Coercive sex as a mode of HIV acquisition among a cohort of women with HIV in Canada: an under-recognized public health concern Mona Loutfy,, Carmen Logie, Alexandra de Pokomandy, Pat O’Campo, Nadia O’Brien, Saara Greene, Wangari Tharao, Jay MacGillivray, Lu Wang, Shahab Jabbari, Nikita Arora, V Logan Kennedy, Allison Carter, Karène Proulx-Boucher, Allison Carlson, Sally Lin, Marisol Desbiens, Kath Webster, Danièle Dubuc, Paul Sereda, Guillaume Colley, Robert Hogg, Angela Kaida, On Behalf of the CHIWOS Research Team Women’s College Research Institute, Women’s College Hospital, Toronto, ON; Department of Medicine, University of Toronto, Toronto, ON; Dalla Lana School of Public Health, University of Toronto; Faculty of Social Work, University of Toronto, Toronto, ON; Chronic Viral Illness Service, McGill University Health Centre, Montreal, QC; Department of Family Medicine, McGill University, Montreal QC; Centre for Research on Inner City Health, St. Michael’s Hospital, Toronto, ON; Faculty of Social Work, McMaster University of Toronto, Toronto, ON; Women’s Health in Women’s Hands Community Health Centre, Toronto, ON; Department of Obstetrics and Gynecology, St. Michael’s Hospital, Toronto, ON; BC Centre for Excellence in HIV/AIDS, Vancouver, BC; Faculty of Medicine, McMaster University, Hamilton, ON; Faculty of Health Sciences, Simon Fraser University, Vancouver, BC Presented at the 25th Annual Canadian Conference for HIV/AIDS Winnipeg, Manitoba – May 13th, 2016

We would like to acknowledge that we gather on the traditional territory of the Anishinaabeg, Cree, Oji-Cree, Dakota, and Dene peoples, and on the homeland of the Métis Nation.

Conflicts of Interest Disclosure In the past 2 years, I have been paid from: Women’s College Hospital and the University of Toronto and paid by the Ministries of Ontario and Saskatchewan. I have received funds from Gilead Sciences, Merck Canada Inc. and ViiV Healthcare. There are no relationships to disclose related to this work.

Exposure Category for Women with HIV in Canada Proportion of Positive HIV Test Reports among Adult Women (≥ 15 yrs of age) by Exposure Category, (N = 5,643) Heterosexual contact includes a) Origin from an HIV-endemic country (11.1%), b) Sexual contact with a person at risk (25.3%), and c) No identified risk (NIR) – Heterosexual (17.5%). PHAC Population Specific HIV/AIDS Status Report: Women, Chapter 3. Retrieved from: sida/publication/ps-pd/women-femmes/chapter- chapitre-3-eng.php

Defining the problem - Violence The World Health Organization provides the following framework on gendered violence: What is Violence against Women? "any act of gender-based violence that results in, or is likely to result in, physical, sexual or mental harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or in private life." Intimate partner violence: “behaviour by an intimate partner or ex-partner that causes physical, sexual or psychological harm, including physical aggression, sexual coercion, psychological abuse and controlling behaviours” Sexual violence: "any sexual act, attempt to obtain a sexual act, or other act directed against a person’s sexuality using coercion, by any person regardless of their relationship to the victim, in any setting. It includes rape, defined as the physically forced or otherwise coerced penetration of the vulva or anus with a penis, other body part or object."  Worldwide women experience high rates of violence related to entrenched gender inequities 1  According to the WHO 2 :  35% of women have experienced either physical and/or sexual intimate partner violence or non-partner sexual violence.  Women who had been physically or sexually abused were 1.5 times more likely to have a sexually transmitted infection and, in some regions, HIV, compared to women who had not experienced partner violence T. Türmen. (2003). Gender and HIV/AIDS. International Journal of Gynecology & Obstetrics, 82(3), 411– WHO Retrieved from: 3. Ogden J, Nyblade L. Common at its core: HIV-related stigma across contexts. International Center for Research on Women, 2005 Available at

Objectives To assess the proportion of women in CHIWOS who have reported non-consensual (coercive) sex as the method of HIV acquisition as compared to the other categories To assess the correlates of women who reported coercive vs. consensual sex as their mode of HIV acquisition

Methods: Study Population and Design CBR longitudinal cohort study: Baseline visit (PRA-administered electronic survey) q18 month follow-up visits (Visit 2 & 3 planned) Inclusion criteria: Self-identified woman (trans inclusive) Living with HIV (self-report) > 16 years; Living in BC, ON and QC For this analysis – answer question on mode of HIV acquisition Sampling & Recruitment Non-random purposive sampling by health region & harder-to-reach From PRAs, ASOs, Clinics, Other

