HIV IN ACB COMMUNITIES
ACB people are one of the groups most impacted by HIV in Ontario.
The primary mode of HIV transmission among ACB people living in Ontario, according to epidemiological categories of exposure, is through heterosexual sexual contact.1 Government of Canada PHA of C. Chapter 13: HIV/AIDS in Canada among people from countries where HIV is endemic – HIV/AIDS Epi Updates – April 2012 – Public Health Agency of Canada [Internet]. 2014 [cited 2017 Jan 3]. Available from: http://www.phac-aspc.gc.ca/aids-sida/publication/epi/2010/chap13-eng.php Heterosexual people from countries where HIV is endemic are disproportionately affected by HIV/AIDS in Canada. In simple terms, a country that is endemic for a virus has continuous transmission of that virus among its population at a relatively high rate. The majority of countries where HIV is endemic are found in Africa, followed by the Caribbean and Central and South America.
In Ontario, HIV/AIDS has a significant impact on women from countries where HIV is endemic. Women from ACB communities remain overrepresented in the province’s HIV epidemic, with new infection rates much higher than those of their white counterparts.
GBMSM from ACB communities are another subgroup that is particularly vulnerable to HIV because of combined social, cultural, behavioural and biological factors. Unfortunately, it is difficult to estimate the number of ACB community members living with HIV who are GBMSM. One study of 165 Black GBMSM in Toronto found a self-reported HIV seroprevalence of 24%.2 George C, Makoroka L, Rourke SB, Adam BD, Remis RS, Husbands W, et al. HIV Testing by Black MSM in Toronto: Identifying Targets to Improve Testing. SAGE Open. 2014 Jun 11;4(2):2158244014529776. The actual number of ACB diagnoses is probably underestimated because of the extent of missing data on priority populations.
Please refer to the Ontario HIV Epidemiology and Surveillance Initiative for the current data: http://www.ohesi.ca/
Definition
Risks: refer to biological, behavioural and relational factors that affect the probability that one may acquire HIV. It is important to note that not all ACB people are at high risk of HIV, because not all ACB people are exposed to the risks and vulnerabilities outlined here.
The primary mode of HIV transmission among ACB people living in Canada, according to epidemiological categories of exposure, is through heterosexual sexual contact.3 Government of Canada PHA of C. Chapter 13: HIV/AIDS in Canada among people from countries where HIV is endemic – HIV/AIDS Epi Updates – April 2012 – Public Health Agency of Canada [Internet]. 2014 [cited 2017 Jan 3]. Available from: http://www.phac-aspc.gc.ca/aids-sida/publication/epi/2010/chap13-eng.php Despite this, some ACB community members hold misconceptions about who is at risk for HIV. One common misconception is that only gay men (particularly white gay men), sex trade workers and persons who inject drugs are at risk of acquiring HIV. In one Toronto-based study, ACB community members described a double barrier to discussing HIV: there is an assumption that HIV is only transmitted through homosexual sex, while the existence of homosexuality within the community is simultaneously denied.4 ACCHO. HIV/AIDS, Stigma, Denial, Fear and Discrimination: Experiences and Responses of People from African, Caribbean and Black Communities in Toronto [Internet]. 2006. Available from: https://accho.ca/hiv_stigma_report/ The lack of visibility of HIV in both the provincial and national contexts perpetuates the view that HIV is not a significant concern here. Many members of ACB communities perceive the risk of exposure to HIV in Ontario, and Canada overall, as negligible to highly unlikely.5 ACCHO. HIV/AIDS, Stigma, Denial, Fear and Discrimination: Experiences and Responses of People from African, Caribbean and Black Communities in Toronto [Internet]. 2006. Available from: https://accho.ca/hiv_stigma_report/6 Logie C. Associations between HIV-related stigma, racial discrimination, gender discrimination, and depression among HIV-positive African, Caribbean, and Black women in Ontario, Canada. AIDS Patient Care STDs. 2013;27(2):114–22. HIV is often seen as something that happens to others, particularly those who are ‘immoral’, have many sex partners or are engaged in sex work. Against this backdrop, complacency and resistance to HIV prevention campaigns and interventions can easily set in.
People from ACB communities generally focus on sexual risk behaviours related to HIV infection and largely ignore non-sexual modes of exposure or transmission. They will recognize relationship factors, such as being in a non-monogamous sexual relationship, not knowing a partner’s sexual history, and general lack of education about safer sex and HIV prevention as risks for HIV infection.7 Baidoobonso S, Bauer GR, Speechley KN, Lawson E. HIV risk perception and distribution of HIV risk among African, Caribbean and other Black people in a Canadian city: mixed methods results from the BLACCH study. BMC Public Health. 2013;13(1):1. There is generally less awareness on the risks associated with sharing injection drug equipment.
It is important for service providers to understand that some ACB people who immigrated to Canada have belief systems about health that are based on their prior experiences in their countries of origin. These beliefs, which are maintained by their cultural community and often remain intact for generations, are often quite different from Canadian/Western attitudes to healthcare. This can affect how some ACB people perceive HIV and whether they see it as a treatable chronic illness. There may be a tendency on the part of service providers to see the low rate of HIV testing within ACB communities as resistance or to characterize communities as hard-to-serve populations; however, choices about healthcare and HIV prevention may be driven by different perceptions of health and well-being and the social determinants of health.8 Kuile S, Rousseau C, Munoz M, Nadeau L, Ouimet M. The Universality of the Canadian Health Care System in Question: Barriers to Services for Immigrants and Refugees. Int J Migr Health Soc Care. 2007 Jul 1;3(1):15–26.9 Othieno J. Understanding how contextual realities affect African born immigrants and refugees living with HIV in accessing care in the Twin Cities. J Health Care Poor Underserved. 2007 Aug;18(3 Suppl):170–88.
