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Abstract 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.

Abstract 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.

ABSTRACTWe integrated safer conception care into a Ugandan HIV clinic. People with HIV (PWH), or partnered with a PWH, and desiring children were eligible for the Healthy Families Clinic Program. Clients completed quarterly safer conception counselling visits and questionnaires to provide information around method preferences and outcomes (partner pregnancy, partner seroconversion). We used clinic level data to evaluate longitudinal viral suppression among PWH. Between November 2016 and January 2020, 361 clients (53% men) accessed services. 75% were PWH (51% women, 96% men): 99% were on antiretroviral therapy (ART) and most reported HIV-sero-different partnerships (97%). Frequently selected safer conception methods included ART (86%), timed condomless sex (74%), and PrEP (40%) with important differences by HIV-serostatus and gender. 22.5% reported pregnancy. Most (97%) PWH were virally suppressed at enrolment and 81% of non-virally suppressed PWH were virally suppressed at 15 months. Two HIV-negative clients (2%) had HIV seroconversion. There is demand for safer conception care in a public sector HIV-clinic in Uganda. Men and women have unique safer conception care preferences. The majority of clients engaged in safer conception care had viral suppression at follow up.

Abstract Background Economic hardship is a potential trigger for intimate partner violence (IPV) perpetration. While higher IPV rates have been reported in low-income regions, few African studies have focused on IPV being triggered by economic hardship among young men during the COVID-19 pandemic. We therefore estimated economic hardship’s effect on IPV perpetration by young men in eThekwini District, South Africa, during the COVID-19 pandemic. Methods A cross-sectional survey of COVID-19 pandemic experiences was conducted among youth aged 16–24 years through an anonymous self-administered questionnaire, including questions about economic hardship (increased difficulty accessing food or decreased income) and IPV perpetration. A prespecified statistical analysis plan with a directed acyclic graph of assumed exposure, outcome, and confounder relationships guided our analyses. We measured association of economic hardship and IPV perpetration through odds ratios (ORs) computed from a multivariable logistic regressions adjusted for measured confounders. Secondary outcomes of physical and sexual IPV perpetration were analyzed separately using the same specifications. Propensity score matching weights (PS-MW) were used in sensitivity analyses. Analysis code repository: https://github.com/CAndrewBasham/Economic_Hardship_IPV_perpetration/ Results Among 592 participants, 12.5% reported perpetrating IPV, 67.6% of whom reported economic hardship, compared with 45.6% of those not reporting IPV perpetration (crude OR = 2.49). Median age was 22 years (interquartile range 20–24). Most (80%) were in a relationship and living together. Three quarters identified as Black, 92.1% were heterosexual, and half had monthly household income

Objectives The community-based, longitudinal, Canadian HIV Women’s Sexual and Reproductive Health Cohort Study (CHIWOS) explored the experiences of women with HIV in Canada over the past decade. CHIWOS’ high-impact publications document significant gaps in the provision of healthcare to women with HIV. We used concept mapping to analyse and present a summary of CHIWOS findings on women’s experiences navigating these gaps.Design Concept mapping procedures were performed in two steps between June 2019 and March 2021. First, two reviewers (AY and PM) independently reviewed CHIWOS manuscripts and conference abstracts written before 1 August 2019 to identify main themes and generate individual concept maps. Next, the preliminary results were presented to national experts, including women with HIV, to consolidate findings into visuals summarising the experiences and care gaps of women with HIV in CHIWOS.Setting British Columbia, Ontario and Quebec, Canada.Participants A total of 18 individual CHIWOS team members participated in this study including six lead investigators of CHIWOS and 12 community researchers.Results Overall, a total of 60 peer-reviewed manuscripts and conference abstracts met the inclusion criteria. Using concept mapping, themes were generated and structured through online meetings. In total, six composite concept maps were co-developed: quality of life, HIV care, psychosocial and mental health, sexual health, reproductive health, and trans women’s health. Two summary diagrams were created encompassing the concept map themes, one for all women and one specific to trans women with HIV. Through our analysis, resilience, social support, positive healthy actions and women-centred HIV care were highlighted as strengths leading to well-being for women with HIV.Conclusions Concept mapping resulted in a composite summary of 60 peer-reviewed CHIWOS publications. This activity allows for priority setting to optimise care and well-being for women with HIV.

Abstract 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.

Background Using data from a national cohort study and focus groups, the Women-Centred HIV Care (WCHC) Model was developed to inform care delivery for women living with HIV. Methods Through an evidence-based, integrated knowledge translation approach, we developed 2 toolkits based on the WCHC Model for service providers and women living with HIV in English and French (Canada's national languages). To disseminate, we distributed printed advertising materials, hosted 3 national webinars and conducted 2 virtual capacity-building training series. Results A total of 315 individuals attended the webinars, and the average WCHC knowledge increased by 29% (SD 4.3%). In total, 131 service providers engaged in 22 virtual capacity-building training sessions with 21 clinical cases discussed. Learners self-reported increased confidence in 15/15 abilities, including the ability to provide WCHC. As of December 2023, the toolkits were downloaded 7766 times. Conclusions We successfully developed WCHC toolkits and shared them with diverse clinical and community audiences through various dissemination methods.

Abstract 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.

Background: The increased stress the world experienced with the coronavirus disease (COVID-19) pandemic affected mental health, disproportionately affecting females. However, how perceived stress in the first year affected menstrual and menopausal symptoms has not yet been investigated. Objectives: This study evaluates the effect that the first year of the COVID-19 pandemic had on female reproductive and mental health. Methods: Residents in British Columbia, Canada, were surveyed online as part of the COVID-19 Rapid Evidence Study of a Provincial Population-Based Cohort for Gender and Sex. A subgroup of participants (n = 4171), who were assigned female sex at birth (age 25–69 years) and were surveyed within the first 6–12 months of the pandemic (August 2020–February 2021), prior to the widespread rollout of vaccines, was retrospectively asked if they noticed changes in their menstrual or menopausal symptoms, and completing validated measures of stress, depression and anxiety. Design: This is a population-based online retrospective survey. Results: We found that 27.8% reported menstrual cycle disturbances and 6.7% reported increased menopause symptoms. Those who scored higher on perceived stress, depression and anxiety scales were more likely to report reproductive cycle disturbances. Free-text responses revealed that reasons for disturbances were perceived to be related to the pandemic. Conclusion: The COVID-19 pandemic has highlighted the need to research female-specific health issues, such as menstruation. Our data indicate that in the first year of the pandemic, almost one-third of the menstruating population reported disturbances in their cycle, which was related to percieved stress, depression and anxiety scores.

Abstract 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.

In Canada, community and policy leaders have issued urgent calls to collect, analyze, and mobilize disaggregated data to inform equity-oriented initiatives aimed at addressing systemic racism and gender inequity, as well as other social inequities. This essay presents critical reflections from a national Roundtable discussion regarding how meaningful community engagement within academia–community–government research collaborations offers the opportunity to harness disaggregated data and advanced analytics to centre and address the priorities of equity-deserving and sovereignty-seeking groups. Participants emphasized four key priorities: (1) Building equitable and engaged partnerships that centre community-driven priorities and address structural barriers to community engagement; (2) Co-creating ethical data governance policies and infrastructure to support community data ownership and access; (3) Stimulating innovation and pursuing community involvement to create contextualized, advanced analyses and effective visualizations of disaggregated data; and (4) Building the capacity of all partners to effectively contribute to partnership goals. Capacity building was viewed as a bridge across a diversity of lived and professional expertise, enabling intersectoral research teams to collaborate in culturally safe and respectful ways. Beyond identifying key structural barriers impeding the promise of disaggregated data, we present practical opportunities for innovation in community-engaged scholarship to address social justice challenges in Canada.

