Chapter 4: Population-specific HIV/AIDS status report: Women - Evidence on factors that impact resilience and vulnerability
Chapter 4 - Current Evidence on Factors that Impact Women's Resiliency and Vulnerability to HIV/AIDS
4.1 Determinants of Health
One of the major developments to emerge in the study of women’s health over the last few decades has been the recognition that women’s health encompasses a “state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. Women's health involves their emotional, social and physical well-being and is determined by the social, political and economic context of their lives, as well as by biology.” . Complex intersections between social and economic factors, the physical environment and individual behaviour can create or enhance vulnerability and resilience regarding one’s health [2;3]. This chapter examines women’s vulnerability and resilience to HIV in Canada through a determinants of health lens .
The Determinants of Health
- Biology and Genetic Endowment
- Income and Social Status/Employment and Income
- Social Environments and Social Support Networks
- Physical Environments
- Personal Health Practices and Coping Skills
- Healthy Child Development
- Health Services
- Culture and Race
Gender refers to the array of society-determined roles, personality traits, attitudes, behaviours, values, relative power and influence that society ascribes to the two sexes on a differential basis. "Gendered" norms influence the health system's practices and priorities. Many health issues are a function of gender-based social status or roles .
Gender is distinct from sex, in that sex is generally viewed as having fixed biological characteristicsFootnote 43, whereas gender is considerably more fluid and culture-based . It is the social constructs of gender and sexuality that shape and govern roles of masculinity and femininity, responsibilities, needs and expectations of men and women, and the gender division of labour, status and power [5-7].
This report recognizes gender as a key determinant affecting women’s health. Although all gendered groups are affected by social and economic factors, women are particularly affected by the way in which gender interacts with the other determinants of health. The compounding and intersecting nature of sex, gender, race, sexual orientation, age, class, and disability impacts how individuals negotiate health through intrapersonal, interpersonal, community, and institutional mechanisms. As a result, women’s experiences with health and illness are collectively quite different from men’s experiences.
... (S)ocial mechanisms produce gender-based inequities and disparities (e.g., in women’s economic potential, women’s control of resources, and gender-based expectations of women’s role in society). These inequalities and disparities are apparent in the public health, social and behavioural sciences, and medical fields as exposures, risk factors, and biological properties. These exposures, risk factors, and biological properties all interact to increase women’s vulnerability to diseases, including HIV .
Gender has a profound impact on women’s vulnerability to HIV . As described by WHO , gender inequalities have been a “key driver” of the female HIV/AIDS epidemic worldwide. For women in Canada, the two most common exposure categories for HIV transmission, heterosexual sex and injection drug use (IDU), accounting for over 91% of positive HIV test reports among women between 1985 and 2008 , involve risk behaviour relating to power relationships and inequalities between genders. While gender is a determinant of health in its own right, its intersection with and influence on other determinants of health increases women’s vulnerability to HIV.
For example, gendered roles of masculinity and femininity may support a stereotyped sexuality, whereby gendered norms associated with masculinity encourage men to have multiple sexual partners (either concurrent or not) and encourage men to have sexual relationships with younger women . Stereotypes around what constitutes “masculine” behaviour may result in men hiding sexual relationships with other men and may also make men reluctant to access health services [5;7]. Conversely, gendered norms around femininity may encourage sexual innocence/ignorance and passivity, meekness, and submissiveness in women, resulting in their increased vulnerability and dependence on sexual partners [5-9;12]. For some women, gendered norms contribute to an inability to negotiate safer sex practices and increase risk of sexual assault. Gendered norms are also manifest in women’s involvement in survival or street-level sex work. Gendered norms lie at the root of all of these behaviours, which facilitate HIV exposure and transmission in women.
Recent literature has also identified a strong association between requiring help injecting and HIV seroconversion in women who use injection drugs [13-16]. This link supports the premise that an injection-dependent relationship exists between injection drug-using women and men, effectively limiting women’s power and control over drug preparation, needles, and injecting. Consequently, beyond increased risk of HIV transmission as a result of sharing contaminated needles, this group of women is further made vulnerable to HIV as a result of behaviour linked to gendered norms.
Gendered roles of masculinity and femininity also strongly impact transgender people. Emerging data on transgender people suggest that this population is at a heightened risk of HIV infection as a result of institutional factors that reinforce a bi-gendered culture. A needs assessment conducted in Québec on transgender people, marginalization, and HIV risk  identified that institutional barriers to changing one’s name and sex on official documents prevent the social integration of transgender people. Institutional barriers affect transgender people’s ability to find employment and satisfy social needs. These barriers also hinder transgender people’s access to health services and secure housing, thereby increasing their vulnerability to HIV/AIDS.
4.1.2 Biology and Genetic Endowment
The basic biology and organic make-up of the human body are a fundamental determinant of health. Genetic endowment provides an inherited predisposition to a wide range of individual responses that affect health status. Although socio-economic and environmental factors are important determinants of overall health, in some circumstances, genetic endowment appears to create predispositions to particular diseases or health problems .
Elements of biology and genetic endowment influence women’s risk of HIV transmission, treatment outcomes, disease progression and comorbidities. For instance, when considering heterosexual sex, the risk of contracting HIV through penile-vaginal intercourse is greater for women than it is for men [5;18-23]. Male-to-female HIV transmission has been shown to be two to four times higher than female-to-male HIV transmission . Reasons behind women’s increased risk related to biology and genetic endowment include the following:
- Concentrations of HIV are higher in semen than in vaginal secretions [19-21].
- Physiologically, the vagina has a much larger area of exposed sensitive skin where HIV can survive longer than on the penis .
- While once believed impenetrable by HIV, research has shown that the genital lining in women is not an effective barrier against HIV [22;23].
- The delicate tissue of the female genital tract can be damaged during intercourse, particularly if sex is non-consensual or traumatic, increasing the likelihood of abrasions, vaginal bleeding, or tearing, leading to increased rates of transmission [5;18-21].
- HIV finds its way into the female reproductive tract by decreasing epithelial cells’ (i.e., the protective barrier that keeps out infection) barrier resistance. This subsequently impacts prevention strategies, such as microbicides and vaccine .
While unprotected penile-anal intercourse is considered to be of higher risk for HIV transmission than penile-vaginal intercourse, the former is rarely reflected in the literature or discourse in the context of heterosexual HIV exposure or sexually transmitted infections (STIs) [19;26;27]. Although similar data were not available for Canada, research from the American National Survey of Family Growth  reported that 5.6% of girls aged 15-17 years had had heterosexual anal intercourse, with the percentage increasing to 29.6% for 20-24-year-old women. An American study, which examined heterosexual intercourse in young adults aged 15-21 years, significantly associated the practice of anal intercourse with being forced to have sex, living with a partner, and having two or more partners . The study also found that some women may practise anal sex as an alternative to vaginal intercourse to avoid risk of pregnancy. Although no Canadian data were found, this study’s findings suggest that condom use may not be consistent with anal sex .
As discussed in Chapter 3, the presence of another STI can augment risk of HIV transmission for women and men. Biological factors, particularly STIs which result in ulcers or vesicles, increase an individual’s risk of contracting HIV as they may compromise the skin's physical barrier to infection. For women the situation is further complicated by the fact that STIs, such as gonorrhoea, chlamydia, syphilis, herpes simplex virus (HSV) types 1 and 2, and human papilloma virus (HPV), may remain asymptomatic in women, and may, therefore, go undiagnosed. According to The Canadian Guidelines on Sexually Transmitted Infections, chlamydia, HPV, and HSV are the most commonly reported STIs in women in Canada . HIV infection may also change the presentation of ulcerative STI, and treatment options need to be evaluated regarding specific HIV/STI co-infections .
a) Impact of HIV Treatment on Women Living with HIV
Women living with HIV are often underrepresented in clinical trials of Highly Active Anti-Retroviral Therapy (HAART) [30;31]Footnote 44. As a result, the full impact of treatment is often unknown and may pose health risks to, or impede the sustainable care of, women living with HIV. For example, a study comparing the side effects of HAART in women and men found that metabolic toxicities associated with treatment occur more frequently in women than in men . Sex-based differences in body masses, fat composition, hormonal secretion and drug metabolism may explain these differences [30;31]. Another study, which examined the effects of HIV treatment on HIV-positive pregnant women, found higher levels of toxicity associated with Nevirapine-based HAART in pregnant women living with HIV as compared to those who took non-Nevirapine-based HAART . These findings contributed to an international review of the drug for use in pregnant women living with HIV.
The inventory of published research included in this report identified a single study that indicated better HIV treatment outcomes for women than men . This study found that women survived longer following HIV seroconversion, and found that HIV-positive women treated during the post-HAART era had a lower risk of progression to AIDS and non-AIDS mortality than treated HIV-positive men. This suggests that HIV-positive women may respond better to HAART than HIV-positive men.
b) Osteoporosis and HIV
Osteoporosis, a disease characterized by low bone mass and deterioration of bone tissue, has long been associated with aging women in the general population and is increasingly being linked to people living with HIV/AIDS [31;34]. A study on fragility fractures and bone mineral density (BMD) in women living with HIV reveals that they report a significantly higher risk of bone fragility compared to women in the general population, despite having normal BMD. The study identifies the need for additional research to assess bone fragility in women living with HIV and for a risk assessment tool on fractures .
Health status improves with level of education. Education is closely tied to socio-economic status, and effective education for children and lifelong learning for adults are key contributors to health and prosperity for individuals, and for the country. Education contributes to health and prosperity by equipping people with knowledge and skills for problem solving, and helps provide a sense of control and mastery over life circumstances. It increases opportunities for job and income security, and job satisfaction. It also improves people's ability to access and understand information to help keep them healthy .
Studies show that women with limited education are hindered in their ability to access and understand HIV prevention and treatment information. One study found that women with limited education may have trouble communicating their needs to health providers, a disadvantage when it comes to accessing health services. Further, this group of women may not be able to obtain and fully comprehend health education and health promotion materials [35-37]. Limited language skills can also prevent women from accessing or understanding HIV prevention and treatment information . Diminished educational opportunity combined with abuse, lack of economic opportunity, and experiences with child welfare system, make certain groups of women, such as Aboriginal women, more vulnerable to sexual exploitation  and, as a result, to infections such as HIV.