The past experiences of ACB community members with the healthcare system —in Ontario or elsewhere in Canada, in their country of origin, and in other countries (e.g., lack of access, social exclusion) — may also affect whether they perceive service providers and/or their services as trustworthy. It may be difficult for some ACB people to accept sexual health education for children/youth, to challenge their views about the role(s) of women and men, to discuss HIV prevention in common-law or marital relationships (i.e., using condoms and testing in long-term relationships), and to acknowledge the dangers of racism, heterosexism and homophobia.10 ICAD, ACCHO, WHIWH. Towards the Improvement of HIV Prevention Services for African, Caribbean and Black Communities in Canada: A Gap Analysis [Internet]. Ottawa; 2011. Available from: https://accho.ca/gap_analysis_eng_final/11 Kuile S, Rousseau C, Munoz M, Nadeau L, Ouimet M. The Universality of the Canadian Health Care System in Question: Barriers to Services for Immigrants and Refugees. Int J Migr Health Soc Care. 2007 Jul 1;3(1):15–26.12 Othieno J. Understanding how contextual realities affect African born immigrants and refugees living with HIV in accessing care in the Twin Cities. J Health Care Poor Underserved. 2007 Aug;18(3 Suppl):170–88.
RELIGION AND SPIRITUALITY
Religion and spirituality play an important role in the lives of many ACB people. Some religious adherents overtly or covertly believe that they cannot acquire and/or transmit HIV infection simply because they are ‘saved’, believers, protected by a deity/divine power, born again or have converted/recommitted to a religion or spiritual path. Scientific evidence and the millions of people living with HIV infection worldwide who are religious adherents demonstrate that those beliefs on their own do not prevent HIV acquisition and transmission.13 Othieno J. Understanding how contextual realities affect African born immigrants and refugees living with HIV in accessing care in the Twin Cities. J Health Care Poor Underserved. 2007 Aug;18(3 Suppl):170–88.14 Collins P, von Unger H, Armbrister A. Church ladies, good girls, and locas: stigma and the intersection of gender, ethnicity, mental illness, and sexuality in relation to HIV risk. Soc Sci Med. 67(3):389–97.
A study of young Africans in Windsor explored the link between religiosity and sexual behaviour. Young people with strong religious convictions indicated that sexual networking between members of the same faith influenced the sexual activities they engaged in. Patterns of sexual behaviour were the outcome of conceptualizations of sex as sinful and the belief that premarital sex and condom use contravened religious beliefs and laws. Although religious youth perceived premarital sex as sinful, young women perceived that anal sex allowed them to preserve their virginity and family honour.15 Omorodion F, Gbadebo K, Ishak P. HIV vulnerability and sexual risk among African youth in Windsor, Canada. Cult Health Sex. 2007 Aug;9(4):429–37. It has also been found that ACB young women who attended religious services or activities on a monthly basis were 2.78 times less likely to report condom use at last vaginal intercourse than those who attended either less or more frequently.16 Maticka-Tyndale E, Kerr J, Mihan R, Mungwete R, Team AS. Condom Use at Most Recent Intercourse Among African, Caribbean, and Black Youth in Windsor, Ontario. Int J Sex Health. 2016 Jul 2;28(3):228–42. Religious leaders were described as preferring a message of abstinence until marriage over support for condom use. The authors hypothesized that a moderate amount of religious attendance provided the socialization and support for risk avoidance while very frequent attendance exposed and immersed youth in the more negative condom messaging.17 Maticka-Tyndale E, Kerr J, Mihan R, Mungwete R, Team AS. Condom Use at Most Recent Intercourse Among African, Caribbean, and Black Youth in Windsor, Ontario. Int J Sex Health. 2016 Jul 2;28(3):228–42.
Religious and spiritual beliefs also affect many people’s responses to HIV/AIDS. For example, HIV is perceived by some as a punishment, dividing the world into those who deserve assistance and those who do not. These attitudes and beliefs can directly affect a service provider’s ability to talk to individuals and communities about HIV prevention methods (e.g., condom use, negotiating safer sex). Religion-based condemnation of homosexuality and pressure to follow cultural expectations about having a heterosexual marriage and raising a traditional family may make African GBMSM less comfortable with discussing their sexuality. One study found that childhood exposure to religions that discourage homosexuality is associated with adult HIV risk behaviours and HIV infection in Black men who have sex with men18 Nelson LE, Wilton L, Zhang N, Regan R, Thach CT, Dyer TV, et al. Childhood Exposure to Religions With High Prevalence of Members Who Discourage Homosexuality Is Associated With Adult HIV Risk Behaviors and HIV Infection in Black Men Who Have Sex With Men. Am J Mens Health. 2017 Sep 1;11(5):1309–21. However, it should be noted that three-quarters of the men participating in the MaBwana study did not identify with organized religion. It is also less clear to what extent findings regarding Christians would be applicable to GBMSM of other religions.19 George C, Adam BD, Read SE, Husbands WC, Remis RS, Makoroka L, et al. The MaBwana Black men’s study: community and belonging in the lives of African, Caribbean and other Black gay men in Toronto. Cult Health Sex. 2012 May 1;14(5):549–62.
TRADITIONAL MALE CIRCUMCISION
While male circumcision is now recognized as a means of reducing the risk of HIV transmission for men, it is a common traditional practice in many African cultures. The recent focus on male circumcision as a medical intervention to reduce the transmission of HIV could give a boost to traditional practices and practitioners. They may feel that there is now wider recognition of the value of this practice that they have been carrying out for centuries and that the men who have already been circumcised by them are protected against acquiring HIV. However, male circumcision as a rite of passage into manhood was not designed for the purpose of HIV prevention, and there are certain aspects of the practice that could undermine its potential benefits for HIV prevention or even put people at increased risk of contracting HIV.20 World Health Organization. Traditional Male Circumcision Among Young People [Internet]. Available from: http://apps.who.int/iris/bitstream/10665/44247/1/9789241598910_eng.pdf
In traditional settings, one instrument may be used to circumcise many young men, which means the risk of HIV can be high because of blood-to-blood contact. Men who have been circumcised within this context should be advised to have an HIV test if they cannot be certain that a new, sterilized knife was used. Published studies on traditional male circumcision in eastern and southern Africa are limited; thus, it is not possible to accurately assess the prevalence of complications following the procedure or the contribution of different traditional practices to subsequent adverse events.21 Wilcken A. Traditional male circumcision in eastern and southern Africa: a systematic review of prevalence and complications. Bull World Health Organ. 88(12):907–14.