Plain language summary 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 16–49 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

Gender-based power dynamics within intimate relationships such as controlling behaviours are driven by inequitable gender norms that perpetuate intimate partner violence (IPV). Yet, the ways in which we understand and measure gender-based power dynamics focus on the relationships of monogamous, cisgender, white, heterosexual women. This paper outlines our process of planning and implementing a qualitative, youth-led, community-based research (CBR) study exploring how diverse youth with intersecting identities perceive existing measures of gender equity and understand gender equity based on their own relationships. Between August-November 2022, we used purposive sampling to recruit 30 gender-inclusive young women and non-binary youth aged 17–29 with diverse identities, who live in British Columbia (BC), and have recent experience in a non-heterosexual and/or non-monogamous relationship (within prior 12 months). Using CBR methods, we hired and trained three Youth Research Associates (YRAs) and convened a 10-member Youth Advisory Committee (YAC) comprised of youth aged 19–28 years with queer, trans, and/or non-monogamous identities and experiences to consult on all aspects of our study. YRAs conducted cognitive interviews using an interview guide co-developed and piloted in partnership with the YAC and YRAs. Cognitive interviews explored youth perceptions of gender equity and two gender equity measures widely used in health research today. Interview data will be analyzed collaboratively using intersectional descriptive and thematic analysis. Results from our CBR study will be used to make recommendations to advance gender equity measurement to be more inclusive of and applicable to a diversity of youth relationships, experiences, and identities.

Introduction: This study assessed the relationship between intention to receive a COVID-19 vaccine and intention to receive a seasonal influenza vaccine, as well as how intention to receive a COVID-19 vaccine has changed during the pandemic. Methods: Residents of British Columbia aged 25–69 years were invited to complete an online cross-sectional survey from August 2020 - March 2021. Mixed-effects logistic regression models assessed the relationship between intention to receive a COVID-19 vaccine and intention to receive the seasonal influenza vaccine. A generalized additive mixed model was used to investigate changes in COVID-19 vaccine intention during the pandemic (August 2020–March 2021). The relationship between intention to receive a COVID-19 vaccine and retrospective overall perceived value of vaccines prior to and during the pandemic was also considered. Results: Of 6,333 participants, 80.2 % of participants were ‘somewhat or very likely’ to receive a COVID-19 vaccine and 69 % of participants reported intending to receive a seasonal influenza vaccine. In multivariable modeling, intention to receive a COVID-19 vaccine was strongly associated with intention to receive a seasonal influenza vaccine (aOR = 4.25, 95 %CI 3.33–5.43). Intention to receive a COVID-19 vaccine increased over the study period (p

Abstract Background Women with an undetectable viral load can become pregnant and have children with no risk of HIV transmission to their sexual partners and low risk of transmission to their infants. Contemporary pregnancy intentions of women living with HIV in Canada are poorly understood, evidenced by high rates of unintended pregnancy and low uptake of contraceptives. Methods We used longitudinal survey data from the Canadian HIV Women’s Sexual and Reproductive Health Cohort Study (CHIWOS) to measure and compare pregnancy intentions (Yes vs No vs Unsure) at baseline, 18-months and 36-months follow-up (from 2013 to 2018) among women living with HIV of reproductive age (16–49 years) and potential. We used Sankey diagrams to depict changes in pregnancy intentions over time and multivariable logistic regression to examine the relationship between pregnancy intention within 2 years and subsequent pregnancy. Results At baseline, 41.9% (119/284) of women intended to become pregnant, 43.3% did not, and 14.8% were unsure. Across 36-months of follow-up, 41.9% (119/284) of women changed their pregnancy intentions, with 25% changing from intending to not intending to become pregnant and 13.1% vice versa. Pregnancy intentions were not strongly associated with subsequent pregnancy between baseline and 18-months (aOR 1.44; 95% CI 0.53, 3.72) or between 18 and 36-months (aOR 2.17; 95% CI 0.92, 5.13). Conclusions Our findings underscore the need for healthcare providers to engage in ongoing discussions with women living with HIV to support their dynamic pregnancy intentions.

The COVID-19 pandemic and public health protection measures aimed at mitigating the transmission of the virus have both resulted in tremendous physical and mental health impacts. The study at hand used a gender-based analysis and social determinants of health approach to investigate which communities had trouble coping during times of strict protection measures and symptoms and strategies employed during the COVID-19 pandemic.Participants were recruited from previously established cohorts as a part of the COVID-19 Rapid Evidence Study of a Provincial Population-Based Cohort for Gender and Sex (RESPPONSE) study. Being a young adult, female, woman, gender diverse, low-income earner or LGBTQ/2S+ was significantly associated with not being able to cope during the first wave of the pandemic. The effects for females, women, and gender diverse were attenuated yet still significant when controlling for various covariates. Those who reported not coping were more likely to present maladaptive coping symptoms and strategies. Our findings demonstrate the need to support marginalized communities in coping with the current ongoing COVID-19 pandemic and build proactive support for future pandemics.

The Canadian HIV Women’s Sexual and Reproductive Health Cohort Study – Positive Aboriginal Women (CHIWOS-PAW) actively Indigenizes and honours re-search by, with, and for Indigenous communities. In this study, as Indigenous and non-Indigenous researchers, we weave our ways of knowing and doing together on the Ancestral, Traditional, and stolen lands of the x w mƏθk w ƏýƏm (Musqueam), Skwxwú7mesh Úxwumixw (Squamish), sƏĺilwƏtaɁɬ tƏmƏx w (Tsleil-Waututh), S’ólh Téméxw (Stó:lō), and the Kwantlen Territories. We conceptualize ‘re-search’ as a cyclical journey that is not about ‘discovering’ new knowledge but designing a process to search for what is known, existing, and embodied by Mother Earth and our Ancestors. In this paper, we describe our process of using strengths-based approaches grounded in our connections with the Lands and Waters to explore how Indigenous Women living with HIV support their health and well-being by drawing upon Indigenous teachings and healing. Over the course of multiple gatherings conducted over 1 year with the same group of women, we utilized arts-based research methods, Indigenous teachings and ceremony, and Sharing Circles to collect and analyze women’s perspectives and experiences of their health and healthcare. The Wise Women were living in the Coast Salish Territories, yet came from different Communities, including Coast Salish, Cree, Blackfoot, and Navajo Nation. Our Indigenized re-search process was healing for the Wise Women who participated in the study and for us as the re-search team, which promoted re-connection to self, nature, and culture. We share insights on our learnings to support other community-based research teams to engage in re-search by , with , and for Indigenous Women that prioritizes safety, healing, and benefit for those who participate. Such insights include the importance of centering Indigenous Ways of Knowing, Ceremony, and Cultural Practices; changing re-search jargon to more inclusive and honouring language; and reaffirming commitment to Indigenous Communities.

