Rod Knight

‘Not the swab!’ Young men’s experiences with STI testing

In Canada, STI rates are high and rising, especially amongst young men. Meanwhile, the needs of young men regarding STI testing services are poorly understood, as are the socio-cultural and structural factors that influence young mens sexual health-seeking behaviours. To better understand this phenomenon, we draw on interviews with 45 men (ages 15-25) from British Columbia, Canada. Our research reveals how structural forces (e.g. STI testing procedures) interact with socio-cultural factors (e.g. perceptions of masculinities and feminities) to shape young mens experiences with STI testing. STI testing was characterised as both a potentially sexualised experience (e.g. fears of getting an erection during genital examinations), and as a process where young men experience multiple vulnerabilities associated with exposing the male body in clinical service sites. In response, participants drew on dominant ideals of masculinity to reaffirm their predominately hetero-normative gender identities. Despite growing up in an era where sexual health promotion efforts have been undertaken, participants did not feel they had permission to engage in discussions with other men about sexual health issues. Attending to young mens perspectives on STI testing represents a starting point in reforming our approaches to addressing how socio-cultural and structural factors shape these experiences.

Youth’s experiences with STI testing in four communities in British Columbia, Canada

Objectives: To analyse the experiences of youths accessing sexually transmitted infection (STI) services and to examine the perspectives of service providers in four British Columbia communities. Methods: In-depth qualitative interviews were completed with 70 young men and women (15–24 years). In total, 22 service providers (for example, clinicians, staff) were interviewed about their experiences providing STI testing services as well as the policies and practice guidelines that inform their work with youths. In addition, naturalistic observation was conducted at 11 clinic sites, including: youth clinics, doctors’ offices, public health units and a large clinic specialising in STI testing. Results: “Youth-friendly” STI testing services were rare despite being strongly desired by youth and service providers. Participants identified five barriers to accessing and/or providing youth-friendly STI testing: geography isolates many youths from testing service times or services, and presents privacy concerns, especially for rural youths. Clinic décor was perceived to be tailored for women and most service providers were female. Disclosing risky sexual behaviour to clinicians may be difficult for youths, especially for lesbian, gay, bisexual and transgender youths—particularly in contexts that are perceived to be homophobic. Many young women mistakenly believe that Pap smears include STI testing procedures, while many young men avoid testing because they fear the urethral swab and are unaware of alternative methods of specimen collection. Conclusion: This research reveals how structural and socio-cultural forces (for example, gender, place, physical space, culture) interact to shape the experiences of youths accessing STI testing services.

Heteronormativity hurts everyone: experiences of young men and clinicians with sexually transmitted infection/HIV testing in British Columbia, Canada

Heteronormative assumptions can negatively influence the lives of young gay and bisexual men, and recent sociological analyses have identified the negative impacts of heteronormativity on heterosexual men (e.g. ‘fag discourse’ targeted at heterosexual adolescents). However, insights into how heteronormative discourses may be (re)produced in clinical settings and how they contribute to health outcomes for gay, bisexual and heterosexual men are poorly understood. This analysis draws on in-depth interviews with 45 men (15–25 years old) and 25 clinicians in British Columbia, Canada, to examine how heteronormative discourses affect sexually transmitted infection testing. The sexually transmitted infection/HIV testing experience emerged as a unique situation, whereby men’s (hetero)sexuality was explicitly ‘interrogated’. Risk assessments discursively linked sexual identity to risk in ways that reinforced gay men as the risky ‘other’ and heterosexual men as the (hetero)normal and, therefore, relatively low-risk patient. This, in turn, alleviated concern for sexually transmitted infection/HIV exposure in heterosexual men by virtue of their sexual identity (rather than their sexual practices), which muted discussions around their sexual health. The clinicians also positioned sexual identities and practices as important ‘clues’ for determining their patients’ social contexts and supports while concurrently informing particular tailored clinical communication strategies. These findings highlight how men’s experiences with sexually transmitted infection/HIV testing can (re)produce heteronormative assumptions and expectations or create opportunities for more equitable gendered relations and discourses.

Sex and straight young men: Challenging and endorsing hegemonic masculinities and gender regimes

Young men are considered to have power and to be powerful in many social settings and in particular within the realm of sexual relations. This article details research that directly asks young men how they perceive, interact with, and deploy power within intimate heterosexual relationships. Semi-structured interviews were conducted with 13 Canadian-based young men (aged 17-22 years) to explore how power was understood and enacted within their intimate heterosexual relationships. A social constructionist gendered analysis was used to inductively derive themes and situate the experiences of the participants within societal discourses of hegemonic masculinities and gender regimes. Power within relationships was most often described as operating equitably, with a few participants describing the deployment of power in coercive/controlling ways. Results reveal that the use of power by men can be understood as challenging or endorsing hegemonic masculinities and traditional heterosexual gender regimes. By including young mens voices in such discussions, our research contributes important understandings and some traction towards describing what might constitute more equitable gender and power relations.

