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Published in final edited form as: Health Soc Care Community. 2021 May 12;30(1):e138–e147. doi: 10.1111/hsc.13420

IN THE MIDST OF PLENTY: EXPERIENCES OF FOOD INSECURITY AMONGST WOMEN LIVING WITH HIV IN VANCOUVER, CANADA

Ariel Sernick 1,2, Kate Shannon 1,3, Flo Ranville 1, Kamal Arora 1, Patience Magagula 4, Jean Shoveller 5,6, Andrea Krüsi 1,3
PMCID: PMC8586035  NIHMSID: NIHMS1746779  PMID: 33978282

Abstract

Globally, people living with HIV (PLWH) are disproportionately affected by food insecurity. Yet there is limited understanding of the impacts of food insecurity among cisgender and transgender women living with HIV (WLWH) in high-income countries. Thus, it is critical to examine the lived experiences of WLWH and food insecurity to inform policy and service provision. As part of the community-based SHAWNA (Sexual Health and HIV/AIDS: Women’s Longitudinal Needs Assessment) study, we conducted 64 semistructured qualitative interviews with WLWH in Vancouver, Canada (2015–2017). Drawing on a socio-ecological framework, this analysis explores the lived experiences of navigating food security and health among WLWH in Metro Vancouver. Our findings indicate that WLWH relied heavily on food banks and other food-related supportive services. Despite the abundance of programs, access to nutritious foods remained difficult, and women often relied on processed foods that were more affordable and readily available. For many, food insecurity was exacerbated by unresponsive food services regulations that did not reflect the actual needs of food service users in terms of opening hours and locations, and a lack of nutritious food. Additionally, the absence of trauma-aware, women-centred and culturally responsive services, as well as, spatial and material barriers related to the recent loss of funding for HIV-specific support services, impeded food security among WLWH. Our findings emphasise that recognizing and addressing the social and structural disparities that exist for WLWH in high-income setting are essential for addressing food insecurity and ultimately optimal health among this population.

Keywords: food security, gender, HIV/AIDS, urban health

1. INTRODUCTION

Food security has increasingly been acknowledged as a critical determinant of health outcomes (Barreto et al., 2017; Bryant et al., 2010; Marmot et al., 2008). Commonly, food security is defined as ‘[access] to enough food for an active healthy life and includes at minimum (a) the ready availability of nutritionally adequate and safe foods and (b) the assured ability to acquire acceptable foods in socially acceptable ways (e.g., without resorting to emergency food supplies, scavenging, stealing, and other coping strategies)’ (Anderson, 1990). Food insecurity presents differently in high-income versus low-income countries. Unlike in low-income settings where food scarcity due to extreme poverty and famine can lead to low caloric intake, in high-income settings, individuals experiencing food insecurity are often prone to eating large portions high in carbohydrates when food is available, with significant intervals between meals. This can destabilise blood sugar levels and can lead to or exacerbate conditions such as obesity, high blood pressure and type-two diabetes (Sirotin et al., 2012, 2014). Research conducted in North America highlights that food insecurity is more common among women, those who live in poverty, experience mental illness, unstable housing or have histories of illicit substance use (Cutler-Triggs et al., 2008; Holmes 2008; Weiser et al., 2011; Willows et al., 2008). This highlights how food insecurity is shaped by intersecting social and structural factors such as poverty, racialisation and colonial polices, such as restrictions that impact the traditional eating habits of Indigenous communities, gender inequities and criminalisation (The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2019).

Food insecurity has been shown to more profoundly affect immune-compromised populations, including people living with HIV/AIDS (PLWH) (Normén et al., 2005). It is associated with an increased risk of mortality, reduced drug effectiveness, reduced treatment adherence, suboptimal HIV RNA suppression and a lower CD4 count for PLWH (Aibibula et al., 2017; Anema et al., 2009; Miewald et al., 2010). Previous studies in North America suggest that food insecure individuals receiving highly active antiretroviral therapy (HAART) have a higher risk of mortality, reduced CD4 cell counts and lower adherence and odds of virological suppression (Anema et al., 2009; Normén et al., 2005; Weiser, Bangsberg, et al., 2009; Weiser, Fernandes, et al., 2009). Recent research has also highlighted the burden of food insecurity in exacerbating chronic health conditions among women living with HIV (WLWH), including chronic inflammation (Leddy et al., 2019). Longitudinal research from our team in Metro Vancouver Canada indicated that 69% of WLWH reported experiencing food insecurity and 23% cited food insecurity as a barrier to adherence to HIV medication (Erickson et al., 2021).

