Chapter 5: Population-specific HIV/AIDS status report: Women - Current research

Chapter 5 - Current HIV/AIDS Research

HIV/AIDS research in Canada extends to behavioural, biomedical, clinical, economic, epidemiological, legal and psychosocial fields of studies. This chapter provides an overview of current research projects on HIV/AIDS and women in Canada that were underway from 2006 to 2009. Each project is presented by geographic distribution, specific population and theme. A complete list of projects can be found in Appendix B.

5.1 Methodology

The information provided in this chapter was gathered from the following organizations: the Canadian Institutes of Health Research (CIHR), the Canadian Association for HIV Research (CAHR), the Canadian Foundation for AIDS Research (CANFAR), the Social Sciences and Humanities Council of Canada (SSHRC), the Michael Smith Foundation for Health Research, and the Ontario HIV Treatment Network (OHTN).

Research projects included in this chapter meet the following three criteria:

  1. HIV/AIDS specific,
  2. Canadian; and
  3. women-centred.

Projects include those completed in 2006 or later and those currently under development. It was assumed for the purposes of this report that research completed before 2006 had already been published, and, therefore, was likely already included in the academic and grey literature reviewed in earlier chapters of this report.

It should be noted that there are limitations to restricting criteria to women-specific research projects only. The selected research does not take into account projects that focus on the general population or any other populations of in which capture women incidentally. Consequently, the decision to focus on women-specific research projects has the effect of limiting the actual number of research projects included in this chapter as only those projects specifically designed for women or those which target women directly are included.

This chapter also includes biological and clinical research on aspects of HIV transmission and infection for women. Studies conducted abroad by Canadian researchers include those studies which provide additional insight for and about Canadian women. Biological or clinical research focusing on the social context of a particular geographic region or country outside of Canada was not included for analysis.

The selection process for project inclusion was sometimes hampered by the absence of project abstracts or descriptors. To counter this limitation, projects were included only if the words “women”, “female”, “feminism”, “feminist studies”, “vertical transmission”, “gender”, “gender analysis or studies”, and “power” were used in the title or as project descriptor keywords. Some projects required further exploration and principal investigators were contacted or researched using Google Scholar to determine whether projects were specifically women-centred.

5.2 Research Analysis

Most of the research projects on HIV/AIDS and women listed below incorporate sex and gender based analysis (SGBA). For instance, some governmental and non-governmental organizations, including the Canadian Institutes of Health Research (CIHR) and the Women’s Health Contribution Program (Health Canada and various partners), have used SGBA to take a closer look at the factors affecting the health status of women and girls. This chapter also uses SGBA to identify gaps in research and determine future research needs.

Using the methodology described above, a total of 87 HIV/AIDS women-specific research projects were identified (Appendix B).

5.2.1 Geographic Distribution of Research Projects

Over half (46 or 52.9%) of all projects identified do not examine women in a specific geographical region. Of the 41 (47.1%) projects that do, most focus on women from Québec (especially Montreal), British Columbia (especially Vancouver) and Ontario (especially Toronto); a few additional studies focus on women from the Prairies. One quarter (10) of these geographically specific projects further target women from Vancouver’s Downtown Eastside (DTES).

5.2.2 Prominent Themes: HIV Prevention, Intervention and/or Treatment

Among the 87 projects identified, more than one half (49 or 56.3%) focus on HIV prevention, interventions and/or treatment strategies and their effects (R1, R2, R3, R4, R6, R10, R11, R12, R13, R20, R21, R22, R24, R25, R27, R28, R29, R34, R35, R37, R38, R39, R40, R41, R42, R43, R45, R46, R47, R50, R52, R53, R54, R56, R57, R58, R65, R66, R68, R71, R72, R73, R76, R77, R78, R79, R80, R83, R84).

Several projects look at a specific intervention initiative (R22, R46, R61, R65), and other projects investigate HIV risks or barriers to prevention and/or treatment (R8, R13, R39, R45, R53, R65, R67, R71, R79). In addition, a number of studies identified are biomedical in nature, focusing on factors related to the physical transmission and susceptibility of women to HIV infection (R3, R8, R9, R11, R15, R17, R18, R19, R30, R31, R85).