Objectives Gathering population-based data on prevalence of SARS-CoV-2 infection is vital to the public health response and planning. Current seroprevalence data in BC are limited with respect to considerations of how socioeconomic and demographic factors, such as age, sex, gender, income, identifying as a visibility minority and occupation, are related to SARS-CoV-2 antibody detection due to infection-acquired immunity. We aimed to estimate the SARS-CoV-2 seropositivity in a cohort of British Columbians, using at-home self-collected dried blood spot (DBS) samples.Design This cross-sectional study included online surveys that collected sociodemographic and COVID-19 vaccine receipt information, and an at-home DBS collection kit.Setting British Columbia (BC), Canada.Participants Eligible participants were aged 25–69 years and residents of BC.Primary outcome measure SARS-CoV-2 anti-spike IgG antibody detection in unvaccinated individuals. Adjusted incidence rate ratios (aIRR) explored factors associated with seropositivity.Results SARS-CoV-2 serology was performed on a total of 4048 unvaccinated participants 25–69 years of age who submitted DBS samples taken from November 2020 to June 2021. A total of 118 seropositive cases were identified, for an estimated overall seropositivity of 2.92% (95% CI 2.42% to 3.48%). Participants identifying as a visible minority had a higher seropositivity, 5.1% vs 2.6% (p=0.003), compared with non-visible minority participants. After adjustment by age and sex, identifying as a visible minority (aIRR=1.85, 95% CI 1.20 to 2.84) remained the only significant factor associated with SARS-CoV-2 antibody detection in this cohort of unvaccinated individuals.Conclusions SARS-CoV-2 seropositivity in the BC population due to infection-acquired immunity was low. Seropositivity indicated that among those unvaccinated, visible minority communities have been most impacted. Continued monitoring of SARS-CoV-2 serology due to both infection-acquired and vaccine-acquired immunity will be vital in public health planning and pandemic response.

Abstract Background The success of any COVID-19 vaccine program ultimately depends on high vaccine uptake. This study determined overall intention to receive a COVID-19 vaccine and identified factors that predict intentions to be vaccinated against COVID-19 in Canada, specifically in key priority groups identified by the American Committee on Immunization Practice (ACIP) and the National Advisory Committee on Immunization (NACI) for early immunization. Methods Individuals from research cohorts from the general population of British Columbia aged 25–69 were invited complete an online survey based on validated scales and theoretical frameworks to explore intention to receive a COVID-19 vaccine. Two multivariable logistic regression models were conducted to determine factors associated with intention to receive the COVID-19 vaccine. Results Of 4948 respondents, 79.8% intended to receive a COVID-19 vaccine. In multivariable modeling, respondents who intended to receive the vaccine had higher vaccine attitudinal scores (p 60 years) were more likely to intend to receive the vaccine, while females (95%CI 0.57,0.93), those with less than high school education (95%CI 0.5,0.76), those who self-identified as non-white (95%CI 0.60,0.92), self-identified as Indigenous (95%CI 0.36,0.84) and essential non-health care workers (95%CI 0.59,0.86) had lower adjusted odds of intending to receive a COVID-19 vaccine. Conclusions To optimize vaccine coverage, public health should focus on key messages around vaccine safety and benefit, and leverage trusted practitioners for messaging. As certain key populations identified by NACI and ACIP for early immunization report a lower intention to vaccinate, there is a need for in-depth education and support for these communities to ensure optimal uptake.

Early menopause (p = 0.28) or biochemical confirmation (50.0 [46.0 to 53.0] vs. 51.0 [46.0 to 53.0] years; p = 0.54). In the multivariable model, no HIV-related or psychosocial variables were associated with earlier age at menopause (all p > 0.05). Overall, HIV status per se was not statistically associated with an earlier age at menopause, emphasizing the importance of comparing socio-demographically similar women in reproductive health and HIV research.

Antiretroviral therapy effectively prevents sexual and vertical transmission of HIV. Yet, some women living with HIV report having unmet needs for reproductive health care. This study measured the prevalence of women discussing reproductive goals with any current healthcare provider and assessed the effect of the current HIV care provider’s gender on such discussions and whether comfort was a mediator. We analysed baseline and 18-month survey data from 533 women living with HIV enrolled in the Canadian HIV Women’s Sexual and Reproductive Health Cohort Study (CHIWOS) (2013–2017), a community-based participatory study, restricting the analysis to participants aged 16–45 years. We used causal mediation analysis to estimate direct and indirect effects of the gender of one’s HIV care provider on reproductive discussions, incorporating mediating and interaction effects of women having any provider with whom they felt comfortable discussing reproductive goals. Between the baseline and 18-month follow-up surveys, 34.3% (183/533) of women discussed their reproductive goals with a healthcare provider. Having a woman HIV care provider was associated with a 1.18 excess relative risk (ERR) of discussion (95%CI: 0.15, 2.20). The mediating effect of comfort was primarily explained by the fact that those participants with women providers felt more comfortable discussing their reproductive goals compared to participants with men providers, accounting for 66% (95%CI: 32%, 99%) of the total effect. Findings support that HIV provider gender affects women’s comfort and whether they discuss reproductive goals, which must be acknowledged and addressed in care delivery.

Action on the World Health Organization Consolidated guideline on sexual and reproductive health and rights of women living with HIV requires evidence-based, equity-oriented, and regionally specific strategies centred on priorities of women living with HIV. Through community–academic partnership, we identified recommendations for developing a national action plan focused on enabling environments that shape sexual and reproductive health and rights by, with, and for women living with HIV in Canada. Between 2017 and 2019, leading Canadian women’s HIV community, research, and clinical organizations partnered with the World Health Organization to convene a webinar series to describe the World Health Organization Consolidated guideline, define sexual and reproductive health and rights priorities in Canada, disseminate Canadian research and best practices in sexual and reproductive health and rights, and demonstrate the importance of community–academic partnerships and meaningful engagement of women living with HIV. Four webinar topics were pursued: (1) Trauma and Violence-Aware Care/Practice; (2) Supporting Safer HIV Disclosure; (3) Reproductive Health, Rights, and Justice; and (4) Resilience, Self-efficacy, and Peer Support. Subsequent in-person (2018) and online (2018–2021) consultation with > 130 key stakeholders further clarified priorities. Consultations yielded five cross-cutting key recommendations: 1. Meaningfully engage women living with HIV across research, policy, and practice aimed at advancing sexual and reproductive health and rights by, with, and for all women. 2. Centre Indigenous women’s priorities, voices, and perspectives. 3. Use language that is actively de-stigmatizing, inclusive, and reflective of women’s strengths and experiences. 4. Strengthen Knowledge Translation efforts to support access to and uptake of contemporary sexual and reproductive health and rights information for all stakeholders. 5. Catalyse reciprocal relationships between evidence and action such that action is guided by research evidence, and research is guided by what is needed for effective action. Topic-specific sexual and reproductive health and rights recommendations were also identified. Guided by community engagement, recommendations for a national action plan on sexual and reproductive health and rights encourage Canada to enact global leadership by creating enabling environments for the health and healthcare of women living with HIV. Implementation is being pursued through consultations with provincial and national government representatives and policy-makers.

Objectives: People living with human immunodeficiency virus in Canada can face criminal charges for human immunodeficiency virus non-disclosure before sex, unless a condom is used and their viral load is

Objectives: We assessed the prevalence and correlates of sexual concerns and associated distress among women living with HIV in Canada. Methods: We analyzed cross-sectional survey data from the Canadian HIV Women’s Sexual and Reproductive Health Cohort Study (2017–2018). Self-identified women living with HIV were asked about sexual concerns post-HIV diagnosis and associated distress (none, mild, moderate, severe). Five areas of concern were assessed, including difficulties related to sexual self-esteem, sexual function, relationships, and emotional and behavioral aspects of sex. Logistic regression analyses identified correlates of reporting any sexual concerns and severe distress about these concerns. Results: Of 906 participants (median age 48, Q1–Q3 = 41–55), 596 (65.8%) reported sexual concerns post-HIV diagnosis. We found a high prevalence of concerns related to relationships (43.3%), sexual self-esteem (49.4%), and emotional aspects of sex (45.4%), relative to sexual functioning (38.4%) and behavioral aspects (33.7%). Of those with sexual concerns, 36.7% reported severe distress. Reports of severe distress were the highest for relationship difficulties (32.5%), relative to other areas of concern (21.4%–22.8%). In adjusted analyses, women reporting sexual dissatisfaction and high HIV-related stigma had significantly higher odds of reporting sexual concerns. Conversely, those reporting higher resilience, better mental health, African, Caribbean, and Black identity, and sex as somewhat unimportant, not at all important, or neutral to their lives had lower adjusted odds. Factors associated with severe distress about sexual concerns included older age, body dissatisfaction, sexual dissatisfaction, and high HIV-related stigma, while better mental health and getting support from someone living with HIV were protective. While 84.4% of women had discussed with a provider how viral load impacts transmission risk, only 40.6% had conversations about sexual wellbeing. Conclusion: More attention to women’s sexual wellbeing within social and relational contexts is critical to ensure the sexual rights of women living with HIV are upheld.

