of being unable to access primary care was associated with (a) having im/migrated to Canada, and, in the past 6 months, (b) identifying as gender minority, (c) experiencing physical or sexual violence, (d) having suicidal ideation or attempts. Decreased odds were associated with recently accessing HIV-specific resources. Our findings suggest that primary health care for WLWH should address high levels of violence and mental health conditions as well as barriers to services for gender minority and im/migrant WLWH.

Positive sexuality: HIV disclosure, gender, violence and the law-A qualitative study.

While a growing body of research points to the shortcomings of the criminal law in governing HIV transmission, there is limited understanding of how cis and trans women living with HIV (WLWH) negotiate their sexuality and HIV disclosure in a criminalized environment. Given the ongoing criminalization of HIV non-disclosure and prevalence of gender-based violence, there is a critical need to better understand the dynamics of negotiating sexual relationships and HIV disclosure among WLWH. We conducted 64 qualitative interviews with cis and trans WLWH in Vancouver, Canada between 2015 and 2017. The interviews were conducted by three experienced researchers, including a cis and a trans WLWH using a semi-structured interview guide. Drawing on a feminist analytical framework and concepts of structural violence, the analysis sought to characterize the negotiation of sexual relationships and HIV disclosure among WLWH in a criminalized setting. For many participants their HIV diagnosis initially symbolized the end of their sexuality due to fear of rejection and potential legal consequences. WLWH recounted that disclosing their HIV status shifted the power dynamics in sexual relationships and many feared rejection, violence, and being outed as living with HIV. Participants' narratives also highlighted that male condom refusal was common and WLWH were not only subjected to the gendered interpersonal violence of male condom refusal but also to the structural violence of legislation that requires condom use but fails to account for the gendered power imbalance that shapes condom negotiation. Despite frequently being represented as a law that 'protects' women, our findings indicate that the criminalization of HIV non-disclosure constitutes a form of gendered structural violence that exacerbates risk for interpersonal violence among WLWH. In line with recommendations by, the WHO and UNAIDS these findings demonstrate the negative impacts of regulating HIV prevention through the use of criminal law for WLWH.