The quantitative findings from the surveillance data examine the sex and age characteristics of HIV screening test recipients between April 16th 2009 and April 15th 2010. By using multiple methods of data collection and analysis, including an examination of the surveillance and interview data in conjunction with a review of previous research and testing policies, a more comprehensive picture of the experiences and perceptions of HIV testing and counselling in Nova Scotia emerged. The qualitative findings reported in this article focus on the gendered implications of HIV counselling and testing in Nova Scotia and focus on the themes that emerged from the perceptions and experiences of the interview participants, both from those who had and had not been tested in the past year (prior to the time of the interview). These three key themes include: perceptions of routine testing, stigma and discrimination, and sexual behaviours and relationships. What follows is a description of the quantitative and qualitative results and findings in greater detail, beginning with the quantitative surveillance data.
In-depth Interview Data
A number of issues relating to gender emerged through the course of the individual, semi-structured in-depth interviews with the 50 adult participants (30 women, 19 men, 1 trans-gendered person). These findings should be viewed as key points that are intended to bring greater awareness to the gender-specific issues related to HIV testing and counselling in Nova Scotia that men and women experience, including the perception and experience of risk factors, the willingness to go for testing, and perceptions of sexual health in general.
The major themes that emerged pertaining to gendered expectations, attitudes and behaviours regarding HIV testing and counselling in Nova Scotia included: the experience and perception of pre-natal screening; the perception of Pap tests and general sexual health services as routine; the availability of accessible testing and counselling services; the experience and perception of stigma and discrimination; and the relationship status and/or perceptions of monogamy as it relates to the decision to be tested.
Based on the interview data, a number of female participants suggested that an HIV test would seem more accessible to them if it was routinized, similarly to prenatal and regular Pap testing that is promoted for women. The availability of accessible HIV testing services encompassed issues of comfort with services, and intersection of gender with other determinants of health, such as ethno-racial and cultural identities. Experiences and perceptions of stigma and discrimination in regards to HIV testing equity were discussed by several participants in regards to their gender, sexuality and sexual identity. Finally, perceptions about sexual relationships and monogamy were also described in terms of gendered norms and expectations regarding HIV testing and counselling.
A) Routine HIV Screening
Several participants interviewed had been tested for HIV while they were pregnant. This was generally discussed as a routine process, and this service was routinely offered, as described in the following quotation:
"I guess they just wanted me to test, 'cause I guess you can get infections and stuff when you're pregnant and they just wanted to check me out and see if I had any STDs..." (Female, 20s, Aboriginal, High School, HRM, Tested)
In some instances, pregnancy was the main reason participants were tested or considered being tested for HIV. One participant suggested this type of testing was easier for her, and she felt for pregnant women in general, because HIV testing during pregnancy is considered to be routine and normalized as part of the prenatal care offered.