FEMALE GENITAL MUTILATION
Female genital mutilation (FGM) refers to the partial or complete removal of the female external genitalia for reasons other than medical therapeutic purposes. It is practiced by followers of some religions and adherents to certain traditional practices. A traditional practitioner usually performs FGM with an instrument and without anesthetic. The risk for HIV transmission is particularly high if multiple female genital mutilations are done with the same instrument without sterilization between procedures. Among the more affluent, FGM may be performed in a healthcare facility by qualified health personnel. The age at which female genital mutilation is performed varies from area to area. It is performed on females ranging from infants who are a few days old to adolescents and mature women. The World Health Organization is opposed to all types of female genital mutilation, whether medicalized or traditional.22 Perron, Liette, Senikas, Vyta, Burnett, Margaret, Davis, Victoria. Clinical Practice Guidelines: Female Genital Cutting. J Obstet Gynaecol Can [Internet]. Available from: https://sogc.org/wp-content/uploads/2013/10/gui299CPG1311E.pdf
Many African women, now living in Ontario, have undergone the FGM procedure. Those who have undergone FGM, particularly type III (infibulations), are at increased risk of HIV infection. The procedure (in which the entire clitoris, labia minora and labia majora are removed and the two sides are sewn together leaving only a small opening for urination) often results in physical trauma to the vaginal lining during sexual intercourse (e.g., abrasions, tearing, bleeding), which increases the risk of the woman acquiring HIV and other STIs.23 Retzlaff C. Female genital mutilation: not just over there. J Int Assoc Physicians AIDS Care. 1999;5(5):28–37.
VAGINAL CLEANSING/DOUCHING
Vaginal cleansing is also a common practice among African women. It is used to dry out vaginal secretions for “dry sex” or to tighten the vaginal lining to increase friction and male pleasure during intercourse. A number of African men indicate that they would not have sex with a woman who has not dried out her vagina.24 Braunstein S, van de Wijgert J. Cultural Norms and Behavior Regarding Vaginal Lubrication During Sex: Impli- cations for the Acceptability of Vaginal Microbicides for the Prevention of HIV/STIs. The Population Council; 2003.25 Nicola L. Intravaginal Practices, Bacterial Vaginosis, and HIV Infection in Women: Individual Participant Data Meta-analysis. PLoS Med. 8(2):e1000416.
Douching is a method believed to maintain personal vaginal hygiene and is a common practice among many ACB women. It is also common among young women who use douching to conceal sexual activities. Products used for vaginal cleansing include herbs, soap and other over-the-counter douching products. These products may cause vaginal dryness, irritation or ulceration and may remove the natural bacteria that maintain the pH balance of the vaginal lining, thereby allowing harmful bacteria to flourish. All of these factors may increase the risk of HIV infection and need to be part of any risk assessment.26 Braunstein S, van de Wijgert J. Cultural Norms and Behavior Regarding Vaginal Lubrication During Sex: Impli- cations for the Acceptability of Vaginal Microbicides for the Prevention of HIV/STIs. The Population Council; 2003.27 Nicola L. Intravaginal Practices, Bacterial Vaginosis, and HIV Infection in Women: Individual Participant Data Meta-analysis. PLoS Med. 8(2):e1000416.
Social and sexual networks may influence HIV risk. The prevalence of HIV in a sexual network, and how a person is positioned within that network, are important factors along with the individual’s sexual behaviours. Sexual networks in which there is high risk for HIV transmission have characteristics such as high connectivity between individuals (i.e., individuals within the network have sex with one another), concurrency of sex partners (i.e., sex with one partner happens between two acts of sex with another partner) and geographical insularity (i.e., proximity based on geography).28 Tieu H-V, Liu T-Y, Hussen S, Connor M, Wang L, Buchbinder S, et al. Sexual Networks and HIV Risk among Black Men Who Have Sex with Men in 6 U.S. Cities. PLOS ONE. 2015 Aug 4;10(8):e0134085.
GBMSM NETWORKS
The way that ACB GBMSM are sexually networked may increase their risk of HIV acquisition. Black GBMSM sexual networks are relatively small and often overlap with their social networks. Furthermore, some studies have shown that Black GBMSM are more likely to have older sex partners which is associated with HIV risk and unrecognized HIV infection.29 Tieu H-V, Liu T-Y, Hussen S, Connor M, Wang L, Buchbinder S, et al. Sexual Networks and HIV Risk among Black Men Who Have Sex with Men in 6 U.S. Cities. PLOS ONE. 2015 Aug 4;10(8):e0134085.
The MaBwana study found that community is an important concept for Black GBMSM, but its definition varies. The social networks of Black GBMSM extend to both Black and gay communities, and beyond. GBMSM often struggle with the denial and suppression of gay identities in their ethno-racial and national communities of origin. They may find themselves estranged from two primary communities simultaneously when their sexual orientation is rejected in Black communities and they face racial discrimination and exclusion from gay communities. Experiences of discrimination can help to explain why some ACB GBMSM appear to distance themselves from their ethno-racial background and identity. The MaBwana study found that Black GBMSM, especially recent immigrants, were more likely to frequent white gay spaces because these locations allowed them to expand their sexual and dating network, provided anonymity (social and cultural distance) and provided more choice of sexual partners because the white gay population was larger than their own population.30 George C, Adam BD, Read SE, Husbands WC, Remis RS, Makoroka L, et al. The MaBwana Black men’s study: community and belonging in the lives of African, Caribbean and other Black gay men in Toronto. Cult Health Sex. 2012 May 1;14(5):549–62.
Among Black GBMSM in the United States, HIV risk is higher when one has a partner who is older or younger than oneself because the relationship bridges younger and older networks with different HIV prevalence. Some studies have shown that Black GBMSM are more likely to have older sex partners and that having older partners was associated with HIV risk and unrecognized HIV infection among Black GBMSM.31 Tieu H-V, Liu T-Y, Hussen S, Connor M, Wang L, Buchbinder S, et al. Sexual Networks and HIV Risk among Black Men Who Have Sex with Men in 6 U.S. Cities. PLOS ONE. 2015 Aug 4;10(8):e0134085.
The MaBwana study found that community is an important concept for Black GBMSM, but its definition varies. The social networks of Black GBMSM extend to both the Black and gay communities, and beyond. Although the concept of Black community is easily defined in terms of country of origin and religion, the concept of gay community is less well defined and varies according to the levels of life experience of individuals.32 George C, Adam BD, Read SE, Husbands WC, Remis RS, Makoroka L, et al. The MaBwana Black men’s study: community and belonging in the lives of African, Caribbean and other Black gay men in Toronto. Cult Health Sex. 2012 May 1;14(5):549–62.