Introduction Women living with HIV (WLWH) experience accelerated ageing and an increased risk of age-associated diseases earlier in life, compared with women without HIV. This is likely due to a combination of viral factors, gender differences, hormonal imbalance and psychosocial and structural conditions. This interdisciplinary cohort study aims to understand how biological, clinical and sociostructural determinants of health interact to modulate healthy ageing in WLWH.Methods and analysis The British Columbia Children and Women: AntiRetroviral therapy and Markers of Aging-Canadian HIV Women’s Sexual and Reproductive Health Cohort Study (CARMA-CHIWOS) Collaboration (BCC3) study will enrol WLWH (n=350) and sociodemographically matched HIV-negative women (n=350) living in British Columbia. A subset of BCC3 participants will be past participants of CARMA, n≥1000 women and children living with and without HIV, 2008–2018 and/or CHIWOS, n=1422 WLWH, 2013–2018. Over two study visits, we will collect biological specimens for virus serologies, hormones and biological markers as well as administer a survey capturing demographic and sociostructural–behavioural factors. Sociodemographics, comorbidities, number and type of chronic/latent viral infections and hormonal irregularities will be compared between the two groups. Their association with biological markers and psychostructural and sociostructural factors will be investigated through multivariable regression and structural equation modelling. Retrospective longitudinal analyses will be conducted on data from past CARMA/CHIWOS participants. As BCC3 aims to follow participants as they age, this protocol will focus on the first study visits.Ethics and dissemination This study has been approved by the University of British Columbia Children’s and Women’s Research Ethics Board (H19-00896). Results will be shared in peer-reviewed journals, conferences and at community events as well as at www.hivhearme.ca and @HIV_HEAR_me. WLWH are involved in study design, survey creation, participant recruitment, data collection and knowledge translation. A Community Advisory Board will advise the research team throughout the study.

Abstract Background A community-based research (CBR) approach is critical to redressing the exclusion of women—particularly, traditionally marginalized women including those who use substances—from HIV research participation and benefit. However, few studies have articulated their process of involving and engaging peers, particularly within large-scale cohort studies of women living with HIV where gender, cultural and linguistic diversity, HIV stigma, substance use experience, and power inequities must be navigated. Methods Through our work on the Canadian HIV Women’s Sexual and Reproductive Health Cohort Study (CHIWOS), Canada’s largest community-collaborative longitudinal cohort of women living with HIV (n = 1422), we developed a comprehensive, regionally tailored approach for hiring, training, and supporting women living with HIV as Peer Research Associates (PRAs). To reflect the diversity of women with HIV in Canada, we initially hired 37 PRAs from British Columbia, Ontario, and Quebec, prioritizing women historically under-represented in research, including women who use or have used illicit drugs, and women living with HIV of other social identities including Indigenous, racialized, LGBTQ2S, and sex work communities, noting important points of intersection between these groups. Results Building on PRAs’ lived experience, research capacity was supported through a comprehensive, multi-phase, and evidence-based experiential training curriculum, with mentorship and support opportunities provided at various stages of the study. Challenges included the following: being responsive to PRAs’ diversity; ensuring PRAs’ health, well-being, safety, and confidentiality; supporting PRAs to navigate shifting roles in their community; and ensuring sufficient time and resources for the translation of materials between English and French. Opportunities included the following: mutual capacity building of PRAs and researchers; community-informed approaches to study the processes and challenges; enhanced recruitment of harder-to-reach populations; and stronger community partnerships facilitating advocacy and action on findings. Conclusions Community-collaborative studies are key to increasing the relevance and impact potential of research. For women living with HIV to participate in and benefit from HIV research, studies must foster inclusive, flexible, safe, and reciprocal approaches to PRA engagement, employment, and training tailored to regional contexts and women’s lives. Recommendations for best practice are offered.

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 ( 0.001). Older WLWH had lower social support (p

Background: Understanding young women and men's perceived barriers and facilitators to participation in biomedical HIV prevention research is important for designing youth friendly services (YFS) and acceptable technologies, which are necessary for preventing high sustained HIV incidence in South Africa. This study explores the multileveled barriers and facilitators to young men and women's willingness to participate in hypothetical biomedical HIV prevention research.Methods: Eight age- (16–18 and 19–24 years) and gender-stratified focus group discussions (FGDs) were conducted using semi-structured interview guides to explore young South African women and men's willingness, perceived barriers, and facilitators to participating in biomedical HIV prevention research. FGD transcripts were uploaded to NVivo and coded collaboratively with youth study team members. Thematic analysis using Bronfenbrenner's ecological model (individual, inter-personal, community, and societal) was used to guide a deductive coding procedure, which was documented and compared by gender.Results: Thirty-one participants from Durban and 34 from Soweto participated in FGDs. Individual facilitators for participation were discussed more by young men and included financial incentives and altruism. Concerns about side-effects of biomedical products were a common barrier. Interpersonal relationships with peers, intimate partners and caregivers influenced young people's willingness to participate in HIV prevention research, more so among young women. For young women, gendered power dynamics and distrust of intimate partners and parents influenced both communication regarding participation and willingness to participate in research that is often stigmatized, due to societal norms around women's sexuality. On a societal level, participants expressed distrust in medical and research institutions, however a sense of community that was developed with the study staff of this project, was a motivator to participate in future studies.Discussion: At each level of the ecological model, we found participants expressed gendered barriers and facilitators for participation. Gender norms as well as distrust of partners, parents, and health care professionals were key barriers that cut across all levels. At each level participants discussed facilitators that were youth-engaged, underscoring the need to implement YFS, establish trust and address gender inequities within future biomedical HIV prevention studies wishing to engage and retain South African youth.

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).

Objectives: Psychological stress is an important determinant of health, including for mental well-being and sexual health. However, little is known about the prevalence and psychosocial and sexual health correlates of perceived stress among young people in South Africa, where elevated life-stressors are an important driver of health inequities. This study examines the association between intimate partner violence (IPV), psychosocial and sexual health, and perceived stress, by gender, among South African adolescents and young adults.Methods: Using baseline survey data from AYAZAZI, a cohort study enrolling youth (16–24 years) from Durban and Soweto, we used the 10-item Perceived Stress Scale (PSS-10) to measure the degree to which an individual perceives their life situations as unpredictable, uncontrollable, and overloaded. Possible scores range between 0 and 40; higher scores indicating higher perceived stress. Crude and adjusted gender-stratified linear regression models examined associations between sexual health factors, experiences (young women) and perpetration (young men) of IPV, anxiety (APA 3-item Scale, ≥2 = probable anxiety), and depression (10-item CES-D Scale, ≥10 = probable depression) and perceived stress. Multivariable models adjusted for age, income, sexual orientation, and financial dependents.Results: Of the 425 AYAZAZI participants, 60% were young women. At baseline, 71.5% were students//learners and 77.2% earned ≤ ZAR1600 per month (~$100 USD). The PSS-10 had moderate reliability (α = 0.70 for young women, 0.64 for young men). Young women reported significantly higher mean PSS scores than young men [18.3 (6.3) vs. 16.4 (6.0)]. In adjusted linear regression models, among young women experiences of IPV (β = 4.33; 95% CI: 1.9, 6.8), probable depression (β = 6.63; 95% CI: 5.2, 8.1), and probable anxiety (β = 5.2; 95% CI: 3.6, 6.8) were significantly associated with higher PSS scores. Among young men, ever perpetrating IPV (β = 2.95; 95% CI: 0.3, 5.6), probable depression (β = 6; 95% CI: 4.3, 7.6), and probable anxiety (β = 3.9; 95% CI: 2.1, 5.8) were significantly associated with higher perceived stress.Conclusion: We found that probable depression, anxiety, perpetration of IPV among young men, and experiences of IPV among young women, were associated with higher perceived stress. Critical efforts are needed to address the gendered stressors of young men and women and implement services to address mental health within violence prevention efforts.