Several of the projects that investigate these themes are further broken down by specific population, as described below.

5.2.3 Research Projects Addressing Specific Populations

Of the 87 projects identified in the research inventory, 69 projects (79.3%) target women from specific populations or groups living in Canada. Specific populations studied include women living with HIV, women from countries where HIV is endemic and immigrant or ethnocultural communities, women involved in sex work/survival sex work, female youth, Aboriginal women (First Nations, Inuit and Métis), lesbian/two-spirit/and women having sex with women, transgender persons, women who use injection drugs, and women in prisons.

a) Women Living with HIV

Of the 87 projects, 49 projectsFootnote 50 (56.3%) target women living with HIV in Canada. Of these projects, nearly one half (24) look at reproductive health issues facing women living with HIV, including an examination of their fertility desires (R38, R75), issues around pregnancy (R74), perinatal drug treatment exposure (R6, R16, R18, R54, R59-R61), vertical transmission (R15, R18, R38), and motherhood experiences (R27, R36, R37, R56). Consequently, all of these projects focus exclusively on women living with HIV of reproductive age.

Five other projects target women living with HIV who come from countries where HIV is endemic or from immigrant or ethnocultural communities. These projects examine these women’s experiences with HIV diagnosis, treatment and support. Specifically, these projects highlight ethnocultural interpretations of the disease associated with maternity, treatment and secondary prevention (R24, R26, R28, R36, and R53).

Another five projects target survival sex workers living with HIV, examining issues around accessibility to health services, and uptake and sustainability of treatment and care (R20, R40, R52, R58, and R76).

Other projects address women living with HIV more generally. These projects examine the quality of life and well-being of women living with HIV (R12, R22, R25, R62) and their access to and impact of treatment (R4, R16, R45, R51, R53, R58, R61, R65, R71). These projects also look at the needs, supports and barriers for women living with HIV, such as systematic racism in health care delivery (in the case of African-Caribbean women), lack of health programs for mothers living with HIV, and barriers to treatment such as access and adherence (R12, R34, R37, R49, R62, R71, R75, R84). In addition to examining the well-being and needs of women living with HIV, research on women living with HIV examines the intersection between gender and other health determinants.

b) Women Involved in Sex Work and/or Survival Sex Work

Of the 87 projects reviewed, 14 projects (16.1%) target women involved in sex work (R8, R13, R20, R24, R35, R39, R40, R46, R50, R52, R58, R66, R76, R79).

Within this category, more than one half (8) of projects focus on women involved in survival sex work (R8, R20, R24, R35, R40, R52, R58, R66). Seven of these projects further target women who also use injection or non-injection drugs, while four projects focus on women living with HIV involved in survival sex (with one project specifically targeting HIV-positive Aboriginal women involved in survival sex). These projects look at barriers and facilitators to risk and/or prevention and/or treatment. Specifically, these projects target determinants that affect HIV risk, including social and cultural factors (e.g., sex and drug networks, Aboriginal culture, youth) and their impact on HIV treatment and prevention. These projects also examine environmental and structural issues such as men’s violence and power relationship dynamics with pimps, dates and intimate partners. Other projects research women’s coping skills and health care practices.

Research included in this report focuses almost exclusively on sex workers from Vancouver’s DTES. More research is needed regarding women involved in sex work and HIV in other geographic regions of Canada, such as Montreal and Toronto. Also, more research needs to be done to better understand the experiences of transgender persons involved in sex work, as this population is progressively understood to be at increased risk of infection.

c) Women from Countries where HIV is Endemic or Immigrant or Ethnocultural Communities

Of the eight projects targeting these populations, the majority (five projects) focus on women living with HIV (R26, R28, R34, R36 and R53). These projects focus on capacity building through increased emphasis on healthcare information and improved understanding of ethnocultural constructions of the disease, including cultural constructs related to maternity, treatment and secondary prevention. These projects also look at the ability of women living with HIV to access care, treatment and support.

The remaining projects focus on issues related to HIV prevention in ethnocultural communities. These three projects look at creating culturally appropriate prevention and care programs for immigrants and refugees from countries where HIV is endemic who are living in Ottawa (R34), investigating barriers and facilitators to accessing future HIV vaccines among Black women (R80), and examining the relationship between violence in intimate relationships and HIV among immigrant women in Toronto (R26).

