Structural violence and trajectories of stigma and discrimination among women living with HIV in Vancouver, Canada

BACKGROUND: Women living with HIV and AIDS (WLWH) experience stigma and discrimination rooted in interlocking social-structural processes of oppression. 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 WLWH.
METHODS: We conducted a community-based open longitudinal cohort 'Sexual Health and HIV/AIDS: Longitudinal Women's Needs Assessment' (SHAWNA) with WLWH living in and/or accessing HIV care in Metro Vancouver, Canada. Using data from 2015-2019, semiannual averages in recent (past 6-month):
a) HIV-related stigma and
b) everyday discrimination were plotted.
Latent Class Growth Analysis (LCGA) was then used to identify distinct trajectories of HIV-related stigma and 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 (trans women: 8.1%; Indigenous women: 62.4%; White women: 31.5%; African, Caribbean and/or Black women: 2.5%; other racialized women: 3.6%) with 985 observations over 4 years of follow-up. Semiannual time trend plots showed little variation over time for stigma/discrimination. LCGA identified three distinct trajectories of HIV-related stigma and discrimination: sustained low, medium and high. In multivariable analysis, recent (past 6-month) concurrent food and housing insecurity (CFHS) and physical/sexual violence were associated with higher odds of being in the sustained medium (CFHS: AOR=1.99, 95%CI=1.03-3.83; violence: AOR=1.96, 95%CI=0.88-4.39) and high (CFHS: 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 trajectory). Identifying as a sexual minority (AOR=2.18, 95%CI=1.10-4.31) and recent CFHS (AOR=2.15, 95%CI=1.05-4.40) were associated with higher odds of being in the sustained medium 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 CFHS (AOR=2.24, 95%CI=0.95-5.28) were associated with the sustained high discrimination trajectory.
CONCLUSIONS: Findings signal the role of social inequities (e.g., food/housing insecurity, violence) in sustaining, and the chronicity of, stigma and discrimination toward WLWH. Multi-level strategies are required to address the structural violence embedded in socio-economic systems that elevate poverty and violence exposure and exacerbate stigma/discrimination in order to optimize health and rights among WLWH.

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