Complex and Conflicting Social Norms: Implications for Implementation of Future HIV Pre-Exposure Prophylaxis (PrEP) Interventions in Vancouver, Canada

Background HIV Pre-Exposure Prophylaxis (PrEP) has been found to be efficacious in preventing HIV acquisition among seronegative individuals in a variety of risk groups, including men who have sex with men and people who inject drugs. To date, however, it remains unclear how socio-cultural norms (e.g., attitudes towards HIV; social understandings regarding HIV risk practices) may influence the scalability of future PrEP interventions. The objective of this study is to assess how socio-cultural norms may influence the implementation and scalability of future HIV PrEP interventions in Vancouver, Canada. Methods We conducted 50 interviews with young men (ages 18–24) with a variety of HIV risk behavioural profiles (e.g., young men who inject drugs; MSM). Interviews focused on participants’ experiences and perceptions with various HIV interventions and policies, including PrEP. Results While awareness of PrEP was generally low, perceptions about the potential personal and public health gains associated with PrEP were interconnected with expressions of complex and sometimes conflicting social norms. Some accounts characterized PrEP as a convenient form of reliable protection against HIV, likening it to the female birth control pill. Other accounts cast PrEP as a means to facilitate ‘socially unacceptable’ behaviour (e.g., promiscuity). Stigmatizing rhetoric was used to position PrEP as a tool that could promote some groups’ proclivities to take ‘risks’. Conclusion Stigma regarding ‘risky’ behaviour and PrEP should not be underestimated as a serious implementation challenge. Pre-implementation strategies that concomitantly aim to improve knowledge about PrEP, while addressing associated social prejudices, may be key to effective implementation and scale-up.

Advancing population and public health ethics regarding HIV testing: a scoping review

Recently, scholars have called for more robust population and public health ethical frameworks to inform how the health of populations and individuals ought to be improved through various approaches to HIV testing practices. Our objective is to examine the breadth, range and foci of a variety of ethical issues pertaining to HIV testing approaches within the peer-reviewed literature, and how these issues address population and/or individual interests. We identify potential tensions between individual and collective approaches as well as other concerns, including equity, justice and distribution of health and risk – hallmarks of the emergent field of population and public health ethics. Based on our review, we suggest that additional theoretical work and empirical research are required in order to inform more ethically robust debates related to population HIV testing practices. Specifically problematic were consequentialist arguments that deem testing approaches as either morally permissible or impermissible without sufficient robust empirical and/or theoretical underpinnings and about how a particular approach would unfold among individuals and populations. The current review underscores the need to continue to articulate an evidence- and theory- informed population and public health ethics pertaining to HIV testing.

A scoping study to identify opportunities to advance the ethical implementation and scale-up of HIV treatment as prevention: priorities for empirical research.

BackgroundDespite the evidence showing the promise of HIV treatment as prevention (TasP) in reducing HIV incidence, a variety of ethical questions surrounding the implementation and “scaling up” of TasP have been articulated by a variety of stakeholders including scientists, community activists and government officials. Given the high profile and potential promise of TasP in combatting the global HIV epidemic, an explicit and transparent research priority-setting process is critical to inform ongoing ethical discussions pertaining to TasP.MethodsWe drew on the Arksey and O’Malley framework for conducting scoping review studies as well as systematic approaches to identifying empirical and theoretical gaps within ethical discussions pertaining to population-level intervention implementation and scale up. We searched the health science database PubMed to identify relevant peer-reviewed articles on ethical and implementation issues pertaining to TasP. We included English language articles that were published after 2009 (i.e., after the emergence of causal evidence within this field) by using search terms related to TasP. Given the tendency for much of the criticism and support of TasP to occur outside the peer-reviewed literature, we also included grey literature in order to provide a more exhaustive representation of how the ethical discussions pertaining to TasP have and are currently taking place. To identify the grey literature, we systematically searched a set of search engines, databases, and related webpages for keywords pertaining to TasP.ResultsThree dominant themes emerged in our analysis with respect to the ethical questions pertaining to TasP implementation and scale-up: (a) balancing individual- and population-level interests; (b) power relations within clinical practice and competing resource demands within health care systems; (c) effectiveness considerations and socio-structural contexts of HIV treatment experiences within broader implementation contexts.ConclusionOngoing research and normative deliberation is required in order to successfully and ethically scale-up TasP within the continuum of HIV care models. Based on the results of this scoping review, we identify several ethical and implementation dimensions that hold promise for informing the process of scaling up TasP and that could benefit from new research.