HETEROSEXUAL NETWORKS
By tradition and custom, men in many cultures are permitted to have multiple sexual partners. Generally, women are not permitted to do the same. Polygamy (i.e., one husband, many wives), a predominantly patriarchal practice, occurs in African and Caribbean communities. Migration to Canada, where polygamy is illegal, may have reduced the number of African men entering into official polygamous relationships, but it has not eliminated the practice altogether. Men who had more than one wife before coming to Canada feel a moral and economic obligation to the women and children from these relationships and cannot justify abandoning them. Within African-Caribbean culture, functional polygamy is often not openly discussed, although it may be implicitly understood and practiced, and it may exist alongside and within the context of marriage and long-term relationships. Partners may be women, men or transgendered.33 Kerr J, Maticka-Tyndale E, Bynum S, Mihan R, Team TA. Sexual Networking and Partner Characteristics Among Single, African, Caribbean, and Black Youth in Windsor, Ontario. Arch Sex Behav. 2016 Apr 29;1–9.
ACB community members acknowledge that gender can and does impact the distribution of power in (heterosexual) relationships. The distribution of power between men and women is seen as predetermined by cultural values and expectations, with men having dominant roles that allow them to have more power. In turn, gender has an impact on a woman’s ability to negotiate sex, with men either initiating contact or having power in these circumstances.34 Baidoobonso S, Mokanan H, Meidinger L, Pugh D, Bauer G, Nleya-Ncube M, et al. Final Report from the Black, African and Caribbean Canadian Health (BLACCH) Study. 2012 [cited 2016 Oct 25]; Available from: https://works.bepress.com/shamara_baidoobonso/1/
A study of ACB youth in Windsor, Ontario, found that perceptions of sex, relationships and sexual behaviour were embedded in both the traditional norms and values of their heritage societies and in the day‐to‐day life in modern‐day Ontario. These findings show that establishing residency in a Western society does not eliminate the influence of patriarchal and oppressive cultural values, norms and beliefs that subordinate women and make them powerless.35 Kerr J, Maticka-Tyndale E, Bynum S, Mihan R, Team TA. Sexual Networking and Partner Characteristics Among Single, African, Caribbean, and Black Youth in Windsor, Ontario. Arch Sex Behav. 2016 Apr 29;1–9.
According to a U.S.-based study of African-American heterosexual young adults, four contextual factors appear to be critical in limiting condom use:
- condoms are not always available when passions run high and the lack of a condom is often not a barrier to having sex;
- the decision to use a condom flows from a culturally informed assessment of a partner’s presumed level of risk rather than from a public health understanding of risky behaviours;
- emotional involvement in relationships runs counter to continued condom use, and the decision to curtail condom use is made quickly;
- relationships in which condoms are not used are multiple, overlapping and sequential. The result is a high level of risk for STIs. This risk is not random or meaningless; it is conditioned by socioeconomic factors that press participants to focus on short-term pleasure and emotional and material gains rather than on long-term planning and monogamous partnerships.36 Singer M. Syndemics, sex and the city: understanding sexually transmitted diseases in social and cultural context. Soc Sci Med. 2006;63(8):2010–21.
Partner selection and sexual networking are important factors in the HIV burden within ACB communities. A study from Windsor of 543 ACB youth demonstrated a difference in sexual networking across African-diasporic groups in Ontario. African-Christian and Caribbean-Christian youth were more interested in developing intimate and romantic relationships with persons within the same cultural background than Black-Christian youth whose families had been in Canada longer. Newcomers were more likely to select partners from within their ethno-racial group, although this tendency dissipated as time in Canada increased.37 Kerr J, Maticka-Tyndale E, Bynum S, Mihan R, Team TA. Sexual Networking and Partner Characteristics Among Single, African, Caribbean, and Black Youth in Windsor, Ontario. Arch Sex Behav. 2016 Apr 29;1–9.
Although ACB males tended to have a higher HIV risk because they had a greater number of partners, concurrent partners and non-relational partnering, ACB females were also at risk of HIV. In the same study, ACB females were more likely to select ACB partners than were males. When HIV is introduced into an ACB sexual network, the increased prevalence of the infection places females at greater risk of acquiring it. Thus, risk is situated in the partnership and not the actions of an individual.38 Kerr J, Maticka-Tyndale E, Bynum S, Mihan R, Team TA. Sexual Networking and Partner Characteristics Among Single, African, Caribbean, and Black Youth in Windsor, Ontario. Arch Sex Behav. 2016 Apr 29;1–9.
Another important aspect of sexual networks is sexual concurrency, an under-researched area among Canadian youth. In the Windsor study, approximately 19% of youth reported having two or more partners in one month, with males reporting greater sexual concurrency than females. This was consistent across ethno-religious lines. Newer immigrants reported less concurrency than Canadian-born participants. The majority (approximately 75%) of the sexually active youth in this sample reported at least one non-relational partner (one night stand, casual partner, transactional sex partner). This is in line with other studies, which have variously reported 60%–84% of youth having non-relational sex partners. In the Windsor study, males and Canadian-born youth were more likely to report a non-relational partner than females and youth not born in Canada.39 Kerr J, Maticka-Tyndale E, Bynum S, Mihan R, Team TA. Sexual Networking and Partner Characteristics Among Single, African, Caribbean, and Black Youth in Windsor, Ontario. Arch Sex Behav. 2016 Apr 29;1–9.
