sex as a mode of HIV acquisition among a cohort of women with HIV in Canada an underrecognized public health concern Mona Loutfy Carmen Logie Alexandra de Pokomandy ID: 589517
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Slide1
Coercive
sex as a mode of
HIV acquisition among a cohort of women with HIV in Canada: an under-recognized public health concern
Mona Loutfy,, Carmen Logie, Alexandra de Pokomandy, Pat O’Campo, Nadia O’Brien, Saara Greene, Wangari Tharao, Jay MacGillivray, Lu Wang, Shahab Jabbari, Nikita Arora, V Logan Kennedy, Allison Carter, Karène Proulx-Boucher, Allison Carlson, Sally Lin, Marisol Desbiens, Kath Webster, Danièle Dubuc, Paul Sereda, Guillaume Colley, Robert Hogg, Angela Kaida, On Behalf of the CHIWOS Research TeamWomen’s College Research Institute, Women’s College Hospital, Toronto, ON; Department of Medicine, University of Toronto, Toronto, ON; Dalla Lana School of Public Health, University of Toronto; Faculty of Social Work, University of Toronto, Toronto, ON; Chronic Viral Illness Service, McGill University Health Centre, Montreal, QC; Department of Family Medicine, McGill University, Montreal QC; Centre for Research on Inner City Health, St. Michael’s Hospital, Toronto, ON; Faculty of Social Work, McMaster University of Toronto, Toronto, ON; Women’s Health in Women’s Hands Community Health Centre, Toronto, ON; Department of Obstetrics and Gynecology, St. Michael’s Hospital, Toronto, ON; BC Centre for Excellence in HIV/AIDS, Vancouver, BC; Faculty of Medicine, McMaster University, Hamilton, ON; Faculty of Health Sciences, Simon Fraser University, Vancouver, BC
Presented at the
25th Annual Canadian Conference for HIV/AIDSWinnipeg, Manitoba – May 13th, 2016Slide2
We would like to acknowledge that we gather on the traditional territory of the
Anishinaabeg, Cree, Oji-Cree, Dakota, and Dene peoples, and on the homeland of the Métis Nation. Slide3
Conflicts of Interest DisclosureIn the past 2 years,
I have been paid from: Women’s College Hospital and the University of Toronto and paid by the Ministries of Ontario and Saskatchewan. I have received funds from Gilead Sciences, Merck Canada Inc. and ViiV Healthcare. There are no relationships to disclose related to this work.Slide4
Exposure Category for Women with HIV in Canada 1985-2009Proportion of Positive HIV Test Reports among Adult Women (≥ 15 yrs of age) by Exposure Category, 1985-2009 (N = 5,643) Heterosexual contact includes a) Origin from an HIV-endemic country (11.1%), b) Sexual contact with a person at risk (25.3%), and c) No identified risk (NIR) – Heterosexual (17.5%).
PHAC. 2014. Population Specific HIV/AIDS Status Report: Women, Chapter 3. Retrieved from: http://www.phac-aspc.gc.ca/aids-sida/publication/ps-pd/women-femmes/chapter-chapitre-3-eng.phpSlide5
Defining the problem - Violence
The World Health Organization provides the following framework on gendered violence:What is Violence against Women?"any act of gender-based violence that results in, or is likely to result in, physical, sexual or mental harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or in private life."Intimate partner violence:
“behaviour by an intimate partner or ex-partner that causes physical, sexual or psychological harm, including physical aggression, sexual coercion, psychological abuse and controlling behaviours”Sexual violence:"any sexual act, attempt to obtain a sexual act, or other act directed against a person’s sexuality using coercion, by any person regardless of their relationship to the victim, in any setting. It includes rape, defined as the physically forced or otherwise coerced penetration of the vulva or anus with a penis, other body part or object."Worldwide women experience high rates of violence related to entrenched gender inequities1According to the WHO2:35% of women have experienced either physical and/or sexual intimate partner violence or non-partner sexual violence. Women who had been physically or sexually abused were 1.5 times more likely to have a sexually transmitted infection and, in some regions, HIV, compared to women who had not experienced partner violence3. 1. T.