Project analysis reveals that there is a lack of research on confounding determinants of health related to women from countries where HIV is endemic. More research is needed for this group of women to better understand the way intersecting determinants impact women’s vulnerability to or resilience against HIV. For example, more research among these groups of women is needed to look at whether economic class and income and education levels confound or contribute to women’s vulnerability to HIV. Further population comparisons from a cultural perspective are needed (i.e., there is a need to analyze differences and commonalities between African, Caribbean, and Asian communities within the larger group). Also, generational analysis (i.e., determining whether distinctions exist between first generation immigrants, second generation immigrants, etc.) is another area that may warrant future study.

d) Female Youth

Of the 87 projects identified, five projects target female youth (R14, R33, R43, R72 and R73). One of these projects focuses on gender power relationships (R33), while the other four focus primarily on HIV risks, prevention and capacity-building. One of those four projects targets female street youth (R14), focusing on factors leading to pregnancy and HIV risk. Another project examines Inuit youth in the context of culture, health and gender empowerment (R72), highlighting the interplay between age, culture and gender determinants. The third project examines the effects of the human papilloma virus (HPV) vaccine on HIV-positive girls and women. This project concludes that HIV-positive females have higher rates of HPV infection than HIV-negative females and have a higher incidence of HPV-related cancer (R73). The fourth project looks at increasing HIV/AIDS prevention capacity in female youth.

Project analysis reveals that research on female youth is limited, which is notable because epidemiological data indicate that HIV prevalence is on the rise among female youth (Chapter 3, Figure 14). More specific research on female youth is needed and could include more research on female youth involved in the sex trade, female youth who use injection drugs or other substances, and female youth from other specific populations (e.g., female youth affected by crime, female youth from countries where HIV is endemic, female Aboriginal youth).

e) Aboriginal Women: First Nations, Inuit and Métis

Eight of the 87 projects identified target Aboriginal women (R1, R2, R37, R40, R53, R69, R72 and R83). One project examines Inuit female youth and focuses on HIV/AIDS education, screening and treatment (R72). Another project looks at sexual violence in the context of HIV/AIDS service provision; more specifically, it looks at how gender, culture, violence and HIV/AIDS intersect for women in their experience accessing health services and in their attempts at managing their health (R69). Another project seeks to identify HIV prevention needs for Aboriginal women as compared to non-Aboriginal women and examines the implications of HIV prevention gaps for research, policy and practice/programming (R37).

Three projects look more closely at issues facing Aboriginal women living with HIV. One project explores the cultural importance of motherhood and maternity for Aboriginal women living with HIV (R53). Another project examines survival sex workers’ HIV risk behaviours and barriers to prevention and treatment (R40). The last project looks at the experiences with homophobia of two-spiritFootnote 51 women living with HIV regarding service provision (R83). All of these projects explore the interrelationship between gender and culture, with a view to improving service provision from this population’s perspective.

f) Lesbian, Two-spirited and Women Who Have Sex with Women

Three projects in the research inventory target either lesbian, bisexual women, women who have sex with women (WSW), or two-spirit women (R1, R55, R83). Two projects focus exclusively on Aboriginal women, with one project examining the migration patterns of Aboriginal people in relation to health (R1) and the other project examining homophobia in relation to health services (R83). The third project explores HIV risks, injection drug use and sexual risk behaviours among men who have sex with men and WSW (R55).

None of the projects that involve this group of women focuses exclusively on two-spirit women, lesbian or WSW living with HIV, nor do any of the projects focus on WSW youth or WSW in other ethnocultural communities.

g) Transgender Persons

Two projects on transgender persons were identified in the research inventory. One project targets female-to-male transgender persons (transwomen) and looks at the impact of social isolation and oppression on their health (R44). Another project examines HIV/AIDS-related vulnerabilities associated with transgender persons (R82).

h) Women Who Use Injection Drugs

Of the 87 projects listed in the inventory, six projects target women who use injection drugs and are involved in sex work (R8, R23, R35, R46, R67 and R76). Moreover, one project looks at women who use injection drugs and their access to antiretroviral therapy via a drug treatment program (R42). All of the projects examine the lives of women who use drugs in relation to other factors, and a number of them look at the relationship between drugs and survival sex work. The majority of the projects targeting women who use injection drugs and are involved in sex work, including research reviewed in Chapter 4, focus on women from British Columbia. Consequently, there is a need for studies to look at women who use injection drugs who live in other geographic areas of Canada.

i) Women in prison

One project in the research inventory targets women in prison (R21). The project on women in prison is intended to inform prevention efforts to reduce the transmission of STBBIs among this population. This project, involving men and women, is being conducted within the Manitoba provincial correctional system.