Internal (sometimes referred to as female) condoms and external (sometimes referred to as male) condoms are an essential component of HIV prevention efforts and continue to have an important role to play in the prevention of HIV and STIs. However, significant barriers exist for many ACB people with respect to consistent condom use. In a study of 168 ACB men in the Greater Toronto Area, a large proportion of participants practised inconsistent condom use, but this varied according to the ethnicity of the partner; inconsistent condom use was more likely when the sexual partner was non-Black. Consistency of condom use also varied by place of birth. Canadian-born men and Caribbean-born men were less likely to consistently use condoms than African-born men. The study points to the need for targeted support for Black GBMSM, particularly those born in Canada, and also for older Black GBMSM who are not open about their sexual orientation.40 George C, Makoroka L, Husbands W, Adam BD, Remis R, Rourke S, et al. Sexual health determinants in black men-who-have-sex-with-men living in Toronto, Canada. 2013 Nov 29 [cited 2017 Apr 12]; Available from: https://www.growkudos.com/publications/10.1108%252Feihsc-10-2013-0034
As the time spent in Canada increases, immigrants are more likely to report having a history of forced or unwanted sex, having unprotected sex with a regular or casual partner in the past 12 months, not using a condom in the past 12 months, ever mixing sex with drugs or alcohol, having a history of STIs, ever having sex or having sex in the past year.41 Baidoobonso S, Bauer GR, Speechley KN, Lawson E. HIV risk perception and distribution of HIV risk among African, Caribbean and other Black people in a Canadian city: mixed methods results from the BLACCH study. BMC Public Health. 2013;13(1):1. Overall, ACB youth have been found to have lower rates of condom use than 15- to 24-year-old youth across Canada and in Ontario.42 Maticka-Tyndale E, Kerr J, Mihan R. A profile of the sexual experiences of African, Caribbean and Black Canadian youth in the context of Canadian youth sexuality. Can J Hum Sex. 2016 Apr;25(1):41–52. Promoting a personal norm of responsibility for condom use (e.g., purchase, communication) may increase condom use among both men and women in the ACB community.43 Maticka-Tyndale E, Kerr J, Mihan R, Mungwete R, Team AS. Condom Use at Most Recent Intercourse Among African, Caribbean, and Black Youth in Windsor, Ontario. Int J Sex Health. 2016 Jul 2;28(3):228–42.
Definition
Vulnerabilities: are the social and cultural contexts that affect the ability of individuals and communities to avoid HIV infection.
Heightened HIV vulnerability in ACB communities is situated in structural contexts of social, economic and political inequities. Structural factors such as economic insecurity have a complex and indirect association with HIV risk (i.e. increasing risk by reducing access to HIV testing, prevention and care).44 Logie CH, Jenkinson JIR, Earnshaw V, Tharao W, Loutfy MR. A Structural Equation Model of HIV-Related Stigma, Racial Discrimination, Housing Insecurity and Wellbeing among African and Caribbean Black Women Living with HIV in Ontario, Canada. Faragher EB, editor. PLOS ONE. 2016 Sep 26;11(9):e0162826. Cultural norms and practices within ACB communities also contribute to HIV vulnerability.
- Dimensions of stigma, gender, race and poverty intersect with HIV/AIDS-related stigma, denial, fear and discrimination.45 ACCHO. HIV/AIDS, Stigma, Denial, Fear and Discrimination: Experiences and Responses of People from African, Caribbean and Black Communities in Toronto [Internet]. 2006. Available from: https://accho.ca/hiv_stigma_report/
Definition
Stigma: is understood as “a multi-dimensional concept of which the essence focuses on deviance from an accepted standard or convention.”46 Goffman, E. Stigma: Notes on the Management of a Spoiled Identity. New York: Simon and Schuster; 1963.
Stigmatization takes place in specific contexts of culture and power; it has a history that influences its appearance and the form it takes, and it is used by individuals, communities and the state to produce and reproduce social inequality.
Definition
HIV/AIDS-related stigma: refers to prejudice, discounting, discrediting and discrimination directed at people perceived to have AIDS or HIV, and the groups and communities with which they are associated.47 HEREK GM. AIDS and Stigma. Am Behav Sci. 1999 Apr 1;42(7):1106–16.
Closely connected is the concept of
Definition
Discrimination: referring to the unfair and unjust treatment of an individual on the basis of her or his real or perceived HIV status.48 UNAIDS. Fact Sheet: Stigma and Discrimination [Internet]. UNAIDS; 2003. Available from: http://data.unaids.org/publications/Fact-Sheets03/fs_stigma_discrimination_en.pdf
Different types of stigma operate at different levels and have varying impacts on people living with HIV. Self-stigma refers to the way individuals with stigmatized attributes (i.e. HIV-positive status) expect to be perceived and treated by others.49 Visser MJ, Makin JD, Lehobye K. Stigmatizing attitudes of the community towards people living with HIV/AIDS. J Community Appl Soc Psychol. 2006 Jan 1;16(1):42–58. At another level, enacted stigma involves the stigmatization and discrimination actually experienced by the person with HIV on an interpersonal level.
HIV-related stigma, discrimination and denial often have a negative impact on health status and outcomes via social support networks, employment and/or working conditions, personal health practices and coping skills.50 ACCHO. HIV/AIDS, Stigma, Denial, Fear and Discrimination: Experiences and Responses of People from African, Caribbean and Black Communities in Toronto [Internet]. 2006. Available from: https://accho.ca/hiv_stigma_report/51 Logie C. Associations between HIV-related stigma, racial discrimination, gender discrimination, and depression among HIV-positive African, Caribbean, and Black women in Ontario, Canada. AIDS Patient Care STDs. 2013;27(2):114–22. It is also important to note that HIV-related stigma is compounded by other forms of stigmatization, making it even more challenging to address HIV within ACB communities in Ontario. For example, stigma factors into cultural attitudes regarding sexuality (i.e., sexual practices, notions of morality and promiscuity, orientation). Furthermore, systemic racism and social exclusion contribute to internalized stigma.52 ACCHO. HIV/AIDS, Stigma, Denial, Fear and Discrimination: Experiences and Responses of People from African, Caribbean and Black Communities in Toronto [Internet]. 2006. Available from:https://accho.ca/hiv_stigma_report/53 Logie C. Associations between HIV-related stigma, racial discrimination, gender discrimination, and depression among HIV-positive African, Caribbean, and Black women in Ontario, Canada. AIDS Patient Care STDs. 2013;27(2):114–22. This is evident in a belief, held among many people in the non-African population, that HIV originated in Africa and is being brought to Ontario/Canada by African immigrants.54 ACCHO. HIV/AIDS, Stigma, Denial, Fear and Discrimination: Experiences and Responses of People from African, Caribbean and Black Communities in Toronto [Internet]. 2006. Available from:https://accho.ca/hiv_stigma_report/ GBMSM, women and people with low incomes are uniquely impacted by these intersecting forms of stigma and discrimination.