Methods: Outcome of Interest This analysis includes only the baseline visit (and is therefore, cross-sectional) Primary outcome: Self-report “non-consensual sex" as mode of HIV acquisition Exact question: How do you think you got HIV? (S2Q3a_2) Additional questions: As an adult, has someone ever sexually forced themselves on you, or forced you to have sex? (S7Q5a); Do you think you became HIV-positive as result of these episodes?(S7Q5d) ; During your childhood, did someone ever sexually force themselves on you, or forced you to have sex? (S7Q8a); Do you think you became HIV-positive as result of these episodes? (S7Q8d) Hierarchical singular assignment of seven modes of HIV acquisition based on likelihood of mode (if higher risk of transmission – higher in hierarchy) 1.Perinatal 2.Blood transfusion 3.Sharing needles 4.Contaminated needles 5.Non-consensual sex 6.Consensual sex 7.Other

Methods: Statistical Analyses Summary statistics of socio-demographic, psychosocial and clinical characteristics Medians and IQRs for continuous variables Frequencies and proportions for categorical variables  For total population & by province (BC, ON, QC)  Chi-square, Fisher’s Exact or Wilcoxon’s rank sum test for comparisons between provinces Multivariable logistic regression was used to identify correlates of women who reported coercive vs. consensual sex as their mode of HIV acquisition using backward stepwise elimination

 1425 overall participants – BC: 25% – ON: 50% – QC: 25%  1330 participants included – BC: 26% – ON: 49% – QC: 25% – N=95 excluded due to “DK/PNTA” response to qualifying question for mode of acquisition (S2Q3a_2) and/or sexual assault (S7Q5a,d; S7Q8a,d) Results

Results Table 1. National Demographic Profile N=1330 Variable Overall (N=1330) N (%) BC (N=342) N (%) ON (N=657) N (%) QC (N=331) N (%) P-value Age at interview date (Median, IQR)42(35-50)44(37-51)40(34-49)46(38-53)<0.001 Gender identity Woman1269(95.4)328(95.9)626(95.3)315(95.2)0.877 Transwoman/Two-Spirited/Queer/Other61(4.6)14(4.1)31(4.7)16(4.8) Sexual orientation Heterosexual1155(86.8)284(83.0)566(86.1)305(92.1)0.002 LGBTTQ170(12.8)57(16.7)87(13.2)26(7.9) DK/PNTA5(0.4)1(0.3)4(0.6) Ethnicity Indigenous312(23.5)156(45.6)148(22.5)8(2.4)<0.001 African/Caribbean/Black350(26.3)27(7.9)181(27.5)142(42.9) Caucasian572(43.0)133(38.9)275(41.9)164(49.5) Other96(7.2)26(7.6)53(8.1)17(5.1) Ever incarceration Yes511(38.4)215(62.9)198(30.1)98(29.6)<0.001 No818(61.5)127(37.1)458(69.7)233(70.4) DK/PNTA1(0.1) 1(0.2) Injection drug use ever Yes430(32.3)219(64.0)128(19.5)83(25.1)<0.001 No876(65.9)122(35.7)509(77.5)245(74.0) DK/PNTA24(1.8)1(0.3)20(3.0)3(0.9)

Model 1. Multivariate results RESULTS Table 2. Model 1:HIV Transmission Risk Categories N=1330 Province interview conducted OverallBCONQC (N=1330)(N=342)(N=657)(N=331) VariableN(%)N N N P-value Consensual sex 686(51.6)113(33.0)416(63.3)157(47.4)<0.001 Sharing needles 262(19.7)127(37.1)74(11.3)61(18.4) Coercive sex 219(16.5)61(17.8)94(14.3)64(19.3) Blood transfusion 70(5.3)15(4.4)30(4.6)25(7.6) Perinatal exposure 50(3.8)6(1.8)30(4.6)14(4.2) Don’t Know/Prefer not to answer 21(1.6)5(1.5)10(1.5)6(1.8) Contaminated needles 17(1.3)12(3.5)2(0.3)3(0.9) Other 5(0.4)3(0.9)1(0.2)1(0.3)