HIV care provides an opportunity to integrate comprehensive sexual and reproductive healthcare, including sexually transmitted infection (STI) management. We describe STI prevalence and correlates among men living with HIV (MLWH) accessing safer conception care to conceive a child with an HIV-uninfected partner while minimizing HIV transmission risks. This study reflects an ongoing safer conception program embedded within a regional referral hospital HIV clinic in southwestern Uganda. We enrolled MLWH, planning for pregnancy with an HIV-uninfected partner and accessing safer conception care. Participants completed interviewer-administered questionnaires detailing socio-demographics, gender dynamics, and sexual history. Participants also completed STI laboratory screening for syphilis (immunochromatographic testing confirmed by rapid plasma reagin), and chlamydia, gonorrhea, trichomoniasis, and HIV-RNA via GeneXpert nucleic acid amplification testing. Bivariable associations of STI covariates were assessed using Fisher's exact test. Among the 50 men who completed STI screening, median age was 33 (IQR 31-37) years, 13/50 (26%) had ≥2 sexual partners in the prior three months, and 46/50 (92%) had HIV-RNA

ObjectivesThe SARS-CoV-2 (COVID-19) pandemic has had profound physical and mental health effects on populations around the world. Limited empirical research has used a gender-based lens to evaluate the mental health impacts of the pandemic, overlooking the impact of public health measures on marginalized groups, such as women, and the gender diverse community. This study used a gender-based analysis to determine the prevalence of psychosocial symptoms and substance use (alcohol and cannabis use in particular) by age, ethnicity, income, rurality, education level, Indigenous status, and sexual orientation.MethodsParticipants in the study were recruited from previously established cohorts as a part of the COVID-19 Rapid Evidence Study of a Provincial Population-Based Cohort for Gender and Sex (RESPPONSE) study. Those who agreed to participate were asked to self-report symptoms of depression, anxiety, pandemic stress, loneliness, alcohol use, and cannabis use across five phases of the pandemic as well as retrospectively before the pandemic.ResultsFor all psychosocial outcomes, there was a significant effect of time with all five phases of the pandemic being associated with more symptoms of depression, anxiety, stress, and loneliness relative to pre-COVID levels (p < .0001). Gender was significantly associated with all outcomes (p < .0001) with men exhibiting lower scores (i.e., fewer symptoms) than women and gender diverse participants, and women exhibiting lower scores than the gender diverse group. Other significant predictors were age (younger populations experiencing more symptoms, p < .0001), ethnicity (Chinese/Taiwanese individuals experiencing fewer symptoms, p = .005), and Indigenous status (Indigenous individuals experiencing more symptoms, p < .0001). Alcohol use and cannabis use increased relative to pre-pandemic levels, and women reported a greater increase in cannabis use than men (p < .0001).ConclusionsOur findings highlight the need for policy makers and leaders to prioritize women, gender-diverse individuals, and young people when tailoring public health measures for future pandemics.

Background The ubiquity of cellular phone (cellphone) use in young people’s daily lives has emerged as a priority area of concern for youth mental health. Objective This study measured the prevalence of depression and its association with high cellphone use among youth in Soweto and Durban, South Africa. Methods We analysed cross-sectional, baseline survey data among youth aged 16–24 who participated in a dual-site cohort study, ‘AYAZAZI’, conducted from 2014 to 2017. The primary outcome was depression using the 10-item Center for Epidemiologic Studies Depression Scale, with a score of ≥ 10 indicating probable depression. Cellphone use was measured via self-reported average number of hours of active use, with ‘high cellphone use’ defined as daily usage of ≥ 8. Multivariable logistic regression models assessed the independent relationship between high cellphone use and probable depression, adjusting for potential confounders. Results Of 425 participants with a median age of 19 years (IQR = 18–21), 59.5% were young women. Overall, 43.3% had probable depression, with a higher prevalence among women (49.0% vs. 34.9%, P = .004). Nearly all (94.6%) owned a cellphone. About one-third (29.5%) reported spending ≥ 8 hours per day using their cellphone (39.3% of women vs. 14.9% of men, P

Transitioning from pediatric to adult care is a complicated process for youth with chronic illnesses. This study elucidates the unique factors affecting transition preparedness and perception of adult HIV care among a cohort of young women with HIV. Between 2013 and 2015, 48 women with HIV, who had experience with pediatric HIV care, were enrolled in a large Canadian cohort study. Variables were self-reported during peer-administered surveys. Only 60% reported feeling prepared for transition. Having never had contact with child protection services ( P = .049), never been in foster care ( P = .011), never been in a group home ( P = .036), reporting a higher current CD4 count ( P = .033), and reporting a younger ideal age for transition ( P = .041) were associated with transition preparedness. Eighty-four percent reported equivalent or better HIV care following transition. Correlates of equivalent/better care following transition included lower personal income ( P = .023), higher CD4 count ( P = .021), care by an adult infectious diseases specialist ( P = .002), and transition preparedness ( P = .005). Our findings highlight the importance of adequate transition preparation and its effect on perception of care following transition.

Abstract Background Youth in southern Africa, particularly adolescent girls and young women, are a key population for HIV prevention interventions. Untreated genital tract infections (GTIs) increase both HIV transmission and acquisition risks. South African GTI treatment guidelines employ syndromic management, which relies on individuals to report GTI signs and symptoms. Syndromic management may, however, underestimate cases, particularly among youth. We compared genital tract infection (GTI) prevalence by symptom-based and laboratory assessment among sexually-experienced youth in South Africa, overall and stratified by sex. Methods Interviewer-administered surveys assessed socio-demographics, behaviors, and GTI symptoms among 352 youth (16-24 yrs., HIV-negative or unknown HIV status at enrollment) enrolled in community-based cohorts in Durban and Soweto (2014–2016). Laboratory tests assessed HIV, Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), Mycoplasma genitalium (MG), Trichomonas vaginalis (TV) infections and, among females, bacterial vaginosis (BV) and Candida species. Youth with genital ulcers were tested for HSV-2 and syphilis. We assessed sensitivity (and specificity) of symptom-based reporting in identifying laboratory-confirmed GTIs. Results At baseline, 16.2% of females (32/198) and