Lack of information about sexual and reproductive health is common to all populations. One study found that female and male adolescents demonstrate a poor knowledge of sexual and reproductive health, despite having a reasonable knowledge of HIV/AIDS . Another study, conducted among 234 undergraduate university students (145 women, 85 men, and 4 students sex and age not indicated; mean age, 21.14 years) on the perceived transmissibility of HIV and chlamydia after one sexual exposure (penile-vaginal intercourse), reported that 34.8% of the participants falsely estimated that chlamydia has a lower transmission probability than HIV. Only 3.9% and 5.6% of responses came within 0.5% of the correct probabilities of transmission for both HIV and chlamydia respectively . Consequently, a lack of sexual and reproductive health education may increase girls’ and women’s susceptibility to HIV infection.
4.1.4 Income and Social Status / Employment and Income
Health status improves at each step up the income and social hierarchy. High income determines living conditions such as safe housing and ability to buy sufficient good food. The healthiest populations are those in societies which are prosperous and have an equitable distribution of wealth. Unemployment, underemployment, stressful or unsafe work are associated with poorer health. People who have more control over their work circumstances and fewer stress- related demands of the job are healthier and often live longer than those in more stressful or riskier work and activities .
Low income and poverty are associated with increased risk of HIV infection and disease progression . As demographic data from Chapter 2 reveal, more women are involved in less stable work than men, more women have part-time jobs than men, and women continue to earn less than their male counterparts and are required to do more unpaid labour than men [19;42]. Women’s involvement in unpaid labour and the unequal impact of poverty on women are manifest in dependent relationships, in an inability to acquire stable housing (homelessness), and in their participation in survival sex as a means to make ends meet [10;43;44]. Gender disparities tend to be masked among those with higher incomes.
a) Vulnerable Female Populations
As data from Chapter 2 indicate, women are disproportionately affected by poverty and certain groups of women fall to the outer ends of the socio-economic hierarchy. For instance, Aboriginal women and women from racial minority groups are faced with the double discriminatory effects of gender inequality and racial inequality, which ultimately impacts their socio-economic status [41;45]. As one author notes, “the low socio-economic status of Black women compounds the unequal relationship between women and men. Poverty and lack of economic opportunities disempower Black women, and keep them engaged in an unhealthy relationship with a partner” . Studies show that male-to-female transgender persons (MTF) also deal with multiple layers of discrimination and generally less than the overall population ; accordingly, transgender women also experience low socio-economic status .
You hang around with a man who has money because he can take you out, because he buys you nice clothes… he pays your rent for you when you are unable to do it; Then you will have a relationship with him because that is the only way you can sustain his interest’--- Woman .
Women involved in street-level sex work are one of the most vulnerable groups in Canadian society. Laws and society’s attitudes regarding sex work may prevent women involved in sex work from accessing services such as police services and health care. Women’s involvement in sex work may also subject them to excessive acts of violence, robbery, or abuse [49-51]. Street-level sex workers’ desire to practise HIV prevention may be undermined by societal and personal factors such as gendered power differentials, a history of sexual abuse, violence and discrimination, age, drug or alcohol dependencies, mental health issues, and homelessness. These factors can significantly diminish women’s ability to negotiate the use of condoms and ensure their consistent usage [45; 49;50;52-54; 56-59].
Society has always looked down on working women. You can’t tell anybody about it. You can’t tell the doctor or the police. You should be able to tell doctors so you are medically safe and the police so you can be protected physically--- Woman, Sex worker .
Several studies involving survival or street-level sex workers highlight the intrinsic relationship between survival sex and substance use. Combined, these behaviours may leave women few options for condom negotiation, as money for drugs or shelter may take precedence over self-protection [52;56;57;60]. A Vancouver study highlighted the correlation between drug market prices and the amount which street-level sex workers charge for sexual acts . Studies have identified certain risk factors, such as drug use and incarceration, which put street-level sex workers at greater risk of HIV infection. For example:
- A comparative study between women who use injection drugs who are involved in sex work and those who are not reported that women involved in sex work were generally younger, and more likely to report use of injectable heroin, cocaine, speedballs (heroin and cocaine) and smokeable crack cocaine. They were also more likely to report syringe sharing and less likely to be enrolled in Methadone Maintenance Therapy (MMT) (N=591, 193 of which were sex workers in Montreal and Vancouver) .
- A Vancouver study identified the following factors associated with sex work and women who use injection drugs: incarceration, daily injected cocaine use, daily crack use, borrowing syringes, lending syringes, and having sought after but been unable to access addiction treatment during the previous six months .
One of the prostitutes, Line, said to me: come with me. I’m going to show you how we get a customer. That didn’t tempt me, but I had no choice. I wasn’t able to be treated like this; I wasn’t comfortable in my own skin. I got customers for a couple of weeks, but I didn’t have it in me. To do that, I needed to get stoned two or three times more than usual. I wasn’t able to get my first customer “straight”. I told myself, this won’t work, I’m going to beg (instead) – Woman, sex worker, living with HIV .
Sex workers’ regular sex partners also play a role in HIV transmission and acquisition. Literature shows that while the majority of sex workers consistently use condoms with clients, sex workers have unprotected sex with their regular partners. Additional research indicates that regular sexual partners of sex workers may themselves be using injection drugs or participating in other high-risk activities. This has the indirect effect of increasing sex workers’ risk of HIV acquisition [13;59;63;65;66].
b) Income of Women Living with HIV
Women who have low incomes or who live below the poverty line are at greater risk of HIV progression to AIDS [67;68]. Some HIV-positive women live below the poverty line because their social assistance income benefits do not extend to cover their basic needs.
One study reports that source of income is considered a serious concern for the majority of women living with HIV . In addition to source of income, women living with HIV/AIDS face additional financial concerns relating to travel to and from health services, treatment costs, time off from work with decreased pay, and fear of employment loss. Many single mothers living with HIV/AIDS have the added stress of ensuring adequate daycare support and coping with poverty [70;71]. These issues were of special concern for single parents from Aboriginal and ethnic communities, as women from these communities make up a high number of people living in low- income situations .
According to a British Columbia study, risk factors for inadequate food security and hunger include being female, having a low income, having a low education, and being Aboriginal . Other risk factors include living with children, having a history of injection drug and alcohol use, and unstable housing . The study emphasizes the important role proper nutrition plays in the lives of women living with HIV, particularly in the case of single mothers with lower income. Ultimately, all of the studies cited in this report that examine the relationship between income and women living with HIV indicate a link between poverty and decreased participation in society.
4.1.5 Social Environments and Social Support Networks
A healthy lifestyle can be thought of as a broad description of people's behaviour in three inter-related dimensions: individuals, individuals within their social environments (e.g., family, peers, community, workplace), and the relation between individuals and their social environment. Interventions to improve health through lifestyle choices can use comprehensive approaches that address health as a social or community (i.e., shared) issue. Social or community responses can add resources to an individual's repertoire of strategies to cope with changes and foster health. Support from families, friends and communities is associated with better health. Such social support networks could be very important in helping people solve problems and deal with adversity, as well as maintaining a sense of mastery and control over life circumstances. The caring and respect that occurs in social relationships, and the resulting sense of satisfaction and well-being, seem to act as a buffer against health problems .
Social environments are largely created by gender and cultural norms which shape how women engage with society and how, in return, society engages with women. Gendered power dynamics ingrained in our social fabric are reflected in women’s vulnerability to, or resilience against, HIV acquisition. For instance, research shows that men’s violence against women and women’s social exclusion as a result of sexism, racism, and transphobia put women at increased risk of HIV [36;52;53;58;73-79].
a) Violence and Abuse
Lack of societal power and status make women vulnerable to acts of men’s violence. Research shows that the consequences of men’s violence against women – whether it be sexual, emotional, or physical – include diminished self-esteem and sense of security, damage to physical and emotional health, and a negative impact on children (i.e., it creates a sense of fear and insecurity among children and perpetuates an intergenerational cycle of violence). Men’s violence against women also negatively impacts women’s financial security and may result in women’s self-blame and loss of matrimonial home. Men’s violence against women may ultimately result in women having to relocate outside of the community .
He broke my arm one time trying to throw me off the balcony. He didn’t let me go to the hospital for two days – Woman living with HIV .
Some studies strongly associate repeated physical and sexual violence with a positive HIV test report [81;82]. For example:
- The Vancouver Injection Drug User Survey (VIDUS) cohort identified that of 503 women included in the analysis, 68.6% had experienced sexual violence. Of those who reported sexual violence, 53.4% revealed the age of first incidence was 12 years or less. Although not stratified by sex, the prevalence of HIV among those who experienced sexual violence was higher than those who had not. This study indicates that individuals who have experienced sexual violence are at greater risk of HIV infection .
- The Cedar Project study (a Vancouver and Prince George cohort of young Aboriginal peoples, aged 14-30 years) found that 68.3% of women had experienced some form of sexual abuse at least once in their lifetime. HIV prevalence was greater for those participants with a history of abuse at 15.2% when compared to participants with no history of sexual abuse at 4.4% (results statistically significant, not stratified by sex) .
- Of a cohort of women who use injection drugs in Vancouver, researchers identified that “Young [HIV] seropositive participants were more likely to be female, to work in the commercial sex trade, to have experienced sexual abuse, to have had more than 20 lifetime sexual partners, to inject heroin and speedballs at least daily, and to use crack cocaine at least daily” .
Globally, street-level sex workers are one of the female groups most vulnerable to men’s violence . According to the Global Coalition on Women and AIDS, “violence is a manifestation of the stigma and discrimination experienced by sex workers. In all societies, sex work is highly stigmatized and sex workers are often subjected to blame, labelling, disapproval and discriminatory treatment” . In a recent study of women using drugs and engaging in survival sex work in Vancouver, men’s violence was found to impact women’s access to resources and their ability to practise HIV prevention and harm reduction . Forms of violence experienced and described by the women in this study included having boyfriends as pimps, the everyday violence of being a sex worker (e.g., discrimination, abusive johns,obstacles in accessing policing services), a lack of safe places to take dates, and displacement.