5.2.4 Empowerment: Building Leadership among Women Affected by and Infected with HIV/AIDS

Women’s empowerment relates to women’s sense of self-worth, and their ability to have and make choices, access opportunities and use resources, control their own lives, and influence social change. Empowerment embodies the spirit of self and draws on the support of others to bring about individual change, structural change and gendered relations change. Women’s overall state of health will not change unless women themselves are empowered to challenge and change the contexts in which they live [2].

Different approaches may be used to empower women to articulate their own aspirations, to develop their own strategies for change, and to develop their skills and ability to access the resources necessary to achieve their aspirations. All of the approaches used to empower women increase their capacity to examine and articulate their collective interests, increase their ability to organize their interests, and aid them in linking with other women’s and men’s organizations to achieve change. Generally speaking, approaches to empowerment are used to alter the underlying inequalities experienced in existing gender power relations [2]. Accordingly, many of the projects reviewed focus on empowering women so that they may gain the leadership and skills required to redress the power imbalances that make them vulnerable to HIV/AIDS.

Of these projects, several seek to improve women’s coping skills or promote women’s participation in society (R12, R13, R22, R23, R25, R33, R66, R76 and R84). For example, one study looks at whether case management and standard general health promotion programs have the effect of improving coping skills, increasing social support, and decreasing depression levels for women living with HIV (R25). Another study identifies barriers and factors that improve the ability of women living with HIV to participate in society (R84). The notion of empowerment is also explored in another study that looks at young women in heterosexual relationships (R33). This study found that the sexual empowerment of young women may translate to empowerment in other areas, resulting in a decreased risk of HIV infection. A study on women who use injection drugs and are involved in sex work concludes that programs for women should emphasize health promotion and highlight the various actions women can take to keep themselves safe rather than focusing exclusively on their risk behaviours (R76).

Several other projects give women from vulnerable populations the opportunity to join research projects as peer-intervention agents to create skills-building opportunities. Studies have shown that the active participation of women from vulnerable populations’ participation in studies contributes to their well-being and is critical for the purposes of health promotion [3-5]. One study suggests that peer intervention helps improve the living conditions of women who are involved in sex work and who use injection drugs (R46). Peer intervention is also examined in another study as a means to reach vulnerable female populations (R40). The goal of these studies is to reduce HIV transmission within these female populations, improve their living conditions, and redefine their identity.

Many studies on sex workers also recruit, hire and train women from vulnerable populations as researchers (R13, R40, R41, R52 and R66) to act as interviewers or research assistants. Studies suggest that the active participation of female sex workers in studies “on this community for this community” builds community-based research capacity and promotes community leadership (R40, R52).

Other studies invite women from vulnerable populations to participate in specific decision-making processes, thereby tapping into their expertise to gain knowledge of the community and giving them a voice in decisions affecting them. For example, one project aimed at increasing the decision-making capacity of women living with HIV in research projects invites this group of women to help determine research questions (R49). Another project identifies the need to include women who use injection drugs and are involved in sex work in the decision-making process regarding health care services they require. The study maintains that their involvement will improve the design and implementation of harm reduction strategies among this population (R76). This approach was also adopted in another project that had the objective of fostering community ownership and leadership among female Aboriginal survival sex workers (R40). This study suggests that a participatory approach is highly valuable for providing women who are sex workers with a true voice in HIV prevention and care.