Due to stigma and denial, ACB people may be discouraged from taking advantage of HIV testing, early care and treatment. ACB communities in Ontario are often small and located in specific geographic areas, creating a sense that “everyone knows everyone” and that news about having HIV will travel “back home.” This perceived lack of personal privacy may contribute to the fear of disclosure.55 ACCHO. HIV/AIDS, Stigma, Denial, Fear and Discrimination: Experiences and Responses of People from African, Caribbean and Black Communities in Toronto [Internet]. 2006. Available from: https://accho.ca/hiv_stigma_report/
Religious beliefs and social norms, homophobia or the denial of homosexuality within communities, and silence about health and sexuality are all issues that affect responses to HIV within ACB communities.56 ACCHO. Ontario HIV/AIDS Strategy for African, Caribbean and Black Communities 2013-2018 (the ACB Strategy) [Internet]. ACCHO; 2013. Available from: https://accho.ca/capacity-building/acb_strategy_web_oct2013_en/ Many people from African and Caribbean backgrounds come from communities with strong homophobic attitudes. Experiences of homophobia can cause individuals to avoid other community members and minimize contact with family members.57 Logie C. HIV, Gender, Race, Sexual Orientation, and Sex Work: A Qualitative Study of Intersectional Stigma Experienced by HIV-Positive Women in Ontario, Canada. PLoS Med. 2011;8(11):e1001124.
In the MaBwana study, it was found that homosexuality within the context of Black social and political life in Ontario is complicated by the unwillingness of the general Black community, often reflecting the attitude in their country of origin, to accept Black GBMSM as part of their society, including the stigma of HIV as a gay disease and the intersection of the two.58 George C, Adam BD, Read SE, Husbands WC, Remis RS, Makoroka L, et al. The MaBwana Black men’s study: community and belonging in the lives of African, Caribbean and other Black gay men in Toronto. Cult Health Sex. 2012 May 1;14(5):549–62.
Homophobia can also cause ACB community members to avoid HIV-related services. The use in HIV prevention messages of the word “gay” or “MSM” or of imagery portraying same-sex relationships may deter men from accessing HIV prevention services. Anti-gay stigma may also be a factor in avoidance of HIV testing.59 AIDS Bureau Ontario. Ontario Gay Men’s HIV Prevention Strategy – Gay, Bi, MSM Situation Report. Ontario Minstry of Health and Long Term Care; 2006. Many ACB men do not identify with the terms gay or bisexual because they signify feminine qualities that are undesirable for or inconsistent with their self-perceptions. Some ACB GBMSM have sex with other men without the knowledge of their peers, their family or their female sex partners, which has sometimes been termed being on the “down low”. They are more likely than GBMSM of other ethnic groups to identify as bisexual versus gay, and they are less likely than white GBMSM to disclose their same-sex sexual behaviour to others. Identifying as a gay man may be seen as inconsistent with being African in their communities, and therefore many African GBMSM may hide their sexual identities.60 AIDS Bureau Ontario. Ontario Gay Men’s HIV Prevention Strategy – Gay, Bi, MSM Situation Report. Ontario Minstry of Health and Long Term Care; 2006.
In a study exploring stigma in ACB communities in Toronto, Caribbean participants described the personal impact of homophobic attitudes within their communities and how these relate to stigmatization and discrimination against those who are, or are assumed to be, living with HIV. Participants described mechanisms that are used to monitor sexual practices in general and to condemn same-sex relationships in particular. These negative attitudes are sanctioned by cultural practices and social institutions such as family and church, and they demonstrate how cultural and social norms about gender are constructed and policed.61 ACCHO. HIV/AIDS, Stigma, Denial, Fear and Discrimination: Experiences and Responses of People from African, Caribbean and Black Communities in Toronto [Internet]. 2006. Available from: https://accho.ca/hiv_stigma_report/
The increasing prevalence of HIV/AIDS in women in Ontario is the result of a complex mix of biological factors (e.g., structure and maturity of the reproductive system, length of exposure to HIV) and social factors (e.g., gender inequities). Like many women in Ontario, ACB women are often socialized to be subordinate to the men in their lives. This gender imbalance, which is usually supported by religious teachings and socio-cultural norms, often limits women’s ability to negotiate safer sex to the point where they will not take an HIV test or ask their partners to use condoms (even when they know their partner is having sex outside of the relationship) for fear of being perceived as too sexually knowledgeable, aggressive or promiscuous.62 ACCHO. HIV/AIDS, Stigma, Denial, Fear and Discrimination: Experiences and Responses of People from African, Caribbean and Black Communities in Toronto [Internet]. 2006. Available from: https://accho.ca/hiv_stigma_report/63 Logie C. Associations between HIV-related stigma, racial discrimination, gender discrimination, and depression among HIV-positive African, Caribbean, and Black women in Ontario, Canada. AIDS Patient Care STDs. 2013;27(2):114–22. In other studies, however, young ACB women have been found to be assertive with respect to condom use, and they may act as the gatekeepers with respect to vaginal intercourse and condom use.64 Maticka-Tyndale E, Kerr J, Mihan R, Mungwete R, Team AS. Condom Use at Most Recent Intercourse Among African, Caribbean, and Black Youth in Windsor, Ontario. Int J Sex Health. 2016 Jul 2;28(3):228–42.
Because of gendered cultural norms, some ACB women may believe that they will jeopardize their long-term relationship if they ask a male partner to use a condom. Many women are not prepared to risk their relationship if they believe they are at low/no risk for acquiring HIV. For many ACB men, negotiating safer sex practices is not a priority and/or is perceived as the primary responsibility of the woman.65 Tharao, Wangari, Massaquoi, Notisha, Teclom, Senait. Silent Voices of the HIV/AIDS Epidemic: African and Caribbean Women in Toronto 2002 – 2004 [Internet]. Women’s Health in Women’s Hands Community Health Centre; 2006. Available from: http://www.icad-cisd.com/pdf/CHABAC/RelatedResources/Silent-Voices-of-the-HIV-and-AIDS-Epidemic.pdf A study in Windsor found that culturally entrenched gender inequalities may increase the risk of STI/HIV acquisition among African youth living in Ontario. For example, there was widespread acceptance of men having multiple sex partners, while similar behaviour by young women led to negative stereotyping. These findings reveal the double standard applied to women and men, as well as male dominance and the silencing of young women’s desire for protection. Young women in this study reported that women who challenged male dominance in sexual relations often were labelled HIV transmitters or were seen as wayward and promiscuous.66 Omorodion F, Gbadebo K, Ishak P. HIV vulnerability and sexual risk among African youth in Windsor, Canada. Cult Health Sex. 2007 Aug;9(4):429–37.