If he don’t want to use a condom, we’re in extreme danger. I want to try to use one [condom], but the violence might ensue --- Woman, Sex worker .
According to Statistics Canada, Aboriginal women are three times more likely to experience intimate male partner violence than non-Aboriginal women. Twenty-four percent of Aboriginal women said that they experienced violence from a current or previous spouse or common-law partner in the five-year period up to 2004. This is significantly higher than the 7% of non-Aboriginal women in Canada who reported experiencing violence during the same period. Aboriginal women who had experienced violence were also more likely to report having been beaten, choked, threatened with or having had a gun or knife used against them, or sexually assaulted . According to the Native Women’s Association of Canada, “the ongoing effects of colonization in Canada have led to the dehumanization of Aboriginal women and girls and [the Native Women’s Association of Canada] considers this to be a root cause of the violence [Aboriginal women] experience” . One additional study on Aboriginal women found a link between sexual violence and their initiation into sex work .
Black women, including women who come from countries where HIV is endemic, may also experience heightened levels of violence. For example:
- In many African and African-Caribbean cultures, underlying issues of violence are never discussed within the family and/or community. The few girls or women who come forward often face stigma and reprisal from family for speaking out and/or seeking support, particularly if the perpetrator is a member of the immediate or extended family or part of the larger African and African-Caribbean community .
- Forced sex, rape, childhood sexual abuse and incest may directly lead to infection, while fear of sexual and physical violence limits women’s ability to negotiate condom use. Many African women have fled persecution from war-torn countries of sub-Saharan Africa where they may have experienced rape and torture. This violence may have resulted in physical injury, pregnancy and exposure to HIV .
- Girls, young women, lesbian, gay, bisexual and transgender people, and people living with disabilities are often targeted for physical and sexual victimization. Although boys and men also experience sexual violence, it is important to acknowledge that girls and women are disproportionately affected regardless of their country of origin, culture, social class, religion or ethnic group. Their ability to practise HIV prevention may be affected by the aftermath of sexual violence (e.g., depression, loss of value, loss of sense of well-being) .
Other female populations are also at risk of violence, including transwomen and transwomen involved in sex work who come from racial minority groups [48;87]. Ultimately, men’s violence against women and children, whether sexual or physical, has a direct impact on the ability of women and children to practise HIV prevention .
b) Fear of Disclosure
Under Canadian law, people living with HIV have a legal obligation to disclose their HIV-positive status to sexual partners before engaging in activities that pose a “significant risk of serious bodily harm” (transmitting HIV). Individuals who do not disclose before engaging in these activities may be charged with a crime on the grounds that failure to disclose one’s HIV infection constitutes fraud, thereby invalidating consent to sex. In the absence of consent, the individual may be charged with a criminal offence. Differing court interpretations of which sexual activities pose significant risk of transmitting HIV has created confusion for people living with HIV. Given this context, partners can be a source of positive or negative support for women living with HIV when it comes to disclosure [69;88]. Studies show that some women are reluctant to disclose their status to their partners for fear of being blamed or due to fear of reprisal (i.e., abuse or abandonment), yet they may yearn for a partner who can give them emotional support [69;82;88].
Even though they say, ‘well tell a partner you’ve got it’, you’re so scared to be rejected, to be alone you know, it’s hard --- Woman living with HIV 
You know I was scared, I was scared to tell them (family). Not knowing how’d they react... (feeling like) I’m going to lose my family over this --- Woman living with HIV 
I didn’t know how I was going to approach my husband (…) having to tell him, you know, such news of HIV. In Africa it’s like a death sentence, as far as they’re concerned and, you know, you’re viewed as a moral disgrace, having HIV --- Woman living with HIV 
Many African and Caribbean women living with HIV fear disclosing their status to their partner because of ethnocultural assumptions that link HIV/AIDS to promiscuity. Fear of HIV-related stigma and discrimination is particularly real for women living with HIV, as they are often presumed to be more promiscuous than are HIV-positive men and they risk being ostracized from their cultural community. Women fear that disclosure of HIV infection may lead to physical harm and abandonment by a partner, who may, in turn, prevent them from seeking health services for fear of reprisal from community members . Some women would rather sacrifice their health than sacrifice their anonymity and confidentiality . In addition, fear of disclosure has kept many women from African and Caribbean communities from accessing health services and from establishing contacts with other HIV-positive women .
Disclosure is considered one of the most difficult aspects of living with HIV in Aboriginal communities because of the resulting stigma, discrimination and feelings of being ostracized Footnote 44. As one woman explained, “The worst punishment that can happen in an Aboriginal community is banishment and this is happening to people with HIV/AIDS” . Discrimination against Aboriginal women living with HIV is compounded as gender discrimination adds to the stigma they experience [91;92]. An Aboriginal woman living with HIV/AIDS may be branded as promiscuous, a “bad mother”, or “deserving of HIV/AIDS” if she discloses her HIV-positive test result to community members .
c) Social Exclusion
Social exclusion, which involves “disintegration from common cultural processes, lack of participation in societal activities, alienation from decision-making and civic participation, and barriers to employment and material resources” , limits women’s power and choices regarding health, health services, social capital and equity. Examples of exclusion are particularly pervasive in the lives of women who already experience other forms of discrimination, such as heterosexism, homophobia, transphobia, or racism.
Women who have sex with women (WSW) are believed to be at increased risk of HIV due to their participation in behaviours that result in their discrimination and exclusion. Studies report that growing up in a heterosexist, and, at times, homophobic environment can enhance WSW’s isolation and exclusion and may potentially foster risk behaviours such as injection drug use and sexual experimentation [77-79;94]. For example, a study conducted in British Columbia (multiple locations) and Seattle, WA (USA) , which used comparative data from surveys administered to high school students, revealed that gay, lesbian or bisexual adolescents report higher HIV risk behaviours than their heterosexual counterparts. Risk behaviours included, use of injection drugs, age at sexual debut, number of lifetime sexual partners, condom use during last sexual intercourse, history of previous STI diagnoses, and alcohol or drug use during last sexual encounter. Another study conducted in Montreal found that having a female sexual partner or having a female sexual partner involved in sex work were predictors of involvement in sex work for street-involved female youth . No other sexual behaviours predicted initiation into sex work among this cohort of females.
Sex workers also face increased vulnerability to HIV as a result of factors linked to their social exclusion. For example, laws and society's attitudes regarding sex work stigmatize sex work, thereby limiting sex workers' access to services and health care for fear of discrimination. Further, difficult working conditions reduce sex workers' ability to negotiate and enforce safer sex behaviours. This has the effect of increasing sex workers’ susceptibility to violence and coercion .
Being transgender has also been identified as a factor that increases women’s HIV risk behaviour . Transgender women’s vulnerability to HIV infection increases for transwomen who also identify as Aboriginal, an immigrant, young, or who are involved in sex work, as these factors can contribute to women’s vulnerability to HIV infection.
Racism and discrimination leave groups of people particularly vulnerable to HIV infection by excluding them from the social and economic mainstream and by denying them the social support needed to enhance and preserve life . Studies show that for Black women, the experience of racism intersects with other issues, such as gender, sexual orientation and socio-economic status. This results in a level of social exclusion that elevates their risk of HIV infection and compounds their ability to cope with the disease [35;36;97]. Thus, Black women’s risk of HIV infection can not simply be attributed to individual behaviour as this trait is a product of a larger system.
Aboriginal women also feel the effects of racism and social exclusion in Canada. The complex vulnerabilities that Aboriginal women face stem from a legacy of colonization and the multigenerational effects of social isolation, discrimination, entrenched poverty, and the residential school system [59;81].
d) Women’s Support Groups
Support groups may be a source of resilience for women living with HIV. Support groups can encourage and inspire women living with HIV and remind them that they are not alone . In some cases, support groups act as alternate communities for women living with HIV, and can empower women by promoting their participation in society [88;90]. In addition, women’s interaction with other women living with HIV can help foster a sense of community .
For example, a Vancouver-based study of female sex workers who use illicit substances found that peer-driven interventions positively affect HAART adherence for this population . Another study reveals that seropositive mothers rely on the support of family, friends and professionals, while men rely solely on one or more friends for support . Other studies show that a supportive network is a valuable asset for women living with HIV [88;100]. Respondents in these studies explained that feeling supported was important for helping them deal with the everyday experience of living with HIV/AIDS.
However, some women living with HIV feel that support groups focus too heavily on the negative aspects of living with HIV and complain that not enough women are involved. In the words of a woman living with HIV, “HIV and support groups…it’s always about the disease…it’s like you don’t have anything else in your life…People who have HIV don’t have relationships. It’s like that part of life does not exist. Nothing else exists except having HIV.” 
Community norms and values are propagated through social institutions and networks, which can either help with or act as barriers to HIV prevention. For instance, a qualitative study addressing HIV prevention and Black women in Toronto identified the church as an existing community structure that could be used to spread HIV prevention messaging to a key audience . However, the church’s lack of engagement on HIV in the community was also identified as a barrier to HIV prevention. One key informant described the social impact and influence that churches have on Black women, “There’s lots, I mean thousands of Black women that fill up the churches in Toronto. They may not be the highest income earners, but can find money to support their churches. So we’re talking about emotionally, economically, and spiritually tied [sic] to these institutions . . . unless it comes from the pulpit, it is not happening” . Given their influence, churches should be considered as potential partners to foster resilience and begin dialogue about HIV and its affect on the Black community.
e) Role as Primary Caregiver
As demographic data in Chapter 2 indicate, women act as primary caregivers for their families more often than men, caring for partners, children and/or aging parents. The role of primary caregivers involves the provision of emotional support, bringing with it related pressures and stress. Acting as primary caregiver and living with HIV can be taxing, especially for single mothers . Mothers living with HIV/AIDS must deal with the added stress of ensuring their children’s welfare, which is especially difficult if the woman is ill or dying . Mothers may also face additional stress about their partner’s ability to adequately care for the children and maintain the household in the event of their illness or death .