HIV stigma and the experiences of young men with voluntary and routine HIV testing

As routine HIV testing approaches are implemented to enhance participation rates in HIV testing, it is often widely believed that these approaches are socially and ethically justifiable given the underlying assumption that these practices will result in the widespread reduction of HIV-related stigma. Nonetheless, a variety of empirical and theoretical gaps on how HIV testing practices may impact on HIV stigma remain, raising questions about the social underpinnings of the public health rationale. We draw on 50 interviews with 18-24 year-old men to determine how HIV-related stigma is experienced differentially across subgroups of young men in relation to both voluntary and routine testing practices. The mens experiences with routine testing highlight how (mis)interpretations of universal, routine testing practices may serve to (unintentionally) burden disadvantaged subgroups of men; however, when these practices are adequately explicated, the universal dimension of a routine offer greatly diminished these concerns. These findings also show that, under the right conditions, a routine offer can provide transformative opportunities for individuals to reconceptualise their expectations over HIV and HIV-related stigma.

A review of measures used to assess HIV-related stigma among young people living with HIV: missing accounts of sex and gender

ABSTRACT Most studies of HIV-related stigma focus on adult populations. This study reviews empirical studies that measure HIV-related stigma among young people living with HIV (YLHIV). Using Earnshaw and Chaudoir’s (2009) framework, studies that assessed, enacted, internalized, perceived and anticipated stigma were coded and then evaluated on their use of sex or gender according to the following criteria: (i) recruiting equal number of young men and women; (ii) asking some questions/subsections of young men/women only; (iii) treating sex/gender as a covariate, or stratifying by or controlling for sex/gender; (iv) acknowledging the importance of sex/gender considerations in the discussion. Of the 2272 abstracts initially screened, 27 papers were eligible for analysis. While several studies (n = 12) measured all four types of stigma, four measured anticipated and internalized stigma and one measured perceived and internalized stigma. Moreover, two measured perceived and enacted stigma and two others measured only enacted stigma. Two studies measured only perceived stigma, and two assessed only internalized stigma. Most (n = 15) studies did not account for sex- or gender-based differences regarding HIV-related stigma and 10 did not report on participants’ sexual orientation. Of the 19 studies that included both male and female YLHIV, 6 did not account for sex/gender in their analyses. Very few (n = 6) studies reported on transgender YLHIV. Overall, a limited amount of HIV-related stigma research involved young people, despite the fact that this population experiences over 40% of annual incident rates globally. Additionally, overlooking sex- and gender-based differences is concerning given the evidence on gender differences regarding perceived HIV stigma and social rejection, discrimination, shame and psychological distress. Gender-specific stigma should be considered in future studies. A failure to do so leaves open the possibility of missing (or misunderstanding) relevant considerations (e.g. sex/gender-based differences or similarities) that may be amenable to stigma-reduction interventions.

Implementation challenges and opportunities for HIV Treatment as Prevention (TasP) among young men in Vancouver, Canada: a qualitative study

BackgroundDespite evidence supporting the preventative potential of HIV Treatment as Prevention (TasP), scientific experts and community stakeholders have suggested that the success of TasP at the population level will require overcoming a set of complex and population-specific implementation challenges. For example, the factors that might influence decisions to initiate ‘early’ treatment have yet to be thoroughly understood; neither have questions about the factors that enhance or impede their ability to achieve long-term adherence to ARVs or the social norms regarding various treatment regimens been examined in detail. This knowledge gap may hamper opportunities to effectively develop public health practices that are informed by the various challenges and opportunities related to TasP implementation and scale up.MethodsDrawing on 50 in-depth, individual interviews with young men ages 18–24 in Vancouver, Canada, this study examines young men’s perspectives regarding factors that might affect their engagement with TasP.ResultsWhile findings from the current study indicate young men generally have a high receptiveness to TasP, our findings also identify key social and structural forces that will warrant ongoing consideration for TasP implementation. For example, participants described how an enhanced awareness regarding treatment (including awareness of the universal availability of treatment in Vancouver) would be a necessary, but not sufficient, condition to decide to endorse TasP. Their decisions about engaging in HIV care in the context of TasP (e.g., HIV testing, treatment initiation, long-term adherence) also appear to be contingent on their ability to negotiate or ‘balance’ the risks and benefits to themselves and others. The findings also offer insight into the complex and sometimes controversial narratives that continue to emerge regarding risk compensation practices in the context of TasP.ConclusionBased on the results of this study, we identify several areas that hold promise for informing the effective scale up of TasP, including new information regarding implementation adaptation strategies.