Türmen. (2003). Gender and HIV/AIDS. International Journal of Gynecology & Obstetrics, 82(3), 411–418.2. WHO. 2015. Retrieved from: http://www.who.int/mediacentre/factsheets/fs239/en/3. Ogden J, Nyblade L. Common at its core: HIV-related stigma across contexts. International Center for Research on Women, 2005 Available at www.icrw.orgSlide6
ObjectivesTo assess the proportion of women in CHIWOS who have reported non-consensual (coercive) sex as the method of HIV acquisition as compared to the other categories
To assess the correlates of women who reported coercive vs. consensual sex as their mode of HIV acquisitionSlide7
Methods: Study Population and Design
CBR longitudinal cohort study:
Baseline visit (PRA-administered electronic survey)
q18 month follow-up visits (Visit 2 & 3 planned)Inclusion criteria:Self-identified woman (trans inclusive)Living with HIV (self-report)> 16 years; Living in BC, ON and QCFor this analysis – answer question on mode of HIV acquisitionSampling & RecruitmentNon-random purposive sampling by health region & harder-to-reachFrom PRAs, ASOs, Clinics, OtherSlide8
Methods: Outcome of Interest
This
analysis includes only the baseline visit (and is therefore, cross-sectional)
Primary outcome: Self-report “non-consensual sex" as mode of HIV acquisitionExact question: How do you think you got HIV? (S2Q3a_2)Additional questions: As an adult, has someone ever sexually forced themselves on you, or forced you to have sex? (S7Q5a); Do you think you became HIV-positive as result of these episodes?(S7Q5d); During your childhood , did someone ever sexually force themselves on you, or forced you to have sex? (S7Q8a); Do you think you became HIV-positive as result of these episodes? (S7Q8d) Hierarchical singular assignment of seven modes of HIV acquisition based on likelihood of mode (if higher risk of transmission – higher in hierarchy)PerinatalBlood transfusionSharing needlesContaminated needlesNon-consensual sexConsensual sexOtherSlide9
Methods: Statistical Analyses
Summary statistics of socio-demographic, psychosocial and clinical characteristics
Medians and IQRs for continuous variables
Frequencies and proportions for categorical variablesFor total population & by province (BC, ON, QC)Chi-square, Fisher’s Exact or Wilcoxon’s rank sum test for comparisons between provincesMultivariable logistic regression was used to identify correlates of women who reported coercive vs. consensual sex as their mode of HIV acquisition using backward stepwise eliminationSlide10
356
713
356
1425 overall participantsBC: 25%ON: 50%QC: 25%1330 participants included BC: 26%ON: 49%QC: 25%N=95 excluded due to “DK/PNTA” response to qualifying question for mode of acquisition (S2Q3a_2) and/or sexual assault (S7Q5a,d; S7Q8a,d)
ResultsSlide11
Results Table 1.
National
Demographic Profile N=1330 Variable
Overall(N=1330)N (%)BC (N=342) N (%)ON (N=657) N (%)
QC
(N=331)
N (%)
P-value
Age at interview
date (Median,
IQR)
42
(35-50)
44
(37-51)
40
(34-49)
46
(38-53)
<0.001
Gender identity
Woman
1269
(95.4)
328
(95.9)
626
(95.3)
315
(95.2)
0.877
Transwoman/Two-Spirited/Queer/Other
61
(4.6)
14
(4.1)
31
(4.7)
16
(4.8)
Sexual orientation
Heterosexual
1155
(86.8)
284
(83.0)
566
(86.1)
305
(92.1)
0.002
LGBTTQ
170
(12.8)
57
(16.7)
87
(13.2)
26
(7.9)
DK/PNTA
5
(0.4)
1
(0.3)
4
(0.6)
Ethnicity
Indigenous
312
(23.5)
156
(45.6)
148
(22.5)
8
(2.4)
<0.001
African/Caribbean/Black
350
(26.3)
27
(7.9)
181
(27.5)
142
(42.9)
Caucasian
572
(43.0)
133
(38.9)
275
(41.9)
164
(49.5)
Other
96
(7.2)
26
(7.6)
53
(8.1)
17
(5.1)
Ever incarceration
Yes
511
(38.4)
215
(62.9)
198
(30.1)
98
(29.6)
<0.001
No
818
(61.5)
127
(37.1)
458
(69.7)
233
(70.4)
DK/PNTA
1
(0.1)
1
(0.2)
Injection drug use ever
Yes
430
(32.3)
219
(64.0)
128
(19.5)
83
(25.1)
<0.001
No
876
(65.9)
122
(35.7)
509
(77.5)
245
(74.0)
DK/PNTA
24
(1.8)
1
(0.3)
20
(3.0)
3
(0.9)
Slide12
Model 1. Multivariate results
RESULTS Table 2.