It’s a lot of hard work for me because as someone who is HIV positive, I’ve become a caregiver to everyone around me. I have suppressed all my emotional needs so that becomes another source of stress. I don’t want everyone around me to be depressed or feel sorry for me. So I put on a face that everything is OK or fine, which I do feel most of the time, but not always --- Woman, mother, living with HIV .
f) Role of Children
Children represent a positive force and a source of strength for mothers living with HIV/AIDS. A study has found that HIV-positive mothers depend more often on their own children for social support than they do on friends . The positive influence of children is one of the factors behind the strong presence of women living with HIV in society and their increased participation in the workforce [70;98].
4.1.6 Physical Environments
This section describes the HIV-related vulnerabilities associated with women who are homeless or unstably housed, those living in rural areas, and those in federal and provincial/territorial prisons.
a) Unstable Housing and Homelessness
Many studies clearly illustrate the relationship between homelessness, low income and socio-economic status and HIV risk behaviour [54; 61]. For instance, urban areas with concentrated homeless populations are ripe for non-market economies, such as theft and drug trafficking, that give rise to increased HIV risk behaviours, including sex work and drug use. However, even when socio-economic conditions are poor, neighbourhoods can reduce HIV risk behaviour by addressing the underlying issues related to physical environment – for example, by providing increased access to stable housing. As one study explains, “stable housing could make a critical difference in a woman’s ability to escape violence (and) remain safe” .
Vancouver’s Downtown Eastside (DTES) has received much attention regarding HIV infection. It should be noted that while this community has been identified as “having one of the highest rates of HIV infection in the developed world” , the DTES has shown some resilience of late. Many projects have been put in place to address the poor socio-economic conditions, which characterize the area. These projects, which include affordable housing initiatives, mental health services, harm reduction services, addiction treatment services, and treatment for people living with HIV (including women), are discussed in more detail in Chapter 6.
We’re like the living dead down here, in the Eastside. We’re on the news now… We’re all dyin’, we’re fallin’ off the face of the earth… it’s bad, it’s really bad (Woman) 
One study, based in Vancouver’s DTES, looked at 25 women who used Vancouver’s supervised injection site, Insite. The study found that the female cohort of the study considered the facility a refuge from men’s violence and an escape from male-female power dynamics related to injection drug consumption . However, in spite of Insite’s proven benefits, vulnerable populations of women continue to have trouble accessing its services. For example, another study conducted in Vancouver’s DTES of 198 substance-using women involved in street-based sex work identified violence and policing activities as barriers which prevented these women from accessing Insite’s services . The study noted that of the cohort (from the MAKA project), the women who were most vulnerable – including young women of Aboriginal ethnicity, people who use injection drugs, and daily cocaine smokers -- were the least likely to use its services .
Activities associated with drug use have been shown to increase risk of HIV and other STIs and blood-borne illnesses [43;57;106]. Further, studies indicate that homelessness, drug use and HIV/AIDS are linked. For instance, one study conducted in Toronto on mortality in homeless women found that homeless women 18 to 44 years of age were 10 times more likely to die prematurely than women in the general population of Toronto. The most cited known causes of their early death were HIV/AIDS and overdose . Another study based in Vancouver also found that mortality for women who used drugs was associated with unstable housing and HIV infection .
Another study of street-involved women who inject drugs and who are also involved in sex work in two Canadian cities (Montreal and Vancouver) found that more women involved in sex work had a higher incidence of unstable housing than those who were not involved in sex work . Although the women involved in sex work who participated in this study reported high condom use, the study also found that the practice of borrowing used syringes was independently associated with the sex trade. These studies are evidence of a clear link among homelessness, drug use and HIV risk behaviour.
One study, Positive Spaces, Healthy Places looked at the housing and health needs of people living with HIV across Ontario. The study, which examined the link between HIV and housing insecurities among women living with HIV, found higher rates of homelessness among women living with HIV (12.7%) than among men living with HIV (5.6%) [108;109]. In addition, one third of the study’s female respondents reported having been homeless at least once in their lifetime. This study also revealed that women living with HIV were more concerned about unstable housing than men living with HIV. This was especially true for HIV-positive women living with children (78% of women living with HIV in the cohort reported living with children). Women living with HIV also reported higher rates of depression and lower overall mental health scores than male participants.
Housing security has also been shown to impact women’s well-being. For example, one study found the quality of life for women from African and Caribbean communities was improved by living in affordable housing . Certain factors have also been shown to shape the meaning and experience of “home” for women. For instance, one study that examined the housing needs and experiences of African and Caribbean mothers living with HIV in Toronto found that this group’s housing experience was influenced by factors relating to racism, gender and poverty. Findings from this study highlight the need for culturally appropriate supportive housing services for this group of women and their children .
b) Rural and Remote Environments
Some studies have found that women in rural or remote environments mistakenly associate HIV with particular “urban” populations or behaviours, which they perceive as not belonging to or participating in [37;112]. For example, a qualitative research study conducted in the Maritimes suggests that isolation from urban centres has left many women with only a partial understanding of the facts surrounding HIV. Respondents in this study viewed HIV/AIDS as a disease affecting men who have sex with men (MSM) or as a disease affecting people living in other countries . This study helps to explain how abstinence-based sexual education may prevent women from obtaining information on harm reduction and safer sex practices.
Access to services is the biggest barrier. You go to a community that is isolated, and you don’t have access. You don’t have a doctor. You don’t have the medications. You may not have the knowledge. You may not have the ability. At least in the city we can go to the clinic or the hospital but in the small communities, you don’t even have that. – AIDS educator working with Aboriginal people .
Aboriginal people who live in remote communities may believe that their location, far from urban centres, offers them protection from HIV infection [113;114]. A study of 262 street-involved young Aboriginal women found that there were few differences in terms of HIV risk behaviour (e.g., participation in sex work, injection drug use) experienced by those living in a large urban centre (Vancouver, BC) versus those living in a smaller northern city (Prince George, BC) . A study of the migration patterns of First Nations people from on-reserve communities to urban centres also indicates that issues associated with HIV/AIDS and related risk behaviours, including illicit drug use, are not limited to urban centres .
Moreover, women living in rural and remote environments may be unable to access accurate HIV risk information, care or related services, as these services are more commonly available in larger urban centres. Many Aboriginal people face unique risks and barriers to good health as a result of the geographic isolation of their homes and communities.Footnote 45 For example, Aboriginal women who live in remote and isolated communities may experience decreased access to health and social services as “small and isolated communities generally lack healthcare professionals, transportation, and counselling services, and confidentiality is a greater concern” .
Lack of services, such as harm reduction programs and social supports, in smaller and remote communities may also contribute to the vulnerability of residents who are at risk of, and living with, HIV/AIDS . A study examining people living with HIV/AIDS in Ontario identified Aboriginal peoples and people living in northern Ontario as those with the most need for improved access to family physician services . Another study found that Aboriginal women living with HIV/AIDS are more affected by lack of social supports and services than their male counterparts at it is most often women who act as primary caregivers for their families and as primary caregivers for family members living with HIV/AIDS . As a result, Aboriginal women living with HIV/AIDS may experience a diminished position within their communities as a result of discrimination linked to their positive HIV serostatus and limited access to services and social supports as a result of their remote geographic location.
c) Federal and Provincial/Territorial Prisons
Women in prisons are at increased risk of HIV infection when compared to the general population as a result of existing high prevalence rates and continued high-risk behaviours while incarcerated [119;120]. HIV prevalence among female offenders in federal prisons is significantly higher than that of the general population. HIV prevalence among female inmates in federal prisons is even higher than HIV prevalence among males in federal prison . Women in prison continue to engage in many of the same risk behaviours that they engaged in prior to their incarceration, such as drug use, needle sharing, unprotected sex, and sharing of tattooing equipment [121;122]. These issues will be discussed in greater depth in the Population-Specific HIV/AIDS Status Report: People in Prisons.
In 2007, the following three health education programs were available to individuals in federal prisons: the Reception Awareness Program, the Choosing Health in Prisons Program, and the National HIV/AIDS Peer Education and Counselling Program . Findings from Correctional Service of Canada’s 2007 National Inmate Infectious Diseases and Risk Behaviours Survey revealed that more women than men participated in these programs . However, in spite of higher participation rates among women, women in prison also reported that their access to these programs was limited by a lack of awareness, limited space, and competing clinical demands on nursing staff . In addition, while the vast majority of women in the survey cited no difficulty in accessing bleach in federal prisons for the purpose of harm reduction (72%), 28% of women nonetheless reported concerns relating to access. Concerns cited included maintenance issuesFootnote 46, having to request bleach, lack of confidentiality when accessing bleach and other inmates’ behaviourFootnote 47.
Other studies also found that women in prisons faced difficulty in accessing harm reduction supplies and health services and/or programs, despite their availability in prisons [123;124]. Women participants in a study conducted in 2001-2002 on 156 women in prisons (approximately 40% of the total number of women in federal prisons) reported that they did not receive consistent support from HIV/AIDS community-based groups while in prison, despite the fact that they engaged in high-risk behaviours [122;125]. Further, only 30% of women living with HIV (and/or HCV) reported having received support from community-based organizations . Also, while the majority of respondents described having had positive experiences regarding care and their ability to access community-based organizations while in prison, 34% reported having had problems .
If you want it [information on HIV/AIDS], you have to go down to health care and search it out yourself and it’s hard to get in the door unless you have a doctor’s appointment. Like, it’s impossible to go down there and say, ‘Can I come in and get some AIDS material to read?’ – Woman in Canadian prison .
Access to educational material on reducing risk has also been reported as lacking in prisons . HIV prevention efforts directed at women in prison are limited by a number of factors, including the low number of women in prison (because it may be expensive or difficult to provide services to a low number of participants), the proximity of prisons to major urban centres (because prisons tend to be located outside large urban centres, it decreases women’s ability to access community-based programs), the smaller size and multi-levelled structure of federal women’s institutions, and high turnover rates (which prevents the continuous use of peer intervention programs) .
