HIV/AIDS is an epidemic of intersectional inequality is fueled by inequitable determinants of health with key influences at the macro, meso, and micro levels of any country (Watkin-Hayes, 2014 ) More so, HIV/AIDS has moved from a concept of death verdict to a well-managed chronic disease; thus, new social realities arise as “complex intersections between socio-economic, physical, political, and biological environment with social identities generate vulnerabilities and risks” (Black & Veenstra, 2011) to African women’s health. Their development of resilience to challenging structural determinants is not common to African women as these opportunities are not easily discerned and assessed individually due to increased risk to their social relationships. For instance, an inability to negotiate safer sex during sexual activities due to poverty still exists in Canada due to patriarchal cultural norms being carried down from their sending countries.
Gender has been well-acknowledged as a key determinant for population health in academic literature; however, vital upstream factors of health equity for African women were formally enumerated in PHAC (2009) as determinants of health: These include social supports networks, employment/working conditions, income and social status, healthy child developments, personal health practices and coping skills, education and literacy, social environments, culture, genetic and biologic endowments, and health services. Ironically, all these determinants affect the health of African women in Canada. The health of any populace is entrenched in their ability to access fundamental human rights; women have a right to enjoy their life without any discrimination of their identities. The equity approach, as a principle seen with the intersectionality paradigm, brings in an ease in affordability, accessibility and availability of range of social, economic and environmental products and services that determine the health and well-being of individuals or populations.
African women’s biological determinant of health is an innate constitution of their inheritance and with a predilection to acquiring negative health status from a heightened predisposition to certain diseases such as HIV/AIDS. For instance, there is an inherited predilection that increases the risk of contracting HIV virus during an unprotected penile-vaginal and even penile-anal intercourse due to an intromission of infected semen. This transmission of HIV virus to the women is related to the higher concentration of the virus in infected semen in comparison with vaginal secretion; a larger sensitive vaginal mucosal area transmission inhabits the infected semen for a longer period of time; potentialities of the female genital tract being abraded during an agreed or forced sex (gender violence common in SSA especially in war times and even in that safe confines of formal systems); and the ability of the virus to permeate into the reproductive tract of women by eroding the protective layers, a factor that hinders vaccination and microbicides as preventive strategies for females (PHAC, 2012, p. 42). Also, co-infection of other sexually transmitted infections such as Syphilis, gonorrhea, candida increases the vulnerability of the vaginal mucosa to the HIV virus due to the abraded surfaces arising from inflammatory processes.
The social determinant of health (SDOH) involves a variety of social, environmental and economic circumstances that drive the individual and group differences in health status. Daily, African women are saddled with diverse conditions where they are born, grow, live, work and age, (CSDH, 2010; Marmot, 2008) with obvious connections to their health emanating from the contextual distribution of power, money and resources. The SDOH include income and its distribution, education, unemployment & job security, employment & working conditions, early child development, food security, housing, social exclusion, social safety net, healthcare services, indigenous ancestry, gender, race, and disability. Two more determinants were added by Rapheal (2016) to include immigration status and geography. However, this special population of African women has become a rallying point for different international agenda for the many issues of SDOH that beleaguers them and make them vulnerable. Canada ratified these international documents: however, policy implementation and enforcement are challenging. Human rights for African women is part of the Rio declaration; however, having rights is one thing but it should be contextually ensured that they exercise these rights.
These issues of SDOH in Canada still lag behind in acknowledging and including their needs in social and health care policies; such as homelessness or poor-quality dwelling structures, stigma, addiction, poverty, physical and sexual abuses, untreated mental health problems, lack of unemployment opportunities, powerlessness, lack of choice, lack of legal resident status, and lack of social support. A typical example is their deep-rooted financial concerns that influence their access to social and health services for their lives and their families. Sustained source of income has to be maintained with little or no loss of employment as they are plagued by economic deskilling and low pay. Access to anti-retro viral (ARV) drugs becomes challenging by geographical and financial inaccessibility; more so, for an African woman that is not a conventional refugee or Canadian citizen, procuring their ARV drug procurement is out of pocket expense (PHAC, 2009). The achievement of zero level of blood virus with highly active antiretroviral therapy is far-fetched. Therefore, “Treatment as Prevention” in this time of Undetectable = Untransmittable may not be feasible. This has to be tackled through policy changes that will impact on an economic upturn for African women so as to reinvigorate contemporary HIV prevention, stigma interventions, health promotion and care. Different overlapping social effects with the integration of intersecting inequalities and the impacts of assessing SDOH by these women becomes an interaction of toxic combination of poor social policies and programs, unfair economic arrangements. These toxic combinations comprise structural determinants and conditions of daily life that constitute the larger part of health inequities between the dominant society and the marginalized group (CSDH, 2008).
These drivers or influences, as structural factors define those who accesses health services; such as subsidized mental health centres, social services such as community women centres with free information, counselling and care services for immigrant women with diverse needs; and material resources such as housing and certain safe physical environments. Despite the sensitizing and discriminating stances to HIV for African women, internalized denials that stem from religious norms, gossips and lies within communities and families exists (CHABAC, 2019). These limits support from social structures and capital that function through relationships of interpersonal trust, norms of reciprocity, and mutual aid. These social safety nets act as resources for individuals and facilitate collective action to influence people’s health-relevant behavior. These influences are facilitated through transmission of supportive relationship norms for positive health outcomes. However, their normative identity has not been dismantled through upstream factors. As such their framing by the dominant society perpetuates their non-access to downstream factors. Hence, African women are not socially privileged due to their social location. In effect, effective impact from upstream factors should include removal of social exclusions seen as stigma and discriminations associated with their universal access to health and social services as they are accompanied with life stressors. Watkins-Hayes (2014) pointed out that, “HIV interacts with already existing social advantages or disadvantages, becoming a component of identity (as HIV related stigma) that intersects with other identities and together, these interlocking positions produce social meanings; limit or grant power; and interact with structures, institutions, and individuals to shape the experience of being HIV positive” (p.443). For these abuses and social profiling, these women are expected by their originating culture to keep silent and take it in their stride (Brown-Speights et al, 2017; Etowa et al 2007; Etowa et al, 2017. However, the impact on their access to care and quality of care translates to poor individual and population health outcomes (Caiola, 2014).
As a western nation, the inability of women in certain social situations been incapable of driving the negotiations of current HIV prevention options; such as abstinence to a certain extent, behavior change, condoms and medical male circumcision of their sons or early treatment initiation in their relationships (Kharsany & Karim, 2016) go a long way to reveal the social nature behind the acquisition of HIV/AIDS (Stephenson & Kippax, 2012).