Variable HIV transmission risk Coercive sex vs Consensual sex (REF) Consensual sexCoercive sex (N=686)(N=219)Multivariable Model N(%)N Odds ratio (95% CI)P-value Province interviewed BC113(16.5)61(27.9)2.495 (1.548, 4.022) QC157(22.9)64(29.2)1.403 (0.931, 2.115) ON (REF)416(60.6)94(42.9) Age at interview (categorical) to 39236(34.4)78(35.6)0.957 (0.463, 1.976) 40 to 49207(30.2)71(32.4)0.84 (0.396, 1.78) 50 or more188(27.4)53(24.2)0.923 (0.424, 2.01) 16 to 29 (REF)55(8.0)17(7.8) Years living in Canada (categorical) <0.001 DK/PNTA5(0.7) Less than 5 years33(4.8)42(19.2)3.709 (1.517, 9.065) 5 to 10 years70(10.2)48(21.9)1.638 (0.7, 3.83) More than 10 years125(18.2)27(12.3)0.569 (0.265, 1.222) Born in Canada (REF)453(66.0)102(46.6) Ethnicity Other57(8.3)16(7.3)1.971 (0.917, 4.239) Indigenous150(21.9)37(16.9)0.779 (0.445, 1.366) African/Caribbean/Black171(24.9)106(48.4)3.266 (1.479, 7.216) Caucasian (REF)308(44.9)60(27.4) Education DK/PNTA3(0.4)1(0.5) Lower than high school74(10.8)35(16.0)1.261 (0.758, 2.096) High school or higher (REF)609(88.8)183(83.6) Experiences of foster care <0.001 DK/PNTA3(0.4) Yes78(11.4)49(22.4)2.971 (1.792, 4.927) No (REF)605(88.2)170(77.6) Ever incarceration DK/PNTA 1(0.5) Yes181(26.4)64(29.2)1.093 (0.65, 1.839) No (REF)505(73.6)154(70.3) Injection drug use ever DK/PNTA21(3.1)1(0.5) Yes99(14.4)47(21.5)1.333 (0.74, 2.401) No (REF)566(82.5)171(78.1) Years living with HIV DK/PNTA11(1.6)5(2.3) 6 to 14 years268(39.1)101(46.1)1.548 (0.983, 2.439) More than 14 years209(30.5)56(25.6)1.552 (0.904, 2.665) Less than 6 years (REF)198(28.9)57(26.0) RESULTS Table 3. Model 1: Sociodemographic Characteristics of Women Acquiring HIV through Coercive vs. Consensual Sex in the CHIWOS Cohort N=905 Being from BC: aOR 2.5 (1.5, 4.0) p=0.001 Living in Canada <5 years: aOR=3.7 ( ) p<0.001 ACB Ethnicity aOR=3.3 ( ) p=0.019 Lived in Foster Care aOR=3.0 ( ) p<0.001

VariableHIV transmission risk Coercive sex vs Consensual sex (REF) Consensual sexCoercive sex (N=453)(N=102)Multivariate Model N(%)N Odds ratio (95% CI)P-value Ethnicity African/Caribbean/Black 7(1.5)1(1.0)0.553 (0.055, 5.596) Other 18(4.0)8(7.8)2.039 (0.76, 5.47) Indigenous 149(32.9)37(36.3)0.894 (0.511, 1.566) Caucasian (REF) 279(61.6)56(54.9) Source of income 12 - Parent/friend/relative/partner income DK/PNTA 2(0.4) Yes 23(5.1)15(14.7) (0.842, 4.104) No (REF) 428(94.5)87(85.3) City size Medium 60(13.2)21(20.6) (0.226, 1.399) Large 360(79.5)67(65.7) (0.185, 0.852) Small (REF) 33(7.3)14(13.7) Number of Children (categorical) Not biological women 27(6.0)4(3.9) 1 102(22.5)19(18.6) (0.482, 2.041) 2 73(16.1)21(20.6) (0.655, 2.72) 3 or more 70(15.5)33(32.4) 2.11 (1.073, 4.149) 0 (REF) 181(40.0)25(24.5) Early life experiences-Foster care DK/PNTA 2(0.4) Yes 71(15.7)42(41.2) (1.343, 4.146) No (REF) 380(83.9)60(58.8) Injection drug use current (last 3 months) DK/PNTA 20(4.4)1(1.0) Currently IDU 18(4.0)16(15.7) (1.305, 7.185) Not currently IDU but previously IDU 73(16.1)25(24.5) (0.541, 1.923) Never IDU (REF) 342(75.5)60(58.8) Mental health condition ever DK/PNTA4(0.9)1(1.0) Yes174(38.4)64(62.7)2.054 (1.244, 3.392) No (REF) 275(60.7)37(36.3) RESULTS Table 4. Model 2: Sociodemographic Characteristics of Women Born in Canada Acquiring HIV through Coercive vs. Consensual Sex in the CHIWOS Cohort N=555 Foster Care aOR 2.36 (1.34, 4.15) p=0.003 IDU aOR 3.06 (1.31, 7.19) p=0.028 Large vs. Small City aOR 0.40 (0.19, 0.85) p=0.047 Mental Health aOR 2.05 (1.24, 3.40) p=0.005