Abstract Background Task shifting is increasingly used to address human resource shortages impacting HIV service delivery in low- and middle-income countries. By shifting basic tasks from higher- to lower-trained cadres, such as Community Health Workers (CHWs), task shifting can reduce overhead costs, improve community outreach, and provide efficient scale-up of essential treatments like antiretroviral therapies. Although there is rich evidence outlining positive outcomes that CHWs bring into HIV programs, important questions remain over their place in service delivery. These challenges often reflect concerns over whether CHWs can mitigate HIV through a means that does not overlook the ethical and practical constraints that undergird their work. Ethical and practical guidance thus needs to become the cornerstone of CHW deployment. This paper analyzes such challenges through the lens of Ethical Principlism. Methods We examined papers identifying substantive and ethical challenges impacting CHWs as they provide HIV services in low- and middle-income contexts. To do this, we analyzed papers written in English and published from year 2000 or later. These articles were identified using MEDLINE, Cochrane Database of Systematic Reviews, and Google Scholar databases. In total, 465 articles were identified, 78 of which met our inclusion criteria. Article reference lists and grey literature were also examined. Results CHWs experience specific challenges while carrying out their duties, such as conducting emotionally- and physically-demanding tasks with often inadequate training, supervision and compensation. CHWs have also been poorly integrated into health systems, which not only impacts quality of care, but can hinder their prospects for promotion and lead to CHW disempowerment. As we argue, these challenges can be addressed if a set of ethical principles is prioritized, which specifically entail the principles of respect for persons, justice, beneficence, proportionality and cultural humility. Conclusions CHWs play a crucial role in HIV service delivery, yet the ethical challenges that can accompany their work cannot be overlooked. By prioritizing ethical principles, policymakers and program implementers can better ensure that CHWs are combatting HIV through a means that does not exploit or take their critical role within service delivery for granted.

Abstract Background For women living with HIV (WLWH) in low- and middle-income countries, World Health Organization (WHO) infant feeding guidelines now recommend exclusive breastfeeding until six months followed by mixed feeding until 24 months, alongside lifelong maternal antiretroviral therapy (ART). These recommendations represent the sixth major revision to WHO infant feeding guidelines since 1992. We explored how WLWH in rural Uganda make infant feeding decisions in light of evolving recommendations. Methods We conducted semi-structured interviews with 20 postpartum Ugandan WLWH accessing ART, who reported pregnancy

Abstract Background In sub-Saharan Africa, 58% of adults living with HIV are women. In Uganda, HIV prevalence is 8.3% for women compared to 6.1% for men. Access to antiretroviral therapy (ART) and prevention of mother to child transmission (PMTCT) programs have enabled women living with HIV (WLWH) to have children with minimal risk of perinatal transmission. Nevertheless, pregnant WLWH face many challenges. We explored women’s perceptions of how they cope with the challenges of pregnancy and the postpartum period as HIV-infected women. Methods We conducted semi-structured interviews with postpartum WLWH accessing ART who had a pregnancy within 2 years prior to recruitment between February–August, 2014. Childbearing associated stressors and coping strategies were discussed. We used content analysis to identify major themes and NVivo 10 software facilitated data analysis. Results Twenty women were interviewed with median age 33 (IQR: 28–35) years, CD4 cell count 677 cells/mm3 (IQR: 440–767), number of live births 4 (IQR: 2–6), and number of living children 3 (IQR: 2–4.3). We summarize five identified coping strategies within a socio-ecological framework according to Bronfenbrenner’s Ecological Model. Coping strategies on the individual level included acceptance of self and HIV status, and self-reliance. On the interpersonal level, participants reported coping through support from partners, family, and friends. On the organizational level, participants reported coping through HIV-related healthcare delivery and system supports. At the community level, women reported coping through support from church and spirituality. Conclusions The results highlight coping strategies used by WLWH to manage the myriad challenges faced during pregnancy and the postpartum period. Intervention programs for WLWH must emphasize psychosocial care and incorporate strategies that address psychosocial challenges in the HIV care package in order to optimize well-being. Additionally policies that support networks of WLWH should be put in place and funding support should be provided through existing funding mechanisms in order to respond to the needs and challenges of WLWH. Programmes that support WLWH for economic empowerment and improved livelihoods should be strengthened across all regions in the country.

Objectives: We examined how multiple, nested, and interacting systems impact the protective process of resilience for women living with HIV (WLWH). Methods: Using data from a Cohort Study, we conducted univariate analyses, multivariable logistic regression, and a 2-step structural equation modeling for the outcome, high resilience (N = 1422). Results: Participants reported high overall resilience scores with a mean of 62.2 (standard deviation = 8.1) and median of 64 (interquartile range = 59-69). The odds of having high resilience were greater for those residing in Quebec compared to Ontario (adjusted odds ratio [aOR] = 2.1 [1.6, 2.9]) and British Columbia (aOR = 1.8 [1.3, 2.5]). Transgender women had increased odds of high resilience than cisgender women (aOR = 1.9 [1.0, 3.6]). There were higher odds of resilience for those without mental health diagnoses (aOR = 2.4 [1.9, 3.0]), non-binge drinkers (aOR=1.5 [1.1, 2.1]), and not currently versus previously injecting drugs (aOR = 3.6 [2.1, 5.9]). Structural equation modeling confirmed that factors influencing resilience lie at multiple levels: micro, meso, exo, and macro systems of influence. Conclusion: There is a need to consider resilience as the interaction between the person and their environments, informing the development of multilevel interventions to support resilience among WLWH.

Body Mapping has been used for thousands of years by people who want to achieve a better understanding of themselves, their bodies and the world they live in. Artist Jane Solomon and psychologist Jonathan Morgan transformed Body Mapping for the “Long Life Project”, during the Médecins Sans Frontières (MSF) roll-out of antiretrovirals in Khayelitsha township, South Africa in 2001. Body mapping enables participants to tell their stories in the face of intense HIV/AIDS stigma. We adapted Body Mapping for the Women, Art and Criminalizaton of HIV Non-Disclosure (WATCH) study, a community arts based research (CBR) approach to better understand the impact that Canadian laws criminalizing HIV non-disclosure have on women living with HIV. Our national team includes women living with HIV, service providers, and researchers. This reflection illustrates our collective and iterative process of learning, teaching and doing body mapping workshops with women living with HIV in Canada. We share our experiences of coming to Body Mapping as an arts-based approach to CBR, how our roles as researchers stretched to include community-based education, advocacy, and group facilitation, and how we embodied the artist-researcher identity as we disseminate our research in ways that actively engage the general public on laws criminalizing HIV nondisclosure laws vis-à-vis Body Mapping galleries.

BackgroundUnwanted pregnancies remain a burden for women living with HIV (WLWH). Family planning prevents unplanned pregnancies while promoting longer birth intervals, key strategies to eliminate perinatal transmission of HIV and promote maternal and child health. We evaluated the effect of a family planning voucher, inclusive of immediate postpartum counseling, on uptake, early initiation, and continuation of modern contraceptive methods among recently postpartum WLWH delivering at a publicly funded regional referral hospital in rural, southwestern Uganda.Methods and findingsWe performed a randomized controlled trial between October, 2016 and June, 2018 at a referral hospital in southwestern Uganda. This interim analysis includes adult WLWH randomized and enrolled equally to receive a family planning voucher or standard of care (control). Enrolled postpartum WLWH completed an interviewer-administered questionnaire at enrollment and 6 months postpartum. Our primary outcome of interest for this analysis is initiation of a modern family planning method within 8 weeks postpartum. Secondary outcomes included family planning initiation at 12, 14, 16, and 20 weeks postpartum, family planning discontinuation and/or change, pregnancy incidence, and mean time without contraception. The trial was registered with clinicaltrials.gov (NCT02964169). At enrollment, half of the women in both the voucher (N = 87, 55%) and control (N = 86, 54%) groups wanted to have a child in 2 years postpartum. Over 80% of referent pregnancies in the voucher (N = 136, 86%) and control (N = 128, 81%) groups were planned. All women were accessing ART. The mean CD4 count was 396 cells/mm3 (SD = 61) for those enrolled in the control group versus 393 cells/mm3 (SD = 64) in the family planning voucher group. By 8 weeks postpartum, family planning was initiated in 144 (91%) participants in the voucher group and 83 (52%) participants in the control group (odds ratio [OR] 9.42; CI 4.67-13.97, P < 0.001). We also found high family planning uptake rates for both groups, with higher rates among the intervention group at 12 weeks (OR 5.66; CI 2.65-12.12, P < 0.001), 14 weeks (OR 2.51; CI 1.31-4.79, P < 0.001), 16 weeks (OR 4.02; CI 1.66-9.77, P = 0.001), and 20 weeks (OR 3.65; CI 1.40-9.47, P = 0.004) postpartum. The average time to family planning initiation was reduced to 5.9 weeks (SD = 2.4) for those in the voucher group compared to 9.3 weeks (SD = 5) in the control (P < 0.001). One pregnancy was recorded in the group receiving standard of care; none were reported in the voucher group. Method mix did not differ by group: injectables were selected by most women (N = 150, 50%), and 52% of this proportion were in the experimental arm, with ConclusionThese findings indicate that a well-structured, time-bound family planning voucher program appeared to increase early postpartum contraceptive uptake and continuation in a setting in which users are faced with financial, knowledge, and structural barriers to contraceptive services. Further work should clarify the role of vouchers in empowering WLWH to avoid unintended pregnancies over time.Trial registrationClinicalTrials.gov NCT02964169.

