Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.
St, Michael's Hospital, Li Ka Shing Knowledge Institute, Toronto, Canada.
Int J Equity Health. 2023 Feb 17;22(1):33. doi: 10.1186/s12939-022-01792-4.
Biomedical advances in healthcare and antiretroviral treatment or therapy (ART) have transformed HIV/AIDS from a death sentence to a manageable chronic disease. Studies demonstrate that people living with HIV who adhere to antiretroviral therapy can achieve viral suppression or undetectability, which is fundamental for optimizing health outcomes, decreasing HIV-related mortality and morbidity, and preventing HIV transmission. African, Caribbean, and Black (ACB) communities in Canada remain structurally disadvantaged and bear a disproportionate burden of HIV despite biomedical advancements in HIV treatment and prevention. This institutional ethnography orients to the concept of 'structural violence' to illuminate how inequities shape the daily experiences of ACB people living with HIV across the HIV care cascade. We conducted textual analysis and in-depth interviews with ACB people living with HIV (n = 20) and health professionals including healthcare providers, social workers, frontline workers, and health policy actors (n = 15). Study findings produce a cumulative understanding that biomedical HIV discourses and practices ignore structural violence embedded in Canada's social fabric, including legislation, policies and institutional practices that produce inequities and shape the social world of Black communities. Findings show that inequities in structural and social determinants of health such as food insecurity, financial and housing instability, homelessness, precarious immigration status, stigma, racial discrimination, anti-Black racism, criminalization of HIV non-disclosure, health systems barriers and privacy concerns intersect to constrain engagement and retention in HIV healthcare and ART adherence, contributing to the uncertainty of achieving and maintaining undetectability and violating their right to health. Biomedical discourses and practices, and inequities reduce Black people to a stigmatized, pathologized, and impoverished detectable viral underclass. Black people perceived as nonadherent to ART and maintain detectable viral loads are considered "bad" patients while privileged individuals who achieve undetectability are considered "good" patients. An effective response to ending HIV/AIDS requires implementing policies and institutional practices that address inequities in structural and social determinants of health among ACB people.
在医疗保健和抗逆转录病毒治疗或疗法（ART）方面的生物医学进步，已经将 HIV/AIDS 从死刑转变为可控制的慢性疾病。研究表明，坚持接受抗逆转录病毒治疗的 HIV 感染者可以实现病毒抑制或无法检测到，这对于优化健康结果、降低 HIV 相关死亡率和发病率以及预防 HIV 传播至关重要。尽管在 HIV 治疗和预防方面取得了生物医学进步，但加拿大的非洲裔、加勒比和黑人（ACB）社区在结构上仍处于不利地位，HIV 负担不成比例。本机构民族志研究以“结构性暴力”的概念为指导，阐明不平等如何塑造了整个 HIV 护理过程中，ACB 艾滋病毒感染者的日常生活。我们对 20 名感染 HIV 的 ACB 感染者和包括医疗保健提供者、社会工作者、一线工作者和卫生政策制定者在内的卫生专业人员（n=15）进行了文本分析和深入访谈。研究结果得出了一个综合的认识，即 HIV 的生物医学话语和实践忽视了加拿大社会结构中嵌入的结构性暴力，包括产生不平等并塑造黑人社区社会世界的立法、政策和机构实践。研究结果表明，健康的结构性和社会决定因素不平等，如粮食不安全、财务和住房不稳定、无家可归、不稳定的移民身份、污名化、种族歧视、反黑人种族主义、HIV 不披露的刑事定罪、卫生系统障碍和隐私问题相互交织，限制了 HIV 医疗保健和 ART 依从性的参与和保留，导致难以实现和维持无法检测到以及侵犯他们的健康权。生物医学话语和实践以及不平等现象将黑人贬低为一个被污名化、病态化和贫困化的可检测到的病毒下层阶级。被认为不遵守 ART 且维持可检测病毒载量的黑人被视为“不良”患者，而那些实现无法检测到的特权个人则被视为“良好”患者。要有效应对终结 HIV/AIDS，就需要实施政策和机构实践，以解决 ACB 人群中健康的结构性和社会决定因素的不平等问题。