5.2.5 Violence against Women and HIV/AIDS within Research Projects

Among the 87 research projects included in the inventory, 10 or 11.5% identify men’s violence against women as a risk factor for HIV infection for women. Half of these projects examine men’s violence against women among sex workers and survival sex workers (R24, R40, R52, R76, R79). Some projects examine the issue of men’s violence against women among specific groups of women, including immigrant women (R26) transgender women (R82) and Aboriginal women (R69 and R40), or in particular settings, such as in sexual assault treatment centres (R45). One project conducted a systematic review of studies to uncover the relationship between sexual violence prevention interventions and HIV/AIDS (R77). These projects indicate that men’s violence against women remains an obstacle in HIV/AIDS prevention, especially for certain groups of women, and should continue to be considered and explored in as part of the response to HIV/AIDS.

5.2.6 Capacity Building within the Spheres of Policy, Health Care, Knowledge Transfer

Research included in the inventory highlights the importance of capacity building in sectors related to policy development, prevention, health care practice and guideline development, and knowledge transfer.

Many projects examine the implications of health policy on affected and infected women populations (R15, R24, R39, R43, R45, R56, R57, R68, R72, R76, R77 and R83). Of these, one project examines the impact of policy and service delivery models on HIV/AIDS prevention in female adolescents (R43). One project looked at infant feeding policies to determine their impact on women living with HIV (R56). One project looked at the interconnection between sexual violence, gender, culture and HIV/AIDS and its potential implications for policy and programming (R68). Another project tried to identify policy elements necessary to mitigate homophobia in service provision from the perspective of two-spirit women (R83). 

Other research projects sought to use research findings to inform the development of HIV/AIDS intervention/prevention programs (R12, R13, R20, R21, R23, R24, R33, R39, R41, R45, R46, R50, R52, R57, R71, R74, R76, R79 and R84). Of the 87projects identified, 19 (21.8%) expressed this goal. Almost half of these (8) involved studies on sex workers (including survival sex workers) in support of the development, implementation and/or evaluation of a program in HIV care and/or treatment.

In addition, some projects sought to enhance or inform health care and research practices, guidelines and policies on particular populations of women (R24, R45, R50, R52, R58, R59, R72, R76, R77, R79, R80, and R83). For example, one study intends to use its findings to encourage standardized health care practices for post-exposure prophylaxis (PEP) accessibility for sexually abused women in shelters (R45). Another project intends to use its findings to improve provincial and national antiretroviral therapy guidelines and pregnancy practices in Canada (R59).

Overall, most of the projects included in the inventory focus on capacity building -- both at individual and community levels – for the purpose of identifying intervention, prevention and treatment strategies, and opportunities for various populations of women. The various projects listed demonstrate how complexities that result from the intersection of determinants serve to increase women’s vulnerability to HIV/AIDS. These complexities are further evidenced by the study on Ontario women and HIV prevention (R57) in which 16 unique groups of women have been identified for the purpose of looking more closely at their HIV prevention, treatment and policy needs. Consequently, there is value in examining the intersecting factors that contribute to women’s marginalization to better understand how underlying inequities contribute to their vulnerability and resiliency to HIV/AIDS.

5.3 References

[1] Jackson R., Ristock J., Brotman S., Monette L., Seto J., Atkin W. Two-Spirit women's experience of homophobia in the context of HIV/AIDS service provision.  2008 [cited 2010 Sept]. Available from http://www.caan.ca/pdf/TwoSpiritWomen_HomophobiaHIVProject.pdf

[2] National Association of Friendship Centres. Urban Aboriginal women: Social determinants of health and well-being.  2008 [cited 2010 Sept]. Available from:  http://www.laa.gov.nl.ca/laa/naws/pdf/NAFC-UrbanAboriginalWomen.pdf

[3] Blueprint for Action on Women and Girls and HIV and AIDS. Report card and report card backgrounder: Canada.  2008 [cited 2010 Sept]. Available from: http://womensblueprint.org/en/wp-content/uploads/files/Canada_Background_ENG.pdf

[4] Leonard L. Women and HIV prevention: A scoping review. Ottawa: University of Ottawa. 2007.

[5] Gahagan J, Sweeney E, Jackson R, Mill J, Dykeman M, Prentice T, et al. Challenges and barriers to HIV service delivery: the experience of Aboriginal women in Canada. Presented at the 18th Annual Canadian Conference on HIV/AIDS Research (CAHR); 2009 23-26 Apr; Vancouver, Canada.


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