4.1.7 Personal Health Practices and Coping Skills
Personal health practices and coping skills refer to those actions by which individuals can prevent diseases and promote self-care, cope with challenges, and develop self-reliance, solve problems and make choices that enhance health .
When women lack the power to make decisions about personal health practices and coping skills, they are more vulnerable to HIV infection. This is especially true for women struggling with sexual and reproductive health issues and issues around substance use.
a) Sexual Health
Women face increased risk of HIV infection when they lack the power to negotiate safer sex in intimate relationships. Power imbalance in relationships, coupled with the fear of male partner violence, may impact women’s ability to make choices, such as the ability to negotiate condom use, to prevent HIV transmission. Condom use is still the most effective way to prevent HIV transmission during heterosexual intercourse. Both male and female condoms are available in Canada; however, their consistent use is still not practised among all women and their sexual partners.
Women who do not perceive themselves to be at risk for HIV or other STIs may not be concerned with using condoms regularly . For example, condom use is much more common among younger generations. A survey conducted among the general population in Québec found that respondents over the age of 40 years were less likely to use a condom . This may be explained by the fact that HIV prevention campaigns tend to target younger women. Consequently, women over the age of 40 may not perceive themselves as at risk for HIV or other STIs.
In a Montreal study, 430 sexually active women not living with a partner were surveyed on the subject of condom use. Approximately one third (32%) of women surveyed reported using condoms consistently with their last two partners (vaginal intercourse) . Forty-three percent (43%) of survey respondents reported never having used condoms. Of those engaging in anal intercourse, 21% of respondents reported regular condom use and 75% reported no condom use. It was found that women who reported never or occasionally using condoms adopted “relational strategies” when negotiating condom use, whereby women based their perception of risk on a number of factors related to their relationship with their partner. These factors included how well they felt they knew their partner (or whether he was known to a friend or relative); their overall feelings toward their partner; and their partner’s good physical or clean appearance. In this study, women’s social networks formed a basis for feelings of ‘trust’ and ‘knowing one’s partner’. Findings from this study indicate that heterosexual women’s social networks may have more influence over their perception of risk for HIV or STI than actual risk associated with certain sexual activities.
In another Montreal study of young women accessing sexual health services, participants cited having a stable sexual partner and taking the birth control pill as principal reasons for not using condoms with partners . These findings are consistent with findings from another study which found that occasional partners use condoms more frequently than regular partners . While a monogamous sexual partner may reduce risk of HIV infection, monogamy does not eliminate risk. For instance, as HIV and other STIs may not be accompanied by symptoms , a partner may enter into a monogamous relationship unknowingly infected. Also, repeat sexual exposure can increase the likelihood of transmission of infection, particularly for HIV .
It’s like telling women, ‘Here is a condom you have control over, but for you to be able to use it you still have to go and talk with your partner.’ Women need more, more prevention strategies and tools which they have control over --- Woman .
Extramarital or extra-relational affairs also create opportunities for introducing HIV or other STIs into seemingly monogamous partnerships. One report explains the double-standard that exists in Canada’s African and Caribbean community. The community “lauds male promiscuity” but penalizes and labels “women who are knowledgeable about their sexuality and express their desire to engage in safer sex practices . . . as being promiscuous” . These types of culturally specific attitudes about male and female sexuality present challenges in HIV prevention for this group of women.
Data addressing condom use in women who are involved in sex work vary across Canada [54;63;65;66;75;131]. However, the majority of findings indicate that women involved in sex work are less likely to use condoms with regular partners than with occasional partners or clients. This contributes to the vulnerability to HIV of women who are involved in sex work, especially women who also use injection drugs or who have a partner who uses injection drugs. Regarding condom use with clients, a recent study attributed the inability of women who are involved in sex work to negotiate condom use to fear of client aggression and language barriers (especially for migrant sex workers) . However, a recent meta-analysis suggests that peer-based interventions can increase condom use among women who are involved in sex work and their clients and may serve to empower women to refuse clients without a condom .
Another study showed that transgender women tend not to use condoms as unprotected sex “validates their female gender identity and boosts their self-esteem" . According to the U.S. Center for AIDS Prevention Studies, male-to-female transgender sex workers are willing to forgo the condom with paying partners if they are offered more money .
Condom use also affects the ability of women living with HIV to achieve intimacy. Women living with HIV may struggle with issues of intimacy as they are counselled to either cease having sex or negotiate safer sex to avoid HIV transmission . Women living with HIV may live in fear of transmitting HIV to their partner. They may also live with feelings of guilt if HIV transmission to their partner occurs .
Women need more female-controlled barrier methods that they can initiate themselves. A female condom currently exists but is often overlooked as a means of preventing the spread of HIV infection. While there are disadvantages associated with the female condom, such as cost and aesthetics, currently it is the only effective non-pharmaceutical female-controlled barrier on the market that prevents the acquisition or transmission of HIV and other STIs [136;137]. Promising results from recent studies offer hope that an effective microbicide may one day be made available for women. To date, 11 of 60 microbicideFootnote 48 products have made it past animal tests with human trials now underway .
b) Reproductive Health
As the result of improved HIV treatment, women living with HIV are living longer and with an improved quality of life. As a result, women living with HIV share many of the same needs and desires as their HIV-negative counterparts. For instance, one study reports that women living with HIV have increasingly expressed an interest in having children, and their desire for children has reached levels comparable to those of women who live without HIV . However, in spite of their desire, women living with HIV in certain areas of Canada may have limited access to fertility services and advanced reproductive technology . Women’s limited access to specialized fertility and reproductive technology has implications for healthcare providers who work with HIV-positive women to secure healthy pregnancies and birth outcomes [139;141;142]. Canadian safer pregnancy guidelines for HIV-positive men and women are currently being developed by a team of over 30 Canadian experts [143-145].
c) Substance Use
Substance use may increase women’s vulnerability to HIV in a number of ways. Studies show that women’s increased vulnerability to HIV infection may arise as a direct result of ways in which substances are administered (e.g., injecting drugs with contaminated needles), or more indirectly as a result of the physical, mental, and economic effects of dependency. While the reasons behind substance use vary, many women cite being introduced to substances through a spouse or common-law partner . In addition, literature indicates that many people use substances as a mechanism for coping with childhood sexual, emotional or physical abuse, stress, violence, isolation, neglect and other mental health issues (i.e., they may engage in substance use as a form of self-medication) [19;76;103;146-148].
Using alcohol and drugs was helping me forget the mistakes I made and that kind of thing. But in the same sense, I was making new mistakes. And that’s where I became really sexually active, … two straws short of a hooker but didn’t get paid --- Woman 
Being under the influence of substances can impair women’s judgement and decision-making ability when faced with choices between behaviours that can put them at risk for HIV infection. Alcohol, for example, may lower inhibitions and diffuse consenting partners’ discussions around safer sex and condom negotiation [150;151-153]. Similarly, crystal methamphetamine is said to lead to increased risk of HIV infection “through unprotected and uninhibited sex while under the influence. The liberating feeling that comes with crystal meth use means that safer sex is often discarded while higher sexual risk activity increases greatly” .
“I guess it’s my only tool of knowing how to cope [using drugs]… they help you forget about your problems, push them away, push them down, push them deeper and that is nothing but creating your own volcano, then it all comes exploding out. Learning the coping skills other than drug use to deal with my problems is important --- Woman living with HIV .
The disorienting effect of other street drugs may also place women who use them at risk. A study conducted among sex workers in Vancouver found that “disorientation and lack of control due to intensive cocaine use impeded women’s self-protection and ability to insist on condom use” . According to the Canadian Medical Association Journal, alcohol is the number one drug used in instances of drug-facilitated rape, followed by marijuana and cocaine. However, the use of other more potent “date-rape drugs” such as flunitrazepam (Rohypnol) and gamma hydroxybutyrate acid (GHB) is becoming more common .
Because the high is so addictive, it’s not uncommon to inject 50 times a day if you have the money. Once on a coke high, using a clean rig is less of a priority than getting the next fix --- Woman living with HIV 
Injection drug use is an identified risk behaviour for HIV infection. The act of injecting substances can put a user in direct contact with the virus if the user shares injection equipment and preparation paraphernalia. Injection drug use is the second most common HIV exposure category for women in Canada . According to the I-Track Study , cocaine is the most common drug injected in Canada. While the actual number of people who use injection drugs in Canada is not known, in 2005, the Canadian Centre on Substance Abuse estimated that between 75,000 and 125,000 of Canadians used injection drugs . Women were estimated to account for approximately one third of those people .
At the time I was drinking and partying a lot. I was drunk at the time and you don’t think about using condoms--- Youth, woman mother 
Women are also more likely to share injection equipment than men, putting them at greater risk of HIV infection. The At-Risk Youth Study (ARYS) of 154 IDU participants (N=50 females) in Vancouver noted that 42% of women reported sharing syringes in the past 6 months as compared with only 12% of men . Another study of people who use injection drugs (VIDUS) reported that of the 565 female participants, 37.5% (N=212) had borrowed syringes in the last 6 months and 41.8% reported lending syringes . Finally, a Montreal-based study on people who use injection drugs found that HIV-positive women were more likely to obtain syringes from “shooting galleries” (a place where people go to “shoot up” or inject in groups) than were HIV-negative women .
Reasons behind sharing injecting and preparation paraphernalia are complex. Inability to obtaining clean syringes and other paraphernalia, trusting partners to be free of infections, not believing one is at risk, or requiring help injecting are explanations cited in the literature [15;16]. Some studies have found that women are more likely to require help injecting than men as they have smaller surface veins than men and may be more prone to anxiousness or dopesickness. Women are also more likely than men to engage in “jugging” (i.e., injection through the jugular vein located in the neck), may lack knowledge about how to self-inject , and are more likely to trust a male partner’s knowledge of injecting . In addition, men more often control the administration of drugs [13;14]. VIDUS found that needing help injecting was an independent predictor of HIV seroconversion, even in a setting with widespread access to needle exchange. This study also concluded that women were more likely to be injecting drug recipients (odds ratio = 2:3) and those who required help to inject were twice as likely as those who were able to self-inject to become infected with HIV .