WLWH are disproportionately affected by food insecurity (Anema et al., 2009; Tsai et al., 2012; Weiser et al., 2011). However, limited research has focused on how social and structural factors shape the lived experiences of food insecurity among WLWH in high-income settings. To address this gap, this research draws on a modified socio-ecological approach that situates health in the context of physical (e.g. housing environments and access to food storage), social (e.g. gender-based violence; culturally-sensitive supports) and structural (e.g. poverty, colonialism) environments (Baral et al., 2013; Krieger, 2001; Poundstone et al., 2004) to help elucidate the complex connections between sociocultural and structural factors, individual practices, the physical environment and food security among WLWH.

2. METHODS

2.1. Study context

The primary research site is located in the Downtown Eastside (DTES) of Vancouver, where many nutritional support services for marginalised populations are concentrated. The DTES has traditionally been a working-class neighbourhood, and during the mid-1990s, it became the centre of Vancouver’s HIV outbreak fuelled by injection drug use and insufficient harm reduction services (Strathdee et al., 1997). Despite ongoing gentrification, there remains a high concentration of healthcare and supportive services for marginalised people including addiction treatment, mental health, HIV support services and food services, yet there is a notable lack of grocery stores in the area.

2.2. Data collection

This study draws from qualitative interviews with 64 participants in the SHAWNA (Sexual Health and HIV/AIDS: Women’s Longitudinal Needs Assessment) project. SHAWNA is a longitudinal, participatory and community-based research project that was launched in 2010 and includes a quantitative and qualitative arm both focused on examining the social, political, legal, gender and geographic barriers to care in cis and trans women’s sexual health and HIV care across Metro Vancouver, Canada. SHAWNA was initiated after extensive community consultation with WLWH, service providers, community organisations and clinicians and follows the greater and meaningful involvement of WLWH/AIDS (GIWA/MIWA) principles (UNAIDS, 2007). SHAWNA is guided by two advisory boards: a Community Board and a Positive Women’s Board comprised of WLWH that identified food security as a community research priority. The research team includes people with diverse experiences, including WLWH, sex workers, Indigenous, African, im/migrant and trans women.

Guided by a socio-ecological framework, the semistructured interview guide was developed collaboratively with WLWH and community partners; it is designed to allow exploration of a broad range of social and structural factors shaping participants’ lives (Farmer, 1999; Poundstone et al., 2004). These include issues related to food security, healthcare and social service access, employment, housing, parenting and stigma. Participants were recruited through peer outreach and from the SHAWNA cohort study. A stratified purposive sampling strategy helped ensure representation of WLWH with diverse backgrounds, including Indigenous and Black/African WLWH and participants living in both urban suburban areas of Metro Vancouver.

All participants were accessing HIV care or living with HIV in Metro Vancouver and were at least 14 years old. Three experienced interviewers, including two Indigenous WLWH, conducted qualitative interviews August 2015–2017. All participants provided written informed consent. The interviews lasted 60–120 min, and participants were remunerated with a CAD $30 honorarium for their time, expertise and travel. The study holds ethical approval by the Providence Healthcare/University of British of Columbia Research Ethics Board.

Participants were prompted with several questions relating to food security and associated factors to better understand the lived experiences of navigating food security and health among WLWH in Metro Vancouver. Interview questions included: ‘How are you meeting your nutritional needs? Are there things you need that you can’t afford?’ Interviewers prompted participants to discuss general food security, food security among family members, and special dietary requirements. Participants were also asked about HIV related support services (‘What types of support services for WLWH do you access? Are there any other support services that you need but are not currently accessing?’ and ‘Is there a food program in your building? Can you describe what it involves? How has the food program affected your health?’).

2.3. Data analysis

Audio recordings were transcribed verbatim and checked for accuracy. Data collection and iterative analysis occurred concurrently, and narratives are reported using pseudonyms to ensure confidentiality. The research team discussed the content of interviews, emerging themes throughout the data collection and analytic processes (Creswell & Poth, 2018). Data were analysed thematically using ATLAS.ti 7 (Bradley et al., 2007; Braun & Clarke, 2006). Analysis involved repeated readings of interview transcripts; generating initial codes drawing on a priori (e.g. spatial and material barriers; food security & medication adherence) and emergent themes (e.g., abundance versus quality; gendered safety). Deductive and inductive methods informed by the modified socio-ecological framework and insights gained from the literature were used to additionally refine themes (Bradley et al., 2007; Holloway & Todres, 2003). The study received ethical approval from the Providence Healthcare/University of British Columbia Research Ethics Board.

3. FINDINGS

3.1. Participant characteristics

Participants included 64 WLWH. Fifty-four were cisgender women, whilst 10 were assigned male at birth. Of those 10, 3 identified as ‘transgender’, 3 as ‘two-spirit’, 2 as ‘women’, 1 as ‘heterosexual female’ and 1 as ‘gender queer’. Participants ranged in age from 24–68, with a median age of 46. Thirty-one (48%) participants were identified as Indigenous, 19 (14%) participants were White, 9 (14%) participants were Black/African and the remaining 5 (8%) participants were of mixed ethnicity or other visible minorities.

