Poverty, Stigma, and Health Outcomes Among African, Caribbean and Black Women Living with HIV in Ontario, Canada

Purpose: Poverty is a powerful structural driver of HIV infection. Once diagnosed, women living with HIV (WLWH) are more likely to experience poverty due to the convergence of illness, healthcare costs, stigma and discrimination. For WLWH, poverty may contribute to deleterious health outcomes, including disease progression. Structural drivers of HIV, such as poverty, HIV-related stigma, racism and sexism, are strongly implicated in African, Caribbean and Black women's overrepresentation in HIV infections in Ontario. Few studies have explored how poverty continues to impact the lives of African, Caribbean and Black WLWH. The study objective was to explore associations between poverty and: social (social support), stigma (racism, sexism, HIV-related stigma) and health (quality of life, continuity of care) factors among African, Caribbean and Black WLWH in Ontario, Canada. We hypothesized that a) poverty would be associated with higher stigma, and lower social/health outcomes, and b) poverty would be associated with increased stigma, which would contribute to lower social/health outcomes.

Methods: We conducted a community-based multi-method study to explore the multifold impacts of poverty on the lives of African, Caribbean and Black WLWH. Building on qualitative findings from 15 focus groups with WLWH (n=104) in Ontario, we implemented a cross-sectional survey in 3 Ontario cities with adults over 18 years old who identified as HIV-positive African, Caribbean and Black women. We used modified peer-driven recruitment and venue based sampling. We conducted multivariate regression analyses to assess social, stigma and health correlates of perceived poverty. We used Preacher and Hayes bootstrapping method to conduct mediation analyses to assess if stigma (racism, sexism, HIV-related stigma) variables would mediate the associations between poverty and health (quality of life [QOL], continuity of care) or social (social support) outcomes.

Results: Participants' (n=176) mean age was 40.7 years (SD 8.8) and median monthly income was $1400.00 (range 0-7917). Over half (52%) of participants reported perceiving themselves as poor. Controlling for socio-demographic characteristics, perceived poverty was associated with higher reported mean stigma frequencies, including HIV-related stigma (R²=0.18, p<0.001), racism (R²=0.16, p<0.001), and sexism (R²=0.10, p<0.001). Perceived poverty was correlated with lower mean frequencies of health and social outcomes, including QOL (R²=0.14, p<0.001), continuity of care (R²=0.05, p<0.01), and social support (R²=0.14, p<0.001). The direct effects of poverty on QOL remained significant after controlling for stigma (HIV-related stigma, racism, sexism), suggesting that stigma did not fully mediate the effects of poverty on QOL. HIV-related stigma mediated the effects of poverty on social support and continuity of care.

Conclusions and Implications: This research highlights the salience of an intersectional approach to explore the convergence of multiple axes (e.g. poverty, racism, HIV-related stigma, sexism) of social exclusion. Perceived poverty was associated with higher stigma and reduced QOL; the effects of poverty on social support and continuity of care were mediated through HIV-related stigma. Understanding the complex social, structural and health correlates of poverty among African, Caribbean and Black WLWH can inform multi-level interventions to challenge poverty, enhance health care access and treatment, build multi-dimensional networks and sources of social support, and reduce intersecting stigmas.