A woman’s capacity to negotiate safer sex is complicated by one or more of the following factors:67 Baidoobonso S, Bauer GR, Speechley KN, Lawson E. HIV risk perception and distribution of HIV risk among African, Caribbean and other Black people in a Canadian city: mixed methods results from the BLACCH study. BMC Public Health. 2013;13(1):1.
- Her male partner may be the main income earner and the only person who speaks one of Canada’s official languages.
- She may fear deportation either because of threats from her sponsor/partner or a lack of understanding of current immigration law. Leaving a relationship is not grounds for a permanent resident to lose their status, but if a partner/sponsor is abusive they may use the threat of deportation as a manipulative tool. If a woman is undocumented (e.g. overstayed a temporary work or study permit), her partner could report her situation and potentially cause her to be deported.68 HIV & AIDS Legal Clinic Ontario. Women living with HIV and intimate partner violence [Internet]. Available from: https://www.halco.org/wp-content/uploads/2016/07/Women-with-HIV-and-intimate-partner-violence-2016May-EN.pdf Conditional permanent residency, a policy eliminated in 2017, may lead people to believe that a sponsored partner can still be required to stay with their partner for a certain length of time in order to keep their permanent residency.
- Some women, particularly African women who do not speak either of Canada’s official languages, may depend on their family to provide translation and interpretation. This may limit their autonomy and their ability to receive information about HIV prevention (when members of the family translate for women, they have control over the information the women receive).
- A husband/partner may withhold legal documents, passports and other identification documents, thereby limiting a woman’s ability to leave an unsafe situation.
- The need for love or acceptance in the context of sexual and marital relationships can act as a barrier to ACB women protecting themselves from HIV infection.
- Lack of empowerment among women manifests as a lack of ability to negotiate condom use, intimate partner violence and abuse in general.
- ACB women may trust in their sexual partners despite infidelity, and cultural and religious attitudes may discourage condom use and communication about sex and safer sex practices.
- Some women are unaware of HIV in their communities and lack education about how to protect themselves.
- According to the Windsor-based study, young African women need to be empowered and supported to develop the negotiation skills required to decrease their vulnerability to STIs, including HIV. Young African men are likely to benefit from sexual health education to respect women’s rights to their bodies and their sexuality.69 Omorodion F, Gbadebo K, Ishak P. HIV vulnerability and sexual risk among African youth in Windsor, Canada. Cult Health Sex. 2007 Aug;9(4):429–37.
Some ACB men also face barriers in HIV prevention. Social norms around expression of masculinity, for example, may lead to ACB men being less likely to access health and social services than ACB women, or they may lead ACB men to believe that their sexual needs/desires are out of their own control. There may be cultural norms and beliefs dictating that ACB men not disclose information, and ACB men may not seek information because they are expected to be knowledgeable about everything. Some heterosexual men believe that they cannot become infected, are generally not reached by HIV prevention messages and are unlikely to access HIV/AIDS services because of the underrepresentation of heterosexual ACB male staff in AIDS service organizations (ASOs).70 Baidoobonso S, Bauer GR, Speechley KN, Lawson E. HIV risk perception and distribution of HIV risk among African, Caribbean and other Black people in a Canadian city: mixed methods results from the BLACCH study. BMC Public Health. 2013;13(1):1.
In relation to HIV, heterosexual Black men are too often portrayed as sexual predators.71 Tharao, Wangari, Massaquoi, Notisha, Teclom, Senait. Silent Voices of the HIV/AIDS Epidemic: African and Caribbean Women in Toronto 2002 – 2004 [Internet]. Women’s Health in Women’s Hands Community Health Centre; 2006. Available from: http://www.icad-cisd.com/pdf/CHABAC/RelatedResources/Silent-Voices-of-the-HIV-and-AIDS-Epidemic.pdf They are characterized and understood as performing masculinity in ways that are dangerous, risky and unproductive and that undermine women’s well-being. Black men are stereotyped as being different from other men because of presumed attributes such as: being unable to decline sex; seeking to have sex with many women, often concurrently; not possibly being gay or bisexual; not acknowledging their vulnerabilities; and being indifferent fathers who abandon families. Societal depictions, particularly through popular and news media, reinforce stereotypes that sex with Black men may be inherently risky and that they have overly abundant erotic endowment, exempt themselves from HIV prevention and delegate responsibility for condoms to women. Ultimately, these racist stereotypes result in heterosexual Black men internalizing stigma, fear and shame about HIV and avoiding available services or supportive networks.72 Husbands W. Stop it! Heterosexual Black men are not pricks [Internet]. HIV Endgame: Stopping the Syndemics that Drive HIV; 2016 Oct 24; Toronto, Ont. Available from: http://www.ohtn.on.ca/wp-content/uploads/2016/12/Husbands-Stop.pdf
Poverty status, immigration experience and employment status are linked to the distribution of HIV risk and protective behaviours. Thus, prevention interventions for ACB people locally, and possibly in other parts of Canada, should consider gender, poverty status, immigration experience and employment status.73 Baidoobonso S, Bauer GR, Speechley KN, Lawson E. HIV risk perception and distribution of HIV risk among African, Caribbean and other Black people in a Canadian city: mixed methods results from the BLACCH study. BMC Public Health. 2013;13(1):1. It is futile to undertake HIV/AIDS prevention programs without addressing the larger problems that keep ACB populations at the margins of Canadian society. An understanding of these multiple issues is not limited to local experiences but rather is situated in global processes such as crossing borders in search of better opportunities, safety and security; the isolation of living in a foreign place; the loneliness from missing loved ones; the difficulty of trying to establish new relationships and networks; and the decision to shield family “back home” from the news of an HIV-positive diagnosis received in Ontario or elsewhere in Canada. Some members of ACB communities not only struggle with negotiating daily life in Ontario but also worry about the material well-being of loved ones in their home countries who depend on them.74 ACCHO. HIV/AIDS, Stigma, Denial, Fear and Discrimination: Experiences and Responses of People from African, Caribbean and Black Communities in Toronto [Internet]. 2006. Available from: https://accho.ca/hiv_stigma_report/
HIV risk may be related to the length of time a person has lived in Canada. Overall, recent immigrants appear to be at lower risk for HIV exposure and transmission than people born in Canada. However, as the length of time in Canada increases, immigrants’ risk profile more closely mimics that of native-born Canadians. In particular, the sexual behaviours of immigrants begin to mimic those of members of the dominant culture. This may be particularly true among youth who immigrated during their formative years and before their sexual debut. As the time spent in Canada increases, immigrants are more likely to report having a history of forced or unwanted sex, having unprotected sex with a regular or casual partner in the past 12 months, not using a condom in the past 12 months, ever mixing sex with drugs or alcohol, having a history of STIs, ever having sex, or having sex in the past year.75 Baidoobonso S, Bauer GR, Speechley KN, Lawson E. HIV risk perception and distribution of HIV risk among African, Caribbean and other Black people in a Canadian city: mixed methods results from the BLACCH study. BMC Public Health. 2013;13(1):1.