Our analysis highlighted that the vast majority of participants identified food and nutrition as a critical factor in their well-being, health and self-worth. Participants were knowledgeable about good nutrition and vocal about foods they desired and made strong connections between healthy food consumption and their overall health. Yet most faced substantial structural and sociocultural barriers that impeded their food security. Drawing on a socio-ecological framework to centre this analysis, two central themes emerged: (a) structural factors that impeded food security, including the dearth of nutritious food despite an abundance of food services, and (b) sociocultural barriers, such as barriers to accessing culturally specific foods and concerns regarding gender safety in food access.

3.2. STRUCTURAL BARRIERS

3.2.1. Abundance, access and quality

Participant narratives highlight various structural barriers WLWH faced in accessing nutritious foods for themselves and their families. Participants’ accounts indicate that food insecurity among WLWH in our setting is an issue of access barriers and poor quality, rather than a lack of food availability in and of itself. Due to the high costs of living, insufficient social assistance payments and difficulty accessing affordable supermarkets, most participants relied on food support services such as food banks and meal programs. Sage, an Indigenous transgender women said, ‘Groceries- and just everything is so expensive. […]It’s expensive just living in Vancouver. Clothes, food…everything’. For Sage, financial insecurity limited her agency and purchasing power for many necessities, including nutritious food.

Savahna, a cisgender Indigenous woman, highlighted that whilst purchasing groceries was cost prohibitive, thanks to the various food programs offered in the DTES, ‘you really can’t starve. […]There’s so many places to go’. Yet Savanah’s experience affirms a common narrative among WLWH, that there remains a ready availability of food, without a corresponding abundance of nutritious foods, or supportive environments to prepare, store and enjoy these foods. In Savahna’s discussion of supportive housing, she said:

I live mostly on toast and cereal, you know, stuff like that. Rice…because rice, you get from food banks and noodles, your pastas, and everything.

[Savahna, cisgender, Indigenous]

Whilst Savahna desired food that would better meet her nutritional needs, the limited supply of nutritious and fresh foods at food banks coupled with high grocery costs limited her access to a nutritious diet and ultimately maintaining good health. Sarah who was living in supportive housing in the downtown core, stated:

I never have enough food, enough of the right kinds of foods for my diet I should say. There’s always lots of pasta and stuff like that but I need fresh fruits and vegetables.

[Sarah, cisgender, White]

Sarah’s narrative reaffirms that food insecurity in this setting was not predominantly about the lack of food but rather about the quality and accessibility of nutritious foods. Participants’ narratives consistently indicated that most food banks provided predominantly processed foods and starches, which are easily storable and do not spoil. In this way, supportive services inadvertently undermined efforts for WLWH to maintain or improve overall health. Affordability and accessibility of nutritious foods remained a significant barrier to support overall health, despite knowledge of nutrition, and regular use of food services.

3.2.2. Spatial and material barriers to food access

WLWH also faced spatial and environmental barriers to accessing food programs. Some participants discussed area-specific factors in access to nutritious food within Metro Vancouver. Some WLWH were not able to travel to food services due to the cost of transportation, family responsibilities, as well as mobility limitations, including medication side effects such as illness and fatigue, which impacted women’s ability to stand in line at food services.

Participants identified the disadvantageous regulations of food services as barriers to food security. This included restricted hours, bureaucratic rules, limited eligibility and food banks running out of food. Many participants, especially those living in supportive housing, also experienced a lack of adequate cooking equipment and food preparation space. Housing facilities with a limited availability of stoves and refrigerators, or spaces with pest infestations, meant that WLWH were unable to cook or store desired meals in their homes.

One participant, Patricia a cisgender Indigenous woman, was unable to accommodate her nutritional needs using strategies like purchasing food in bulk, because of limitations in her housing environment. She explained:

Not having this freezer space, it really affects like what you get at the grocery store. […]It’s just my husband and I so if open the whole thing…the rest of it go to waste.

[Patricia, cisgender, Indigenous]

Sage, a transgender Indigenous woman, echoed desires for more robust food preparation and storage facilities, ‘I do wish that I could get into better housing, right. Something with um, a kitchenette or something with a kitchen’. As indicated in narratives by both Sage and Patricia, housing-related limitations exacerbated existing factors in their food insecurity. Some supportive housing settings offer meal preparation programs, and many participants recounted positive experiences of preparing/eating food collectively. These programs provided food as well as a sense of community belonging and purpose, as residents were able to share meals and the responsibilities of cooking and cleaning. However, there were often restrictions around mealtimes as well as the types of foods served, which prevented some women from participating in these programs.