IntroductionMeasures used to assess equitable relationship dynamics, including the sexual relationship power scale (SRPS) have previously been associated with lower HIV-risk among young women, and reduced perpetration of intimate partner violence among men. However, few studies describe how the SRPS has been adapted and validated for use within global youth sexual health studies. We examined gender-specific psychometric properties, reliability, and validity of a SRPS used within a South African youth-engaged cohort study.MethodsYoung men and women (16-24 years) enrolled in community-based cohorts in Durban and Soweto (2014-2016) reporting a primary partner at 6-month follow-up completed a 13-item (strongly agree/agree/disagree/strongly disagree) South African adaptation of Pulerwitz's SRPS (range 13-52, higher scores indicating greater sexual relationship power [SRP] equity). SRPS modifications were made using gender-specific exploratory factor analyses (EFAs), removing items with factor loadings Results235 sexually-active youth (66% women, median age = 20) were included. Mean scores across all 13 scale items were 2.71 (SD 0.30) for women and 2.70 (SD 0.4) for men. Scale Cronbach's alphas were 0.63 for women and 0.64 for men. EFAs resulted in two gender-specific single-factor SRPS. Modified SRPS Cronbach alphas increased to 0.67 for women (8-items) and 0.70 for men (9-items). After adjusting for age, site and current employment, higher education remained associated with SRP equity across genders. In adjusted models, correlates of SRP equity included primary partnerships that were age-similar (ConclusionsResults highlight important gender differences in SRP equity measures and associations, highlighting the critically need for future research to examine gendered constructions of SRP equity in order to accurately develop, validate and use appropriate measures within quantitative surveys.

OBJECTIVES:To measure the prevalence and correlates of abnormal menstruation among women living with HIV (WLWH) in Canada. METHODS:We used cross-sectional questionnaire data from the community-based Canadian HIV Women's Sexual and Reproductive Health Cohort Study (CHIWOS), which enrolled WLWH aged ≥16 from British Columbia (BC), Ontario, and Quebec. For this analysis, we excluded women >45 years, who had primary amenorrhea, were pregnant, on hormonal contraception, or who reported history of endometrial cancer, last menstrual period >12 months ago, or premature ovarian failure. The primary outcome was abnormal menstruation (Yes vs No) based on responses to five questions about menstrual regularity, frequency, volume, duration, and intermenstrual bleeding in the six months prior to interview. An exploratory multivariable logistic regression analysis examined independent correlates of abnormal menstruation. RESULTS:Of 1422 women enrolled, 521 (37%) met eligibility criteria. Overall, 55.9% (95% CI:52%-60%) reported abnormal menstruation. In adjusted analyses, abnormal menstruation was associated with having a biologic sister/mother who entered menopause before age 40 (AOR 5.01, 95%CI 1.39-18.03), Hepatitis B co-infection (AOR 6.97, 95%CI 1.52-31.88), current smoking (AOR 1.69, 95%CI 1.55-3.41); and currently taking antiretroviral therapy (ART) (AOR 2.36, 95%CI 1.25-4.45) compared to being ART-naïve. Women in BC had higher adjusted odds of abnormal menstruation (AOR 2.95, 95%CI 1.61-5.39), relative to women in Ontario and Quebec. CONCLUSIONS:Over half of WLWH in this analysis had abnormal menstruation. Correlates of abnormal menstruation include genetic, socio-behavioural factors (province of residence, smoking), Hepatitis B co-infection, and current ART use.

BackgroundWomen living with HIV (WLWH) continue to experience poorer outcomes across the HIV care cascade and overall health, an appreciable proportion of which may not be disease-related but due to socio-structural barriers that impact health. We compared socio-structural determinants of health and self-rated health between WLWH and expected general population values.MethodsPrevalences of socio-structural determinants and self-rated health were estimated from 1,422 WLWH aged 16+ in the 2013-2015 Canadian HIV Women's Sexual and Reproductive Health Cohort Study (CHIWOS). Prevalences were also estimated from 46,831 general population women (assumed HIV-negative) in the 2013-2014 Canadian Community Health Survey (CCHS), standardized to the age/ethnoracial group distribution of WLWH. Standardized prevalence differences (SPDs) and 95% confidence intervals (CI) were reported.ResultsCompared to general population women, a higher proportion of WLWH reported annual personal income ConclusionsSignificant socio-structural inequalities and lower self-rated health were found among WLWH compared to general population women. Such inequities support the integration of a social-determinants approach, social service delivery, and programming into HIV care, with additional resource allocation tailored to the particular needs of WLWH.

Abstract Background Youth trauma exposure is associated with syndemic HIV risk. We measured lifetime prevalence, type, and correlates of trauma experience by gender among adolescents living in the HIV hyper-endemic setting of Soweto, South Africa. Methods Using data from the Botsha Bophelo Adolescent Health Survey (BBAHS), prevalence of “ever” experiencing a traumatic event among adolescents (aged 14–19) was assessed using a modified Traumatic Event Screening Inventory-Child (TESI-C) scale (19 items, study alpha = 0.63). We assessed self-reported number of potentially traumatic events (PTEs) experienced overall and by gender. Gender-stratified multivariable logistic regression models assessed independent correlates of ‘high PTE score’ (≥7 PTEs). Results Overall, 767/830 (92%) participants were included (58% adolescent women). Nearly all (99.7%) reported experiencing at least one PTE. Median PTE was 7 [Q1,Q3: 5-9], with no gender differences (p = 0.19). Adolescent men reported more violent PTEs (e.g., “seen an act of violence in the community”) whereas women reported more non-violent HIV/AIDS-related PTEs (e.g., “family member or someone close died of HIV/AIDS”). High PTE score was independently associated with high food insecurity among adolescent men and women (aOR = 2.63, 95%CI = 1.36-5.09; aOR = 2.57, 95%CI = 1.55-4.26, respectively). For men, high PTE score was also associated with older age (aOR = 1.40/year, 95%CI = 1.21-1.63); and recently moving to Soweto (aOR = 2.78, 95%CI = 1.14-6.76). Among women, high PTE score was associated with depression using the CES-D scale (aOR = 2.00, 95%CI = 1.31-3.03,) and inconsistent condom use vs. no sexual experience (aOR = 2.69, 95%CI = 1.66-4.37). Conclusion Nearly all adolescents in this study experienced trauma, with gendered differences in PTE types and correlates, but not prevalence. Exposure to PTEs were distributed along social and gendered axes. Among adolescent women, associations with depression and inconsistent condom use suggest pathways for HIV risk. HIV prevention interventions targeting adolescents must address the syndemics of trauma and HIV through the scale-up of gender-transformative, youth-centred, trauma-informed integrated HIV and mental health services.