Model 1:HIV Transmission Risk Categories N=1330
Province interview conducted
Overall
BC
ON
QC
(N=1330)
(N=342)
(N=657)
(N=331)
Variable
N
(%)
N
(%)
N
(%)
N
(%)
P-value
Consensual sex
686
(51.6)
113
(33.0)
416
(63.3)
157
(47.4)
<0.001
Sharing needles
262
(19.7)
127
(37.1)
74
(11.3)
61
(18.4)
Coercive sex
219
(16.5)
61
(17.8)
94
(14.3)
64
(19.3)
Blood transfusion
70
(5.3)
15
(4.4)
30
(4.6)
25
(7.6)
Perinatal exposure
50
(3.8)
6
(1.8)
30
(4.6)
14
(4.2)
Don’t Know/Prefer not to answer
21
(1.6)
5
(1.5)
10
(1.5)
6
(1.8)
Contaminated needles
17
(1.3)
12
(3.5)
2
(0.3)
3
(0.9)
Other
5
(0.4)
3
(0.9)
1
(0.2)
1
(0.3)
Slide13
Variable
HIV transmission risk
Coercive sex vs Consensual sex (REF) Consensual sex
Coercive sex (N=686)(N=219)Multivariable Model N(%)N(%)Odds ratio (95% CI)
P-value
Province interviewed
0.001
BC
113
(16.5)
61
(27.9)
2.495 (1.548, 4.022)
QC
157
(22.9)
64
(29.2)
1.403 (0.931, 2.115)
ON (REF)
416
(60.6)
94
(42.9)
Age at interview (categorical)
0.932
30 to 39
236
(34.4)
78
(35.6)
0.957 (0.463, 1.976)
40 to 49
207
(30.2)
71
(32.4)
0.84 (0.396, 1.78)
50 or more
188
(27.4)
53
(24.2)
0.923 (0.424, 2.01)
16 to 29 (REF)
55
(8.0)
17(7.8) Years living in Canada (categorical) <0.001 DK/PNTA5(0.7) Less than 5 years33(4.8)42(19.2)3.709 (1.517, 9.065) 5 to 10 years70(10.2)48(21.9)1.638 (0.7, 3.83) More than 10 years125(18.2)27(12.3)0.569 (0.265, 1.222) Born in Canada (REF)453(66.0)102(46.6) Ethnicity 0.019 Other57(8.3)16(7.3)1.971 (0.917, 4.239) Indigenous150(21.9)37(16.9)0.779 (0.445, 1.366) African/Caribbean/Black171(24.9)106(48.4)3.266 (1.479, 7.216) Caucasian (REF)308(44.9)60(27.4) Education 0.372 DK/PNTA3(0.4)1(0.5) Lower than high school74(10.8)35(16.0)1.261 (0.758, 2.096) High school or higher (REF)609(88.8)183(83.6) Experiences of foster care <0.001 DK/PNTA3(0.4) Yes78(11.4)49(22.4)2.971 (1.792, 4.927) No (REF)605(88.2)170(77.6) Ever incarceration 0.736 DK/PNTA 1(0.5) Yes181(26.4)64(29.2)1.093 (0.65, 1.839) No (REF)505(73.6)154(70.3) Injection drug use ever 0.339 DK/PNTA21(3.1)1(0.5) Yes99(14.4)47(21.5)1.333 (0.74, 2.401) No (REF)566(82.5)171(78.1) Years living with HIV 0.147 DK/PNTA11(1.6)5(2.3) 6 to 14 years268(39.1)101(46.1)1.548 (0.983, 2.439) More than 14 years209(30.5)56(25.6)1.552 (0.904, 2.665) Less than 6 years (REF)198(28.9)57(26.0)
RESULTS Table 3.Model 1: Sociodemographic Characteristics of Women Acquiring HIV through Coercive vs. Consensual Sex in the CHIWOS Cohort N=905
Being from BC: aOR 2.5 (1.5, 4.0) p=0.001
Living in Canada <5 years: aOR=3.7 (1.5-9.1) p<0.001
ACB EthnicityaOR=3.3 (1.5-7.2) p=0.019
Lived in Foster
C
are
aOR
=3.0 (1.8-4.9)
p<0.001Slide14
Variable
HIV transmission risk
Coercive sex vs Consensual sex (REF)Consensual sex
