Structural Violence and Trajectories of Stigma and Discrimination Among Women Living with HIV in Vancouver, Canada

Background: Women living with HIV experience stigma and discrimination rooted in interlocking social and structural processes of oppression. Food and housing insecurity, resource insecurities associated with poorer health outcomes, disproportionately impact women living with HIV. Poverty, itself a deeply stigmatized phenomenon, contributes toward food and housing insecurity. HIV stigma intersects with structural inequities and other forms of discrimination. Yet knowledge gaps remain regarding how and why HIV-related stigma and other forms of discrimination shift over time. We examined associations between social-structural factors (food/housing insecurity, violence, sexual minority identity) and HIV-related stigma and discrimination trajectories among women living with HIV in Vancouver, Canada.

Methods: We conducted a community-based open longitudinal cohort study with women living with HIV living in and/or accessing HIV care in Metro Vancouver, Canada. Using data from 2015-2019, semi-annual averages in recent (past 6-month) a) HIV-related stigma (including perceived, anticipated, enacted, and internalized stigma dimensions) and b) everyday discrimination (including chronic, routine mistreatment in day-to-day life) were plotted. Latent Class Growth Analysis (LCGA) was then used to identify distinct trajectories of HIV-related stigma and everyday discrimination, and baseline correlates of each trajectory were examined using multinomial logistic regression. Adjusted odds ratios (AORs) and 95% confidence intervals (95% CIs) are reported.

Results: The sample included 197 participants (transgender women: 8.1%; Indigenous women: 62.4%; White women: 31.5%; African, Caribbean and/or Black women: 3.6%; other racialized women: 3.6%) with 985 observations over 4 years of follow-up. Semi-annual time trend plots showed little variation over time for stigma and discrimination. LCGA identified three distinct trajectories of HIV-related stigma and everyday discrimination: sustained low, medium, and high. In multivariable analysis, recent (past 6-month) concurrent food and housing insecurity and physical/sexual violence were associated with higher odds of being in the sustained medium (concurrent food and housing insecurity: AOR=1.99, 95% CI=1.03-3.83; violence: AOR=1.96, 95% CI=0.88-4.39) and high (concurrent food and housing insecurity: AOR=6.93, 95% CI=2.00-24.04; violence: AOR=2.61, 95% CI=0.76-8.98) HIV-related stigma trajectories (vs. sustained low HIV-related stigma trajectory). Identifying as a sexual minority (AOR=2.18, 95% CI=1.10-4.31) and recent concurrent food and housing insecurity (AOR=2.15, 95%CI=1.05-4.40) were associated with higher odds of being in the sustained medium everyday discrimination trajectory. Recent physical/sexual violence (AOR=2.90, 95% CI=1.07-7.85), sexual minority identity (AOR=2.43, 95% CI=1.06-5.55), and recent concurrent food and housing insecurity (AOR=2.24, 95% CI=0.95-5.28) were associated with the sustained high everyday discrimination trajectory.

Discussion: Findings signal the role of social inequities (food and housing insecurity, violence, sexual minority identity) in sustaining, and the chronicity of, stigma and discrimination among women living with HIV. There is an urgent need to tackle resource insecurity and violence to get to the heart of stigma and discrimination. Multi-level approaches are required: at structural levels, policy changes can reduce poverty drivers among women living with HIV; at institutional levels, social workers and healthcare providers can employ stigma-free, trauma and violence aware care that addresses the social determinants of health; and at community levels, intersectional stigma reduction and violence prevention strategies are needed to optimise health and rights of women living with HIV.