"For me the testing was done at the time when I was pregnant, so I'm thinking for women who are expecting it's easier for them because it is a test that the doctor usually asks do you want... and I think it happens anyway when you're pregnant." (Female, 30s, African Nova Scotian, College/University, HRM, Not Tested)
A male participant commented on the fact that HIV testing is routinely, but also exclusively, being offered to women who are pregnant or are planning on becoming pregnant. This is an important gender-based issue in that it may prevent many heterosexual men from coming forward for testing:
"HIV is not being suggested by health care providers unless you are a woman and you are either expecting a baby or interested in becoming pregnant..." (Male, 50s, Caucasian, College/University, Outside HRM, Tested prior to past year)
The relationship between HIV testing and general sexual health, Pap tests in particular, also became apparent in conversation with the participants. In a number of instances, female participants mentioned the idea that HIV testing could be normalized, in the way that they perceived Pap tests to be promoted routinely for sexually-active women. The following participants' comments summarize some of the perceptions about HIV testing and the participants' ideas about routinizing this test:
"I haven't been [tested for HIV] actually. And I know it's probably something everyone should have done, kind of like a woman should always have a Pap smear kind of thing..." (Female, Teens, Caucasian, Outside HRM, In High School, Not Tested)
"It [HIV testing] is almost like a Pap test; you have to get it done every year. So I think that everybody should have to get it done every year." (Female, 30s, Aboriginal, HRM, College/University, Tested prior to past year)
"For women anyway, maybe it [HIV testing] could be a mandatory part when you go through your yearly check-up, for your Pap test, or maybe it could be a mandatory test that is run when they send your Pap test..." (Female, 20s, Caucasian, Outside HRM, College/University, Not Tested)
"I guess making it [HIV testing] more mainstream, like in the same way that people are encouraged... to get their Pap smears at 18 or when you become sexually active. You have your HIV test, you're sexually active, or this age. It should just become a routine part of your health care." (Female, 20s, Caucasian, College/University, HRM, Not Tested)
Some participants suggested that HIV testing is actually more stigmatized because it is such a specialized test that is set aside from comparably routine sexual health services, such as a Pap test. This sentiment is highlighted in the following:
"You can't just get it [HIV testing] when you get your regular Pap or anything. It's a very specialized test... HIV is so specific like you get tested for HIV/AIDS and it's done, like drawing blood, it's in its own little category. It's easier to be stigmatized 'cause you can't just say oh I just got tested for STIs and that's all encompassing." (Female, 20s, Caucasian, College/University, HRM, Not Tested)
Alternatively, another participant suggested that she was more comfortable getting what she perceived to be routine sexual health services, and did not want to be tested for HIV when it was brought up by her health care practitioner:
"I had gone for a Pap test and I wanted to get some blood work done for other things, I think it was an iron thing and she asked me had I ever gone for an HIV test before and I said no I hadn't... I just wanted to go for my normal Pap test and get my blood work done and go home." (Female, Teens, Caucasian, HRM, Some High School, Not Tested)
Suggestions about ways to make HIV testing more routine, both in relation to prenatal HIV screening and general sexual health Pap tests, was discussed by many female participants when they were asked about their perceptions about HIV testing. HIV testing was perceived to be routine during prenatal screening, and participants generally promoted the idea that HIV testing would be more acceptable if it was routinely offered similarly to Pap tests.
B) Stigma and Discrimination
Stigma and discrimination also emerged as significant to many participants in relation to health equity and HIV testing. Stigma has been defined as an association with socially-unacceptable behaviours resulting in discrimination or social exclusions derived from this association . The stigma and discrimination associated specifically with being tested for HIV was discussed by several participants, particularly in terms of how this intersected with sexuality or ethno-racial identity. One participant commented on the association between AIDS, male homosexuality, and homophobia:
"I know that there are people out there that automatically assume if you have AIDS that it has to do with homosexuality, that there are people who are homophobic..." (Female, 60s, African-Nova Scotian, Some College/University, Outside HRM, Not Tested)
One participant discussed that having HIV would compound the stigma and discrimination she already feels based upon her ethno-racial identity.
"Even though you cannot have it [HIV] by touching me or by sitting beside me, they will run from you... already because you are Black, people don't really associate enough with you anyway." (Female, 50s, African-Nova Scotian Immigrant, Master's, HRM, Tested prior to past year)
Another participant suggested that stigma and discrimination were the biggest barriers to accessing HIV testing, in specific reference to being gay or transgendered.
"I think that's one of the big problem is that a lot of people being gay or transgendered or being involved in risky behavior, they don't have the support mechanism, they don't want the stigma or discrimination attached to them." (Trans, 30s, Caucasian, Some College/University, Outside HRM, Not Tested)
One participant suggested that she and several of her friends who had also immigrated to Canada would prefer to access sexual health services at hospitals, where the reason for the visit would be obscured, given that they did not feel comfortable accessing sexual health services:
"As far as taking an immigrant woman to get testing, even if the doctor has 100 other things ticked off, she knows everybody knows that this is what she's coming in for. It's a mental state and there's not a whole lot you can do about it other than holding her hand..." (Female, 50s, African-Nova Scotian Immigrant, Master's, HRM, Tested)
The issues of stigma and discrimination in terms of health equity in HIV testing was shown to influence individual's perceptions and experiences in terms of how gender intersects with ethno-racial identity, sexuality and sexual health-seeking behaviours.