Coercive sex (N=453)(N=102)Multivariate Model N(%)N(%)Odds ratio (95% CI)
P-value
Ethnicity
0.443
African/Caribbean/Black
7
(1.5)
1
(1.0)
0.553 (0.055, 5.596)
Other
18
(4.0)
8
(7.8)
2.039 (0.76, 5.47)
Indigenous
149
(32.9)
37
(36.3)
0.894 (0.511, 1.566)
Caucasian (REF)
279
(61.6)
56
(54.9)
Source of income 12 - Parent/friend/relative/partner income
0.125
DK/PNTA
2
(0.4)
Yes
23
(5.1)
15
(14.7)
1.859 (0.842, 4.104) No (REF)428(94.5)87(85.3) City size 0.047 Medium60(13.2)21(20.6)0.563 (0.226, 1.399) Large360(79.5)67(65.7)0.397 (0.185, 0.852) Small (REF)33(7.3)14(13.7) Number of Children (categorical) 0.109 Not biological women27(6.0)4(3.9) 1102(22.5)19(18.6)0.992 (0.482, 2.041) 273(16.1)21(20.6)1.334 (0.655, 2.72) 3 or more70(15.5)33(32.4)2.11 (1.073, 4.149) 0 (REF)181(40.0)25(24.5) Early life experiences-Foster care 0.003 DK/PNTA2(0.4) Yes71(15.7)42(41.2)2.359 (1.343, 4.146) No (REF)380(83.9)60(58.8) Injection drug use current (last 3 months) 0.028 DK/PNTA20(4.4)1(1.0) Currently IDU18(4.0)16(15.7)3.062 (1.305, 7.185) Not currently IDU but previously IDU73(16.1)25(24.5)1.019 (0.541, 1.923) Never IDU (REF)342(75.5)60(58.8) Mental health condition ever 0.005 DK/PNTA4(0.9)1(1.0) Yes174(38.4)64(62.7)2.054 (1.244, 3.392) No (REF)275(60.7)37(36.3) RESULTS Table 4.Model 2: Sociodemographic Characteristics of Women Born in Canada Acquiring HIV through Coercive vs. Consensual Sex in the CHIWOS Cohort N=555Foster CareaOR 2.36 (1.34, 4.15) p=0.003IDU aOR 3.06 (1.31, 7.19) p=0.028Large vs. Small CityaOR 0.40 (0.19, 0.85) p=0.047Mental Health aOR 2.05 (1.24, 3.40) p=0.005Slide15
Variable
HIV transmission risk
Coercive sex vs Consensual sex (REF)
Consensual sexCoercive sex (N=232)(N=117)Multivariate Model
N
(%)
N
(%)
Odds ratio (95% CI)
P-value
Years living in Canada (categorical)
<0.001
DK/PNTA
4
(1.7)
Less than 5 years
33
(14.2)
42
(35.9)
5.174 (2.549, 10.504)
5 to 10 years
70
(30.2)
48
(41.0)
2.37 (1.243, 4.519)
More than 10
years (REF)
125
(53.9)
27
(23.1)
Ethnicity
0.444
Indigenous
1
(0.4)
Other39(16.8)8(6.8)1.195 (0.306, 4.672) African/Caribbean/Black164(70.7)105(89.7)1.842 (0.569, 5.963) Caucasian (REF)28(12.1)4(3.4) Personal gross yearly income 0.164 DK/PNTA4(1.7) < $20000145(62.5)90(76.9)1.889 (0.737, 4.842) $20000-$3999952(22.4)20(17.1)1.111 (0.381, 3.242) >=$40000 (REF)31(13.4)7(6.0) Mental health conditions 10- [Post Traumatic Stress Disorder] 0.001 DK/PNTA3(1.3)3(2.6) Yes6(2.6)14(12.0)6.747 (2.246, 20.265) No (REF)223(96.1)100(85.5) African countries that experienced histories/ongoing war/conflict and noted high rates of GBV in conflict 0.026 Unknown1(0)1(1) South Sudan/DRC/Rwanda/Nigeria24(10)30(26)2.127 (1.094, 4.137) Others (REF)207(89)86(74) RESULTS Table 5.