Youth who recently immigrated may have already developed attitudes regarding sexual activity before their arrival, making them less vulnerable or slower to acculturate to Canadian norms.76 Kerr J, Maticka-Tyndale E, Bynum S, Mihan R, Team TA. Sexual Networking and Partner Characteristics Among Single, African, Caribbean, and Black Youth in Windsor, Ontario. Arch Sex Behav. 2016 Apr 29;1–9. Immigrant youth may begin their sexual experiences more conservatively than Canadian-born youth but exhibit similar behaviours in subsequent generations. These results suggest that public health efforts to reduce vulnerability to negative sexual health outcomes may need to take different approaches to immigrant than Canadian-born populations, even within the same ethno-racial group.77 Kerr J, Maticka-Tyndale E, Bynum S, Mihan R, Team TA. Sexual Networking and Partner Characteristics Among Single, African, Caribbean, and Black Youth in Windsor, Ontario. Arch Sex Behav. 2016 Apr 29;1–9.
Immigrants, in general, experience less well-being than the general population, with elevated risks of depression, chronic pain and other somatic complaints. In addition, there may be a higher prevalence of psychotic disorders among immigrants after migration.78 Logie CH, Jenkinson JIR, Earnshaw V, Tharao W, Loutfy MR. A Structural Equation Model of HIV-Related Stigma, Racial Discrimination, Housing Insecurity and Wellbeing among African and Caribbean Black Women Living with HIV in Ontario, Canada. Faragher EB, editor. PLOS ONE. 2016 Sep 26;11(9):e0162826.
The immigration process itself may contribute to the risk of HIV acquisition for some people. It is quite common for one member of a family to come to Canada first, get established and then send for the other(s). This means that partners may be separated for a year or more. When they are apart, they may be involved in sexual relationships that could put them at risk. For many ACB women, migration disrupts many aspects of their lives. Changes in gender roles can lead to conflicts within the relationship. This means that people whose marriages break down and who find themselves single may start dating with little preparation for negotiating safer sex and limited knowledge about HIV/AIDS or other STIs.79 Tharao, Wangari, Massaquoi, Notisha, Teclom, Senait. Silent Voices of the HIV/AIDS Epidemic: African and Caribbean Women in Toronto 2002 – 2004 [Internet]. Women’s Health in Women’s Hands Community Health Centre; 2006. Available from: http://www.icad-cisd.com/pdf/CHABAC/RelatedResources/Silent-Voices-of-the-HIV-and-AIDS-Epidemic.pdf
Sexual and physical violence have a direct impact on the ability of ACB individuals to practise HIV prevention. Issues of sexual violence or abuse may be taboo topics in ACB families and communities, and those who come forward often face stigma and reprisal from family members for speaking out and/or seeking support, particularly if the perpetrator is a member of the immediate or extended family or part of the larger community. Forced sex, childhood sexual abuse and incest may directly lead to HIV infection, while fear of sexual and physical violence limits women’s ability to negotiate condom use. Many African women, now living in Ontario, have fled persecution from war-torn countries of sub-Saharan Africa where they may have been raped and tortured, which may have resulted in physical injury, pregnancy and exposure to HIV.80 Public Health Agency of Canada. Perinatal HIV Transmission in Canada [Internet]. HIV AIDS Epi Update; 2010. Available from: http://www.phac-aspc.gc.ca/aids-sida/publication/epi/2010/7-eng.php81 Wilcken A. Traditional male circumcision in eastern and southern Africa: a systematic review of prevalence and complications. Bull World Health Organ. 88(12):907–14.82 Perron, Liette, Senikas, Vyta, Burnett, Margaret, Davis, Victoria. Clinical Practice Guidelines: Female Genital Cutting. J Obstet Gynaecol Can [Internet]. Available from: https://sogc.org/wp-content/uploads/2013/10/gui299CPG1311E.pdf
Girls, young women, lesbian, gay, bisexual, transgendered and queer people (LGBITQ) and people living with disabilities are the subject of physical and sexual victimization. Although boys and men also experience sexual violence, it is important to acknowledge that girls and women are disproportionately affected by sexual and physical violence, regardless of their country of origin, culture, social class, religion or ethnic group. Their ability to practise HIV prevention may be affected by the aftermath of sexual violence (e.g., depression, loss of value, loss of sense of well-being). Research findings also indicate that sexual abuse in childhood may place survivors at risk for physical and sexual abuse in adulthood, which may limit their ability to negotiate safer sex and/or identify their right to protect their body.83 Williams JK, Wilton L, Magnus M, Wang L, Wang J, Dyer TP, et al. Relation of Childhood Sexual Abuse, Intimate Partner Violence, and Depression to Risk Factors for HIV Among Black Men Who Have Sex With Men in 6 US Cities. Am J Public Health. 2015 Dec;105(12):2473–81.84 Phillips D. The intersection of intimate partner violence and HIV in U.S. women: a review. J Assoc Nurses AIDS Care. 2014;25(Supp1):S36-49.85 Dunkle K. Gender-based violence and HIV: reviewing the evidence for links and causal pathways in the general population and high-risk groups. Am J Reprod Immunol. 2013;69(Supp1):20–6.