The dependencies that addictions can create – especially dependencies related to drugs, such as crack, cocaine, and heroin -- can further exacerbate women’s vulnerability to HIV infection. The need to support a drug habit has been cited as a possible reason as to why women enter sex work and engage in survival sex [14;159]. As described by Spittal et al. , there is an “established connection between the HIV-related vulnerabilities of female injectors and the practice of using sex to secure money or drugs”.
For example, a study conducted among 265 young street-involved women in Montreal  found that women involved in sex work were more likely to have reported a history of injection drug use as compared to women with no history of sex work. Another study conducted in Vancouver among a cohort of people who use injection drugs  found an association between sex trade involvement and elevated rates of HIV infection. This study reported that the HIV prevalence at baseline for participating women who use injection drugs was 17% compared to only 3% of participating men who use injection drugs. This study shows that survival sex work is positively associated with injection drug use and an increased risk of HIV seropositivity .
Initiation into injection drug use at a young age is also a risk factor for HIV seroconversion. A study conducted among young (under 29 years of age) VIDUS participants revealed that women made up the highest proportion of young initiators. Over one half of the women in the sample population had initiated injection drug use before the age of 17. Younger initiation was positively associated with both HIV and HCV, and those women who initiated drug use early also engaged in other HIV risk behaviour, including drug bingeing and sex work . This study’s findings are consistent with other data showing that women are more likely to be initiated into injection drug use at a younger age than men .
Much of the literature available on women who use injection drugs indicates that Aboriginal women make up a disproportionate number of this population [13;63;131]. For example, a study identifying risk factors for HIV infection in a cohort of people who use injection drugs found that HIV incidence was 40% higher for women than for men in Vancouver’s DTES and that over 40% of the total women in the study self-identified as Aboriginal . These findings are mirrored in HIV surveillance data, as nearly two thirds of Aboriginal women with positive HIV test reports are exposed through injection drug use, with only one third exposed via heterosexual sex. This contrasts sharply with data on non-Aboriginal women, in which approximately two thirds of non-Aboriginal women with positive HIV test reports are exposed through heterosexual sex and one third are exposed through injection drug use [11;161].
The illegal nature of injection drug use means that when women who use injection drugs are subject to men’s violence they receive little protection from traditional sources. As described by Spittal et al. , “this is one of the challenges of harm reduction programming, particularly for women whose negotiating powers may be affected by violence, homelessness and drug-related interactions out of their own control”. Supervised injection sites, such as Insite, have been identified in the literature as a safer space for women to inject to avoid intimate partner violence and street violence .
d) Other Coping Skills
Some studies highlight the different coping skills or strategies used by women living with HIV in their day-to-day lives. A study of people living with HIV/AIDS using complementary or alternative medicine (CAM) revealed that more women than men use marijuana for pain management (45% of women versus 5% of men) . Moreover, more women than men reported using CAM as treatment – a trend that is also seen in the general population . However, another study on CAM found that supplement use among people living with HIV/AIDS is evenly distributed among both sexes but varies from that of the general population .
One study found that African and Caribbean women living with HIV preferred using culturally based traditional medicine to deal with illness and only used mainstream medicine as a last resort. This group of women’s preference for traditional medicine may reduce their likelihood of obtaining mainstream medical services and HIV treatment .
HIV-positive women use different coping skills than men to deal with their illness. One study found that women seek social support and cry for emotional release as a form of coping more often than men. Other differences in coping strategies employed by women and men include housework and walks (women) and sports and exercise (men) .
4.1.8 Healthy Child Development
Childhood represents a highly sensitive developmental period that is unique to each child. These developmental needs are currently not considered within the existing system and, as a result, they need particular considerations. A missed opportunity to support children’s health at any stage in this cycle may reverberate negatively across the lifespan. Scientific research has demonstrated that early detection of developmental problems of challenges coupled with a swift, appropriate response are critical to a healthy childhood trajectory .
a) Childhood Abuse
Some studies show that childhood physical, emotional or sexual abuse may contribute to risk behaviours in later life which, in turn, may facilitate the acquisition of HIV. One study , looking at Aboriginal youth who use injection and non-injection drugs in two Canadian cities, identified that 68.3% of the females included in the analysis (179/262) had experienced sexual abuse at least once in their lifetime. The average age reported for the first incident of abuse was 6 years old. Although the study did not stratify results by sex, the study did find that individuals who had experienced sexual abuse (n=258) were more likely to have spent more than three nights on the street or to have been involved in survival sex than those who had never been sexually abused (n=285). HIV and HCV prevalence were also higher among those who had experienced sexual abuse, with rates of 15.2% and 32.6% respectively, as compared to those individuals who had never experienced sexual abuse (4.4% and 29.1%; differences statistically significant). The study also found that individuals who had experienced sexual abuse were more likely to have overdosed and to have used injection drugs.
As previously discussed, various studies have found that many women involved in sex work (or survival sex) and many women who use injection drugs have histories of abuse including sexual abuse [56;75;76;135;149;166]. For example, a study conducted among VIDUS participants found that childhood sexual violence was predictive of HIV risk behaviours, such as entering the sex trade at or before age 17, ever having been in the sex trade, and borrowing needles from a known HIV-positive person . In another study in Vancouver’s DTES , in which 100 street-level sex workers were interviewed, 82.0% of participants reported a history of childhood sexual abuse by an average of four perpetrators; 72.0% reported physical abuse; and 86.0% reported current or past homelessness. While this study indicates there is a relationship between childhood abuse and sex work, it should be emphasized that not all women who are abused get involved in the sex industry and not all sex workers are or have been abused.
For many Aboriginal peoples, the legacy of residential schools and cultural disruption has resulted in family breakdown, and contributed to childhood sexual abuse and overrepresentation of Aboriginal children in state care [76;80;149;166;168]. Aboriginal youth’s current experiences are strongly impacted by a loss of culture, historical trauma and the legacy of residential schooling. This issue is explored in greater depth in the Population-Specific HIV/AIDS Status Report: Aboriginal Peoples .
4.1.9 Health Services
Health services, particularly those designed to maintain and promote health, to prevent disease, and to restore health and function, contribute to population health. The health services continuum of care includes treatment and secondary prevention .
The World Health Organization’s report on gender inequity in health maintains that “women in most places need more health services than men. A large part of this can be attributed to women’s use of preventive services for contraceptives, cervical screening, and other diagnostic tests, but it can also be attributed to excess female health problems that are not caused by reproductive morbidity” . In spite of the increased need for health services, many women in Canada face barriers to accessing mainstream health services. Barriers facing women include language barriers and lack of available information in languages other than English or French , logistical barriers, such as limited access to childcare or child-friendly services for mothers accessing the health care system, and stigmatizing attitudes expressed by health professionals. Women from visible minority groups and certain ethnocultural communities face an additional set of barriers, including a lack of cultural understanding among health professionals, and a lack of culturally appropriate health services and health information [37;170]. Ultimately, these barriers have the effect of limiting women’s access to diagnostic, care and treatment services, thereby increasing their vulnerability to HIV infection.
Studies show that women who are also members of a visible minority face barriers in accessing mainstream health services as a result of systemic discrimination relating to race and stigmatizing attitudes about HIV. Aboriginal women face particular challenges resulting from discrimination and face challenges in accessing health information and referral resources for HIV-positive women. For example, one study cites that “while many Aboriginal women continue to search for services that are gender-sensitive, culturally competent and inclusive of their children, others live in isolation as a result of multiple stigmas and barriers to services” . The same study found that Aboriginal women experienced discrimination within the mainstream health care system and found that Aboriginal cultural practices were not respected by healthcare providers .
In addition, the health care system is not always sensitive to the needs of women from other visible minority groups. For instance, participants in a study of Toronto visible minority female youth cited racism as a factor that limited their access to health services and affected their ability to trust in their healthcare providers. The study concluded that “systemic issues such as the lack of available healthcare providers from particular ethnic groups, [and] the availability of culturally/linguistically appropriate services and health information”  may limit women from visible minority groups’ ability to access health services.
Evidence indicates that some healthcare providers fail to demonstrate sensitivity to the needs of women from culturally diverse backgrounds [35;172]. For instance, a study of African and Caribbean communities conducted in Toronto found that HIV-related stigma and discrimination stemming from healthcare providers and community-based health organizations impacts this population’s access to health services . The same study found that “African and Caribbean people have become more reluctant to seek HIV-related services and have responded by increasingly rejecting and mistrusting the health care and social systems that, instead of supporting them, often discriminates against them” .
There is also evidence that immigrant women with little to no understanding of English or French report uncertainty in knowing which health services are available to them. Further, this group of women’s inability to communicate in either official language prevents them from acquiring appropriate HIV/AIDS information [36;37;174]. While some community-based organizations offer translation services, many women from African and Caribbean communities do not use these services as they report concerns regarding the confidentiality of their HIV-positive status (especially if the translator belongs to their community) and concerns regarding translation inaccuracies (especially if the translator is their partner) . If HIV-positive women rely on translators or partners for translation, they run the risk of being stigmatized by their community or partner. However, if they chose not to use translators or partners for translation, they may not receive adequate health information. More information on these issues can be found in both the Population-Specific HIV/AIDS Status Report: Aboriginal Peoples  and the Population-Specific HIV/AIDS Status Report: People from Countries where HIV is endemic, Black people of African and Caribbean descent living in Canada .
How about raising awareness? So that when you walk into the doctor's office for the first time, you can say, 'Hi, I am trans', and they don't get this glazed, blank look that goes 'Oh yeah, I've never seen one of you before' (Trans person) .