Model 3: Sociodemographic Characteristics of Women Born Outside Canada Acquiring HIV through Coercive vs. Consensual Sex in the CHIWOS Cohort N=349<5 years living in CanadaaOR 5.17 ( 2.55, 10.50) p<0.001
PTSD aOR 6.75 (2.25, 20.26) p=0.001
High Prevalence GBV country aOR 2.13 (1.09,4.14) p=0.026Slide16
Limitations
The use of self-report leads to the lack of confirmation that coercive sex act was definite cause of HIV The cohort is a non-random – potential sampling biasWomen who experienced violence likely less likely to enrol; so the rate of 16.5% is likely an under-representationMissing data—related to use of questionnaires in generalSlide17
Conclusion & Discussion
Coercive sex is a significant yet under-considered risk factor and mode of HIV acquisition (3rd highest) among women with HIV. Analysis of place of birth highlights the importance of targeted HIV testing and treatment for womenBorn in Canada: precarious housing/shelters, safe injection sites, etc.Born outside of Canada: newcomer welcome centres, shelters, refugee health clinics
Considering the global burden of intimate partner violence (1 out of 3 women) and the risk of HIV transmission through coercive sex in our sample (16.5%), interventions to prevent IPV need to be drastically scaled up as an HIV prevention measure16.5% of women in CHIWOS self-report coercive ex as their mode of HIV acquisitionAsk Public Health to separate the reporting of heterosexual sex – 1. consensual vs. 2. non-consensual/coercive Higher awareness of violence in our patient populationSouthern Alberta Clinic (SAC) IPV screening program135% of 1,721 participants had experienced partner violence in a past relationship, as a child or was currently experiencing IPVPrior to this study only 1 in 5 had ever been screened for IPV1. Raissi SE, Krentz HB, Siemieniuk
RA, et al. Implementing an intimate partner violence (IPV) screening protocol in HIV care. AIDS Patient Care and STDs. 2015 Mar;29(3):133-41.Slide18
Acknowledgments
We would like to thank everyone involved for their invaluable contributions to the study. Thank you to…All the women living with HIV involved in this study;The PIs, Coordinators, Peer Research Associates, and all the co-investigators and collaborators;The Steering Committee, Community Advisory Board members, and CAAB-PAW members;
Our funders: CIHR Institute of Gender and Health, the CTN, and OHTN; Our affiliated studies: CANOC, REACH & OSC; and all of our partners for supporting the study. In MemoriamSlide19
How to get in touch:
For more information about CHIWOS,
please contact:
Allison Carlson (ON Coordinator): 416-351-3800 x 2323, allison.carlson@wchospital.caSally Lin (BC): 604-558-6686, slin@cfenet.ubc.caKarène Proulx Boucher (QC): 514-934-1934 x 32146, chiwos.quebec@gmail.comfacebook.com/CHIWOSwww.chiwos.catwitter.com/CHIWOSresearch