C) Sexual Behaviours and Relationships
Perceptions and experiences surrounding sexual behaviours and relationships were prominently discussed amongst the participants in reference to how their sexual activity might be perceived, and also how they perceive their risk of contracting HIV within the content of a monogamous relationship. One participant discussed the link between testing for HIV and the perception of being considered promiscuous:
"I couldn't go around telling everybody you know I went for an AIDS test or HIV test... cause they'd say oh my god that lady she's promiscuous you know..." (Female, 50s, Aboriginal, HRM, Tested)
Some participants in monogamous relationships, particularly those who were married or who had been together for many years, did not feel they were at risk for HIV, as suggested in the following quotations:
"Don't get me wrong; if I had any suspicion that something like that was going on, I would be tested. But personally, like I said, I strongly believe that I'm in a monogamous relationship..." (Interview 2 - Female, 30, Caucasian, College, Outside HRM, Not Tested)
"It's not an issue for me cause I've been married for twenty-five years so... no like I say not for me, we just celebrated our 25
wedding anniversary so..." (Female, 40s, Caucasian, College/University, Outside HRM, Not Tested)
"I'm not at any risk factors. I'm in a loving relationship so... no I haven't put myself at risk, so why would I want to do that? I get tested for everything, but not even a remote thought about HIV testing." (Male, 60s, Caucasian, College/University, HRM, Not Tested)
On the other hand, several participants commented on the importance of being tested for HIV, despite being in a monogamous relationship, although often these relationships were not long-term:
"There's no guarantee that the other person that you're with is not doing something. I mean, you can't be there 24/7 to watch them... nobody else is going to look out for you, so you've got to look out for yourself, to take care of yourself." (Female, 30s, Aboriginal, College/University, HRM, Tested prior to past year)
"I've been with him for [several months], but when I met him he was a stranger to me... he told me he wasn't with anyone... he's a pretty nice guy, but you can never be sure." (Female, 50s, Aboriginal, College/University, HRM, Tested)
Other participants mentioned that a main reason for seeking testing was their sexual partner's desire for them to be tested. Several heterosexual male participants noted that had their female sexual partners not asked for them to get tested, they would not have accessed HIV testing.
"I think it was more my girlfriend that wanted me to be tested more than my doctor. I think it was like my girlfriend's decision, my girlfriend's decision so..." (Male, teens, Caucasian, Some high school, HRM, Tested)
Another participant stated that he had been tested for STIs only after his female partner asked him to be tested. The following quote speaks to the gender normative help-seeking behaviors for females which are largely absent for males. When asked what might encourage him to be tested for HIV, he said:
"I don't know... nothing. Unless I had a spouse or something and she made me..." (Male, teens, Aboriginal, Some high school, HRM, Not tested)
Other participants still suggested that they were tested or would consider getting tested for HIV prior to getting married or starting a new relationship:
"I told her, let's both go to the hospital and let's get checked... I said I don't want to have to be accused of messing around. Like condoms, what are they on you for?" (Male, 30s, Aboriginal, HRM, Tested prior to past year)
"As a young man... we do have risky behaviors, and sometimes you want [the HIV] test to give you direction to your life... Maybe if you want to marry or something like that." (Male, 30s, African Nova Scotian Immigrant, Master's, HRM, Tested prior to past year)
In summary, perceptions about monogamy and gendered risk-taking within relationships, including risks associated with the gender-based sexual double standard for males, were shown to be wide-ranging yet significant amongst many participants. Additionally, perceptions of what was considered to be acceptable or unacceptable sexual practices, including perceptions linked to HIV risk and help-seeking behaviours, were also embedded in their gender-based explanations for why they would or would not consider being tested for HIV.