A woman’s sexual orientation may also affect her access to health services as healthcare providers may make false assumptions about risk activity. For example, research shows that some healthcare providers falsely assume that women who have sex with women (WSW) are not at risk of HIV infection. This assumption does not account for the fact that many WSW (women who self-identify as lesbian, bisexual or two-spirited) have had or continue to have sexual contact with men. It also demonstrates a general lack of knowledge about WSW and their health care needs [94;175]. One study concludes that lack of health research information on WSW and lack of WSW-specific HIV and other health surveillance data “have inadvertently contributed to the myth, held by both healthcare providers and women themselves, that lesbians are at no risk or low risk for HIV/AIDS and STDs (Sexually Transmitted Diseases)” .
The reality is that WSW may face increased vulnerability to HIV due to a number of factors related to their ability to cope and their comfort in accessing health services. For instance, WSW are reported to have higher rates of mental health issues and poorer coping strategies as compared to heterosexual women . Further, WSW report experiencing barriers to adequate health care as a result of “a heterosexist, and, at worst, homophobic, health care environment” [94;175]. Additionally, fear of healthcare provider discrimination may prompt some WSW to avoid seeking care. In a study of 98 lesbian and bisexual women living in the Atlantic provinces, 38% of participants reported that they had gone without routine physical or mental health care at least once “to keep themselves from having to deal with any mental or physical harm from potentially homophobic [healthcare] providers” . Research indicates that there is a need for accurate health information for WSW about risks related to STIs and HIV.
Academic HIV/AIDS literature explains that the manner in which health is delivered plays a role in the poor health outcomes experienced in certain groups of women . Studies have shown that to reach particularly vulnerable female populations, such as street-involved women or women who are involved in survival sex, population-specific strategies, including outreach programs, are needed to increase access to services [177;178]. For example, a study in Vancouver’s DTES found that 14% of 126 women attending a weekly women-only community health clinic had not accessed sexual health care services (e.g., Pap smear, STI or HIV testing) in the past year . These findings were notable because the only two clients diagnosed with STIs were first-time program participants. This finding led the authors to conclude that “there is a need to bolster outreach screening programs, such as those offered through [the program’s] Street Nurse program, to increase service utilization among these higher risk populations” .
Simple structural factors, such as the hours health services are available, may also create barriers to access for certain groups of women. For instance, in a study of 201 women involved in sex work in Québec, even though over 80% of women reported having consulted a health professional in the previous 12 months with relative ease, they also reported that limited hours of operation and long wait times for certain services, such as mental health services, created access challenges for them .
Women living with HIV may also experience barriers around access to health services related to healthcare providers’ insensitivity or ignorance about HIV/AIDS. Insensitivity may manifest itself as stigma and discrimination towards women living with HIV. For example, women living with HIV have reported feeling hurt and demeaned by health professionals every time they are faced with having to repeat their health history . Evidence also shows that women involved in commercial sex work and in street-level sex work are significantly affected by stigma and discrimination in their interaction with healthcare providers [180;181]. For instance, a B.C. Vancouver Area Network of Drug Users (VANDU) study found that women involved in sex work and/or injection drug use reported that they had kept their high-risk activities from their healthcare providers as a result of feeling stigmatized. Consequently, the health care services they received did not necessarily meet their needs .
Women in Canadian prisons also face a number of barriers to health services and HIV information, including access to discreet, accessible and plain-language information on HIV/AIDS; insufficient pre- and post-test counselling in spite of high testing uptake; and inconsistent access to basic medical services, such as blood work or physicians .
a) Treatment Options
Methadone maintenance therapy (MMT) is one treatment option available in Canada for people who are addicted to heroin, morphine and other opioids. There is, however, conflicting data on women’s access to and usage of MMT. VIDUS participants  identified that being female, HIV positive, and smoking crack cocaine were positively and significantly associated with being on MMT. Aboriginal ethnicity, recent incarceration, sex trade involvement, syringe lending, and heroin injection were significantly associated with not being on MMT. In a study conducted on the participants of a low-threshold MMT Program in Montreal , the probability of withdrawing from the program was twice as high for women as it was for men. Other literature has suggested that women are hesitant to use health services to address addiction issues because of the associated stigma. Children are also a factor in decision-making for women who use drugs. These women may not be able to find care while in treatment for addiction, and they may fear losing their children to child welfare services if they admit to having an addiction problem [19;147;184].
For women who have been sexually assaulted, post-exposure prophylaxis (PEP), a short-term antiretroviral treatment, is available to Canadian women to reduce the likelihood of HIV infection after potential exposure. However, the side effects of the drugs can be severe and the course of treatment lasts for several weeks. In a study of HIV-related PEP following sexual assault (where 97.7% of the participants in the study were female), PEP was offered to 69 of the 71 high-risk participants and 729 of the 829 unknown-risk participants. Of those who were offered PEP, only 66.7% of high-risk participants accepted treatment and 41.3% of participants at unknown risk accepted treatment. Reasons for declining PEP included lack of concern about HIV (63.0%), anxiety about adverse side effects (44.6%), and an inability or unwillingness to follow the regimen or return for follow-up (16.4%) .
b) HIV Testing
Ensuring that people undergo HIV testing is a key component of reducing the spread of HIV and ensuring access to medical care for those who are HIV positive. At the end of 2008, an estimated 26% of the 65,000 individuals living with HIV in Canada were unaware of their infection .
Canadian literature indicates that women-specific barriers to HIV testing include the belief – of either the individual or the healthcare provider -- that women are not at risk of HIV infection. Women-specific barriers to testing also include fear of HIV-related stigma and discrimination ; fear of losing one’s children by revealing HIV-related risk behaviours, such as illegal drug use ; and fear of an HIV-positive test result . Additional literature and studies have further identified that certain groups of women experience specific barriers to testing. For example, the Blueprint for Action on Women and Girls and HIV/AIDS explains that “Aboriginal women, women in many rural and remote locations, [and] visible minority women from a variety of communities have difficulty accessing diagnosis and testing services in Canada because of concerns regarding confidentiality, a lack of knowledge of HIV or a need for testing, and healthcare provider bias” .
Young women also face specific barriers to testing. In a study of barriers to STI testing for youth living in a remote resource-extraction community, young women reported fear of being labelled as promiscuous as a barrier to testing. The study found that these young women’s fears were well-founded. Young men who participated in the study group referred to women who they perceived to be sexually available in stereotypical and negative ways (such as ‘nasty’, ‘sluts’, ‘campies’, or ‘questionable’). They also based assumptions of sexual availability on women’s dress or sexual reputation . This study shows how social norms that stigmatize women’s sexuality may prevent women, particularly young women, from accessing HIV testing.
Maybe [Aboriginal people] don’t want to tell [the tester] exactly why they want that [HIV] test…. [The tester] is full of judgements, and I think that’s a real barrier. I know it’s a barrier for me…. When [the tester] asked why [I wanted the test], immediately that makes me feel like I’m being judged. Puts me on the defensive. Makes me feel like I have to justify myself – Aboriginal woman .
Women engaged in sex work face additional barriers to HIV testing. A qualitative study of 18 women who work in indoor sex establishments in Vancouver found that although the study participants perceived themselves to be at significant risk for HIV infection, they noted challenges in accessing HIV education and testing. Participants who also identified as migrant women reported having had a particularly difficult time accessing HIV education and testing .
I go to my physician for my tests every three months, that’s official. Even if I have a stable partner, I’m really afraid of it. I have friends with AIDS and I don’t know what might happen. I always have my tests every three months – Woman, sex worker .
Obviously when I see the physician I don’t tell him what I do. However, I do consult about diseases, which means I have no choice. But if I’m not asked, I don’t say anything – Woman, sex worker .
Some studies have also looked at broader issues associated with HIV testing. For example, one study looked at HIV testing experiences for women who immigrated to Canada. Participants in the study described the HIV testing they received as part of the immigration medical examination (IME) – a required part of the immigration process - as negative. Women in the study indicated that they felt they lacked knowledge and understanding of the test they were given, and they reported feeling rushed. Study participants attributed their negative experiences with the IME to a lack of positive women-centred counselling after the test, a lack of an appropriate referral mechanism, and what they perceived as breaches of confidentiality .
Another study found that women from countries where HIV is endemic going through the immigration process were reluctant to learn their HIV status for fear that their children would be taken as a result . Fear that one’s children could be taken away was also identified as a significant barrier to HIV testing in a study of HIV-positive mothers of Aboriginal ancestry  and a study of young HIV-positive mothers .
c) HIV Testing for Pregnant Women
As discussed in Chapter 3, there are two different approaches to HIV testing in the prenatal context in Canada, called “opt-in” and “opt-out”. In both approaches, pregnant women are given a choice of whether to undergo HIV testing. The healthcare provider is required to discuss HIV testing with the client and seek consent before conducting the test . The practice of ensuring that women give informed consent and receive adequate pre- and post-test counselling is an important one. Csete et al note that “while consensus apparently remains strong on the value, at least in theory, of informed consent and pre-test counselling [for prenatal HIV testing], it is another question to know the actual practice across Canada of HIV counselling for pregnant women and the sharing of information associated with informed consent” .
A 2008 study of 299 pregnant women’s experiences around informed consent for prenatal HIV testing in Toronto found that 74% of participants recalled a clinician discussing HIV testing with them, and 70% of these women felt that they were given the option to refuse having an HIV test performed . The authors concluded that although “informed consent for prenatal HIV testing is generally being obtained in a manner consistent with provincial guidelines… a significant number of women are not offered testing or, in some cases, are tested without their consent” . Another qualitative study of 44 African and Caribbean women living in Ontario who received prenatal HIV screening identified similar issues around prenatal testing. The majority of women interviewed as part of the study reported receiving inadequate pre- and post-test counselling which resulted in a lack of knowledge about HIV and the risks associated with vertical transmission; fear, panic and suicidal ideation as a result of an HIV-positive diagnosis without adequate professional guidance or social support; and a lack of knowledge about confidentiality policies related to HIV disclosure . Women across Canada who receive prenatal HIV testing, regardless of the policy in their province or territory of residence, report a variety of testing experiences. Studies on prenatal HIV testing practices across Canada reveal that women receive both a lack of adequate pre-test counselling about the risks and benefits of testing and a lack of post-test counselling. Women also experience confusion about whether the test is mandatory [192;195;196].