Abstract Background Community-based research has gained increasing recognition in health research over the last two decades. Such participatory research approaches are lauded for their ability to anchor research in lived experiences, ensuring cultural appropriateness, accessing local knowledge, reaching marginalized communities, building capacity, and facilitating research-to-action. While having these positive attributes, the community-based health research literature is predominantly composed of small projects, using qualitative methods, and set within geographically limited communities. Its use in larger health studies, including clinical trials and cohorts, is limited. We present the Canadian HIV Women’s Sexual and Reproductive Health Cohort Study (CHIWOS), a large-scale, multi-site, national, longitudinal quantitative study that has operationalized community-based research in all steps of the research process. Successes, challenges and further considerations are offered. Discussion Through the integration of community-based research principles, we have been successful in: facilitating a two-year long formative phase for this study; developing a novel survey instrument with national involvement; training 39 Peer Research Associates (PRAs); offering ongoing comprehensive support to PRAs; and engaging in an ongoing iterative community-based research process. Our community-based research approach within CHIWOS demanded that we be cognizant of challenges managing a large national team, inherent power imbalances and challenges with communication, compensation and volunteering considerations, and extensive delays in institutional processes. It is important to consider the iterative nature of community-based research and to work through tensions that emerge given the diverse perspectives of numerous team members. Conclusions Community-based research, as an approach to large-scale quantitative health research projects, is an increasingly viable methodological option. Community-based research has several advantages that go hand-in-hand with its obstacles. We offer guidance on implementing this approach, such that the process can be better planned and result in success.

BACKGROUND:Preventing unintended pregnancy is critical for women living with HIV (WLWH) to safely achieve their reproductive goals. Family planning services should support WLWH at risk of repeat unintended pregnancies. We examined the relationship between unintended pregnancy and subsequent contraception use among WLWH in Uganda. STUDY DESIGN:This was a retrospective analysis of data from a longitudinal cohort of individuals initiating antiretroviral therapy (ART), restricted to women with pregnancy (confirmed via urine β-hcg testing) between 2011-2013. The exposure of interest was intended vs unintended pregnancy, and the outcome was self-report of modern contraceptive use (hormonal methods, intrauterine device, sterilization, and/or consistent condom use) at 12 (range 6-18) months post-partum. A log-binomial model was used to estimate relative risks of modern contraceptive use post-partum based on intent of the index pregnancy, adjusted for age, socioeconomic status, education, relationship and HIV status of pregnancy partner, contraceptive use prior to pregnancy, years since HIV diagnosis, ART regimen, and CD4 cell count. RESULTS:Among 455 women, 110 women reported 110 incident pregnancies with report on intent. Women had a baseline median age of 29 years, baseline CD4 count 403 cells/mm3, and were living with HIV for 3.8 years. Fifty pregnancies (45%) were reported as unintended and 60 (55%) as intended. Postpartum, 64% of women with unintended and 51% with intended pregnancy reported modern contraception (p = 0.24). In adjusted models, there was no association between pregnancy intent and post-partum contraception. However, contraceptive use prior to the referent pregnancy was positively associated with post-partum contraceptive use (aRR 1.97 (95% CI 1.12-3.48, p = 0.02), while higher baseline CD4 cell count was associated with lower post-partum contraceptive use (aRR 0.95, 95% CI 0.90-0.99, p = 0.02). CONCLUSIONS:Almost half of incident pregnancies among WLWH in this cohort were unintended. Experiencing an unintended pregnancy was not associated with post-partum contraceptive use. Creative strategies to support contraceptive uptake for birth spacing and prevention of unintended pregnancies in the post-partum period are needed.

BACKGROUND:Intimate partner violence (IPV) is a significant global health problem. Women who experience IPV have increased HIV incidence, reduced antiretroviral adherence, and a lower likelihood of viral load suppression. There is a lack of evidence regarding how to effectively identify and support women living with HIV (WLWH) experiencing IPV, including uncertainty whether universal or targeted screening is most appropriate for lower-resourced settings. We examined physical and sexual IPV prevalence and correlates among WLWH in Uganda to understand the burden of IPV and factors that could help identify women at risk. METHODS:We utilized data from women receiving ART and enrolled in the Uganda AIDS Rural Treatment Outcomes (UARTO) cohort study between 2011 and 2015. Bloodwork and interviewer-administered questionnaires were completed every 4 months. IPV was assessed annually or with any new pregnancy. Multivariate models assessed independent socio-demographic and clinical factors correlated with IPV, at baseline and follow-up visits. RESULTS:455 WLWH were included. Median age was 36 years, 43% were married, and median follow-up was 2.8 years. At baseline 131 women (29%) reported any experience of past or current IPV. In the adjusted models, being married was associated with a higher risk of baseline IPV (ARR 2.33, 95% CI 1.13-4.81) and follow-up IPV (ARR 2.43, 95% CI 1.33-4.45). Older age (ARR 0.96, 95% CI 0.94-0.99) and higher household asset index score (ARR 0.81, 95% CI 0.68-0.96) were associated with lower risk of IPV during follow-up. CONCLUSION:There was a high prevalence of physical and sexual IPV amongst WLWH, and many women experienced both types of violence. These findings suggest the need for clinic-based screening for IPV. If universal screening is not feasible, correlates of having experienced IPV can inform targeted approaches.

PURPOSE:Women living with HIV experience high levels of trauma exposure before and after diagnosis. One of the most challenging outcomes following trauma exposure is posttraumatic stress disorder. Despite high exposure to traumatic events, the presence and contributors to posttraumatic stress disorder symptoms have not been examined in women living with HIV in Canada. METHODS:The current study examines the presence of, contributors to, and geographical regions associated with self-reported posttraumatic stress symptoms (PTSS) among 1405 women enrolled in the Canadian HIV Women's Sexual & Reproductive Health Cohort Study (CHIWOS). RESULTS:Separate linear regression models were run for the three provinces in the cohort: British Columbia, Ontario and Québec. Scores consistent with posttraumatic stress disorder were reported by 55.9%, 39.1% and 54.1% of the participants in each province, respectively (F(2, 1402) = 13.53, p < .001). CONCLUSIONS:The results demonstrate that women living with HIV have high rates of PTSS, and that rates and variables associated with these symptoms vary by province. These results suggest the need for trauma-informed practices and care for women living with HIV in Canada, which may need to be tailored for the community and identities of the women.

Background: Adolescents are an important age-group for preventing disease and supporting health yet little is known about their health-seeking behaviours. Objective: We describe socio-demographic characteristics and health-seeking behaviours of adolescents in Soweto, South Africa, in order to broaden our understanding of their health needs. Design: The Botsha Bophelo Adolescent Health Study was an interviewer-administered cross-sectional survey of 830 adolescents (14–19 years) conducted in Soweto from 2010 to 2012. Health-seeking behaviours were defined as accessing medical services and/or being hospitalised in the 6 months prior to the survey. Chi-square analysis tested for associations between gender, other socio-demographic and behavioural characteristics, and health-seeking behaviours. Results: Of 830 adolescents, 57% were female, 50% were aged 17–19 years, 85% were enrolled in school, and 78% reported experiencing medium or high food insecurity. Males were more likely than females to report sexual debut (64% vs. 49%; p