Variable HIV transmission risk Coercive sex vs Consensual sex (REF) Consensual sexCoercive sex (N=232)(N=117) Multivariate Model N(%)N Odds ratio (95% CI)P-value Years living in Canada (categorical) <0.001 DK/PNTA 4(1.7) Less than 5 years 33(14.2)42(35.9) (2.549, ) 5 to 10 years 70(30.2)48(41.0) 2.37 (1.243, 4.519) More than 10 years (REF) 125(53.9)27(23.1) Ethnicity Indigenous 1(0.4) Other 39(16.8)8(6.8) (0.306, 4.672) African/Caribbean/Black 164(70.7)105(89.7) (0.569, 5.963) Caucasian (REF) 28(12.1)4(3.4) Personal gross yearly income DK/PNTA 4(1.7) < $ (62.5)90(76.9) (0.737, 4.842) $20000-$ (22.4)20(17.1) (0.381, 3.242) >=$40000 (REF) 31(13.4)7(6.0) Mental health conditions 10- [Post Traumatic Stress Disorder] DK/PNTA 3(1.3)3(2.6) Yes 6(2.6)14(12.0) (2.246, ) No (REF) 223(96.1)100(85.5) African countries that experienced histories/ongoing war/conflict and noted high rates of GBV in conflict Unknown1(0)1(1) South Sudan/DRC/Rwanda/Nigeria24(10)30(26)2.127 (1.094, 4.137) Others (REF) 207(89)86(74) RESULTS Table 5. Model 3: Sociodemographic Characteristics of Women Born Outside Canada Acquiring HIV through Coercive vs. Consensual Sex in the CHIWOS Cohort N=349 <5 years living in Canada aOR 5.17 ( 2.55, 10.50) p<0.001 PTSD aOR 6.75 (2.25, 20.26) p=0.001 High Prevalence GBV country aOR 2.13 (1.09,4.14) p=0.026

Limitations The use of self-report leads to the lack of confirmation that coercive sex act was definite cause of HIV The cohort is a non-random – potential sampling bias – Women who experienced violence likely less likely to enrol; so the rate of 16.5% is likely an under-representation Missing data—related to use of questionnaires in general

Conclusion & Discussion Coercive sex is a significant yet under-considered risk factor and mode of HIV acquisition (3 rd highest) among women with HIV. Analysis of place of birth highlights the importance of targeted HIV testing and treatment for women – Born in Canada: precarious housing/shelters, safe injection sites, etc. – Born outside of Canada: newcomer welcome centres, shelters, refugee health clinics Considering the global burden of intimate partner violence (1 out of 3 women) and the risk of HIV transmission through coercive sex in our sample (16.5%), interventions to prevent IPV need to be drastically scaled up as an HIV prevention measure 16.5% of women in CHIWOS self-report coercive ex as their mode of HIV acquisition Ask Public Health to separate the reporting of heterosexual sex – 1. consensual vs. 2. non- consensual/coercive Higher awareness of violence in our patient population Southern Alberta Clinic (SAC) IPV screening program 1  35% of 1,721 participants had experienced partner violence in a past relationship, as a child or was currently experiencing IPV  Prior to this study only 1 in 5 had ever been screened for IPV 1. Raissi SE, Krentz HB, Siemieniuk RA, et al. Implementing an intimate partner violence (IPV) screening protocol in HIV care. AIDS Patient Care and STDs Mar;29(3):

Acknowledgments We would like to thank everyone involved for their invaluable contributions to the study. Thank you to… All the women living with HIV involved in this study; The PIs, Coordinators, Peer Research Associates, and all the co-investigators and collaborators; The Steering Committee, Community Advisory Board members, and CAAB-PAW members; Our funders: CIHR Institute of Gender and Health, the CTN, and OHTN; Our affiliated studies: CANOC, REACH & OSC; and all of our partners for supporting the study. In Memoriam

How to get in touch: For more information about CHIWOS, please contact: Allison Carlson (ON Coordinator): x 2323, Sally Lin (BC): , Karène Proulx Boucher (QC): x 32146, facebook.com/CHIWOS twitter.com/CHIWOSresearch