I was diagnosed in 1990. I already knew about HIV, and when I experienced classic seroconversion illness, I figured I better get tested. I just had this feeling about it. I didn’t fit the stereotypes, so I had to convince a doctor to test me, and I wasn’t surprised when it came back positive (the doctor was) - Woman living with HIV .
Research suggests that a healthcare provider’s decision to offer HIV testing to a pregnant patient is affected by several factors, including the personal characteristics of the client and their perception of the client’s risk of having HIV. A 2002 study of 2,129 physicians who provided prenatal care found that “a physician’s decision to offer screening for HIV in pregnancy is affected by many personal characteristics, including speciality, age, practice characteristics and knowledge about the risk and prevention of mother-to-child transmission” . Obstetricians and female physicians were more likely than family physicians and male physicians to offer prenatal HIV testing to all or almost all of their pregnant patients. Physicians were also more likely to offer or recommend prenatal HIV screening if they practised in an area where there were provincial recommendations or a formal policy in place, or if they practised in regions where the reported HIV prevalence was greater than 5.0/10,000 (a prevalence rate established by the authors based on the distribution of HIV infections in Canada) .
4.1.10 Culture and Race
Some persons or groups may face additional health risks due to a socio-economic environment, which is largely determined by dominant cultural values that contribute to the perpetuation of conditions, such as marginalization, stigmatization, loss or devaluation of language and culture and lack of access to culturally appropriate health care and services .
Epidemiological data indicate that Aboriginal women and women from countries where HIV is endemic experience higher rates of HIV infection than women belonging to other groups. There is evidence that factors linked to culture and race put women who belong to these ethnocultural groups at increased vulnerability to HIV infection.
Culture, for the purposes of this section, is defined as shared beliefs, values, customs, behaviours, common values and norms existing among specific ethnic communities. For women belonging to specific ethnocultural communities, culture may be experienced through the customs, values, practices and beliefs within their community, and through the impact of dominant culture on their lives as women within their community . Factors relating to culture may have the affect of limiting women’s access to health care, information or services. However, factors relating to culture can also play a significant role in creating resilience to HIV/AIDS as women’s strength and coping mechanisms may be rooted in their community values or linked to their culture and ethnicity.
During colonialism, Europeans displaced Aboriginal communities and imposed their notions about women’s role in society on Aboriginal people. For Aboriginal peoples, the experience of colonialism resulted in the dispossession of Aboriginal women’s rights and in the devaluation of their social roles within their communities . The transformation from traditional systems (including, in some cases, matrilineal or matriarchal) to elected Band Chief and Council, assimilative education systems and policies, as well as the application of a governance system in which women had no legal status, all play a role in rendering Aboriginal women today more vulnerable to HIV infection [91;92;191].
The legacy of colonialism continues to have adverse effects on the socio-economic status of Aboriginal women as they are twice as likely as their non-Aboriginal counterparts to be poor and more likely to live in an environment where substance use and intimate male partner violence are widespread . These socio-economic conditions are strongly associated with a positive HIV test result in Aboriginal women as they set the stage for high-risk behaviours, such as sex work, injection drug use, and alcohol abuse, to occur [91;92]. As Csete observes, “HIV/AIDS among Aboriginal women cannot be understood without reference to poverty, gender power relations, violence and discrimination, including systemic racism in the delivery of health services” . Racist and sexist attitudes within mainstream society also put Aboriginal women at greater risk of sexual violence and sexual assault, thereby intensifying their vulnerability to HIV infection .
One study revealed that the integration of Aboriginal cultures into HIV testing approaches is key to gaining Aboriginal women’s trust. In the study, Aboriginal women explained that culturally appropriate approaches, such as “sensitivity to and knowledge of the issues that Aboriginal women may experience, inclusion of traditional teachings, practices and Aboriginal spirituality, an inviting physical environment and Aboriginal staff” were important to them . This is an important recognition as culture can be a great source of strength and resilience for Aboriginal women. Another study found that Aboriginal women draw on their own spirituality as a coping mechanism when caring for someone living with HIV/AIDS . In the words of the author, “[spirituality] is the glue that keeps [Aboriginal women] together” .
The Canadian Aboriginal AIDS Network (CAAN) has delivered a position statement calling for action to support Aboriginal women, children and families affected by HIV/AIDS. The statement recommends the revision of medical treatment formularies to reflect Aboriginal culture and calls for an increase in culturally-sensitive and gender-sensitive health care services (especially in the provision of HIV testing and counselling for Aboriginal women, which should include the integration of Aboriginal healing methods) . There is some evidence that Aboriginal women do not use mainstream services because they fear discrimination. One study suggests that Aboriginal women associate mainstream HIV health care services with colonialism and racism, and, therefore, tend to avoid these services [92;135].
While the report recognizes that women who come from countries where HIV is endemic are diverse, there are studies which suggest that certain cultural practices within specific ethnocultural or immigrant communities can increase women’s vulnerability to HIV and deter prevention. Cultural practices that increase women’s vulnerability to HIV include polygamy and culturally specific female genital tract practices. Cultural norms, which deter HIV prevention, include culturally specific beliefs and attitudes towards sexuality and HIV/AIDS.
Patriarchal attitudes supportive of male dominance and female submission are manifest in many African and Caribbean cultures. Because these attitudes serve to constrain women’s ability to exert power and exercise choice, it may be difficult for women from these communities to negotiate condom use [35;36]. This is especially true within marriages . One study found that women of Jamaican-descent identified marriage as a factor that increases their vulnerability to HIV infection. According to the study’s participants, there is no way to practise safer sex in marriage . In the same study, women of Caribbean-descent spoke about the vulnerability they experience and their lack of control over their own bodies. Another study of women of Kenyan-descent revealed similar findings as to how difficult it is for married women in their community to say no to sex without a condom.
How we was brought up, if you’re married, you don’t use condoms, you don’t practise safe sex. It’s your husband (…). You can’t do these things. You know, it’s my husband, why should I? And like men, they will say, ‘Oh, maybe you’re sleeping around. Or maybe you’re doing something you’re not supposed to be doing --- Black woman .
Within the African traditional family, even if a woman is aware of her husband’s concubines, she cannot ask him to use a condom --- Black woman .
Polygamy -- a patriarchal, cultural and religious practice that permits a man to have more than one wife -- also increases women’s HIV risk. The risk of transmitting an STI is greater among multiple partner marriages where condom usage may be limited [36;46;198]. While polygamy is illegal in Canada, polygamy has been documented within certain ethnocultural communities [36;38].
Two culturally specific female genital-tract practices, female genital mutilation (FGM)Footnote 49 and douching or vaginal drying, practised by some women of African and Caribbean descent put them at increased risk of HIV/AIDS . Despite being internationally recognized as a violation of the human rights of girls and women , FGM continues to be practised among some African communities in Canada. FGM is when circumcisers narrow or seal the vaginal opening. This practice is linked to a cultural preference for premarital virginity and an emphasis on marital fidelity . FGM is also motivated by beliefs about what is acceptable female sexual behaviour . This practice scars women’s genital tracts, making it easier for infections, including HIV, to proliferate. In addition, FGM and its emphasis on premarital virginity, combined with limitations in sexual education, may influence women’s decision to engage in anal intercourse, as research suggests that women who wish to retain their virginity for marriage may practise anal intercourse as an alternative to vaginal intercourse , thereby increasing their risk for HIV infection.
The second female genital-tract practice, douching or vaginal drying, involves cleansing the vagina and is used by women to remove signs of sexual intercourse. Douching or vaginal drying, dries the vaginal wall and increases friction during intercourse. The practice is most commonly seen in African and Caribbean communities in Canada and is linked to strongly held ideas about cleanliness and purity . Douching or vaginal drying results in increased friction during sex and may lead to tearing of the vaginal lining or condoms, subsequently increasing women’s risk to HIV and other infections .
The reason why she wouldn’t practise safe sex is because God’s seed should not be thrown to the ground…that goes against her religious beliefs---Black woman .
Within certain ethnocultural communities in Canada, HIV/AIDS is primarily seen as an issue of moral impropriety rather than a health concern . Specifically, there is a tendency among African and Caribbean communities in Canada to associate HIV with extramarital sex and promiscuity. This impacts women’s ability to protect themselves against HIV as many feel that they cannot ask their partner to use a condom for fear of being accused of sexual promiscuity . Additionally, sexual matters are considered taboo among some African and Caribbean communities in Canada. The “code of silence” around sexual matters in these communities, where people generally avoid talking about these subjects, makes it difficult to discuss and acknowledge HIV/AIDS within or outside communities [35;36;90].
African and Caribbean norms and values may impede HIV prevention or intervention strategies within these communities in Canada, especially if they run contrary to public health. As one research participant in a study explained, “(I)t is very difficult to get a group of women who have undergone certain traditional rituals to agree or to understand that they need to change some of those rituals in order to avoid any risk” . For instance, religious institutions hamper HIV prevention efforts when they dictate to women certain behaviours that run contrary to public health, including placing restrictions on condom usage . As one study participant explains, “the churches instructed women to obey their husbands, and, therefore, confronting partners about sexual behaviour violated sacred cultural/religious norms and would not be supported by the community” . Without the support of major cultural institutions, public health’s ability to effect change and make headway in HIV prevention remains limited [35;46].
Homophobia among African and Caribbean communities also results in men who have sex with men (MSM) engaging in and maintaining sexual relationships with women. This, in turn, poses a risk of HIV to the female partner . According to one study , “among African and Caribbean communities, homosexuality is generally stigmatized as unhealthy, immoral, or contrary to traditional cultural norms and values.” The assumption that HIV/AIDS is a “gay disease” or that gay men are to blame for HIV/AIDS compounds the stigma felt by MSM in these communities. This stigma also thwarts HIV prevention efforts among both MSM and women involved with MSM in African and Caribbean communities.
I know men who have sex with men within the community; they tend to stay in the closet. They tend to have girlfriends as a cover, so that people won’t suspect that they have another different sexual orientation or that they are gay (…). And because of this hidden dimension, it becomes a risk for women; because you can never know when or if your partner or so has sex with another man---Black woman .
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