Understanding access to HIV-related and gender-affirming healthcare for trans women with HIV in Canada: A mixed methods study

Background: Trans women living with HIV (WLWH) have lower access to HIV care compared to cisgender (cis) people living with HIV. US-based research describes barriers (e.g., trans stigma) and facilitators (e.g., integration of gender-affirming and HIV care) to HIV care engagement among trans WLWH. Scant research has explored factors associated with HIV or gender-affirming care access among trans WLWH in Canada. This three-paper dissertation aims to expand an intersectional and social ecological understanding of the experiences of trans WLWH in Canada accessing HIV, gender-affirming, and other types of healthcare. Methods: A transformative, convergent parallel, mixed methods design was used whereby quantitative and qualitative data were rigorously collected and analyzed, then purposefully merged. Quantitative data was drawn from baseline cross-sectional survey data collected 2013-2015 from the Canadian HIV Women’s Sexual and Reproductive Health Cohort Study (CHIWOS) (n=54 trans WLWH/n=1422 participants) and analyzed using descriptive statistics and bivariate analyses. In-depth semi-structured individual interviews (25-100 minutes) were conducted with a purposive sub-set of trans WLWH (n=11) 2017-2018 who completed the baseline CHIWOS survey, analyzed using framework analysis. Qualitative and quantitative results were merged by comparing data and considering how results converged, diverged, or expanded understanding. Inequities were highlighted and recommendations made, consistent with a transformative design. Results: Three empirically-based chapters report on: (1) the HIV care cascade and factors associated with HIV care cascade outcomes (ever accessed HIV care, received any HIV care in the past year, currently use antiretroviral treatment (ART), ART adherence, and virological suppression); (2) transition and gender-affirming healthcare experiences of trans WLWH; and (3) resilience and empowerment exhibited by trans WLWH as they navigate intersecting stigmas in healthcare settings. Conclusions: Findings suggest a need for multi-level interventions to address barriers to accessing care. Intersecting stigmas were a pervasive barrier to accessing multiple types of healthcare. Trans WLWH resist and reduce stigma in healthcare settings; however, widespread stigma-reduction training for providers, administrators, and students is recommended. These findings inform a trajectory of social work research, theory development, and practice at policy, organizational, and individual levels, all of which may further contribute to health equity for trans WLWH in Canada.Ph.D.2020-11-19 00:00:0