3.3. SOCIOCULTURAL BARRIERS

3.3.1. Culturally specific and traditional foods

In addition to barriers accessing nutritious foods, im/migrant and Indigenous WLWH faced additional barriers in accessing culturally specific and traditional foods. For Indigenous WLWH or participants who had im/migration backgrounds, culturally specific foods formed an important part of food security, as those accustomed to preparing and eating culturally specific foods struggled to maintain the same nutritional integrity in their diets given the available food options. Traditional ingredients were often unavailable or too expensive to purchase. Akuna, a woman from Southern Africa who lives in a suburb, said:

So what stresses newcomers so badly is food. […]You come to Canada, you don’t even know where to get your food. That is too much stress for me. I was in Canada for one month. I was eating rice, which I don’t eat at all. And then pasta. I like my African food. That was too much stress on me for not getting shops where I can purchase [traditional food].

[Akuna, cisgender, Black/African]

Similarly, Nora, a cisgender woman from West Africa living in a suburb, was asked if she continued to prepare her culturally specific foods at home, she replied ‘Yeah I do. You can find the ingredients here to make it but it’s expensive’. Women often carried a greater burden in supporting the food security of loved ones, including cooking for their families—especially young and picky eaters. Demands from dependants for foods that were unavailable due to expense or culturally specific ingredient availability created additional barriers and further underline the gendered burden of food insecurity among WLWH.

Women’s access to traditional foods becomes increasingly difficult when they do not have the equipment required to make and store foods. For women living in supportive housing, limited space to store and prepare food can hinder a nutritious and culturally accessible diet. Patricia, an Indigenous woman, discussed how the lack of freezer space affects the groceries she purchases and her access to traditional foods:

Lately it’s just been focusing on trying to get my traditional foods down from up home [Northern Canada] …my parents prepare them, and they always send me smoked salmon and dried salmon and jarred fish and stuff like that…[I’d] like to be able to store that.

[Patricia, cisgender, Indigenous]

Indigenous WLWH face barriers to accessing traditional and culturally appropriate food, by way of limited local access, and restricted ability to store and prepare these foods.

3.3.2. Gender and safety

The closure of the only cis and trans women-focused HIV support organisation in Vancouver, due to a lack of funding, adversely impacted access to food programs for many participants. Lucy described her experience of accessing this well-liked service before its closure:

I’ve been to [Women focused HIV support service] every week. […]They have meals, and I get food bank, and I can talk to the girls there if there’s something bothering me or go get in contact with counselling and things like that. They’re really good.

[Lucy, cisgender, White]

Lucy’s narrative highlights how in addition to food this cis and trans women-focused service also provided a sense of community and access to supports such as counselling. Raelyn, a Southern African woman, further reiterated this sentiment by highlighting the ways in which support services focused on the needs of cis and trans women facilitated a sense of belonging and community wherein WLWH felt safe, supported and at ease:

Yeah, I go there, because when we go there, we talk with the other ladies; we laugh. Then…anyone can go to their place. We do like that.

[Raelyn, cisgender, Black/African]

Several participants discussed experiences of gendered risk and concerns about safety when accessing food programs that were open to all genders. Jacklyn explained that, whilst some of the services were superior, she felt uncomfortable accessing services that were not responsive to her needs as a woman with a history of trauma and sexual violence. Discussing her experience of accessing a mixed gender food bank, Jacklyn, a cisgender White woman said, ‘a lot of them [people accessing the service] don’t like women…but the food, and the services are amazing’. Kathleen similarly felt more comfortable accessing a cis and trans women-only space:

You don’t know where a woman is in her life, and she might be badly abused or something might have happened to her by a man, and she doesn’t wanna go to a place where that might trigger her emotions or feelings.

[Kathleen, cisgender, White]

Both Kathleen and Jacklyn highlight how histories of trauma and sexual violence bar WLWH from accessing food services that are not reflexive to their needs, further undermining their food security and access to community. Alie, a cisgender Indigenous woman, indicated that ‘the unity’ was the highlight of using women’s-centred services. Many WLWH found that women centred-services provided a more welcoming atmosphere, supported community development and provided an environment safe from gender-based violence.

3.4. Intersections between food insecurity and HIV

Living with HIV presented unique challenges for food insecure women. Several participants experienced nausea or lost the desire to eat as a side effect of their antiretroviral medication [ARVs]. This affected both their intake of nutritious foods and overall health. Orlee discussed the interactions between her medications and the desire to eat:

[When taking ARVs,] every time I eat I feel sick. It’s like when you’re pregnant, you maybe get the smell of food…then you go throw up or you go lay down. It makes it hard to take [ARVs…].

[Orlee, cisgender, White]

Orlee’s food insecurity was exacerbated by medication regimens that caused side effects and limited her activity due to related illness.

Some participants who used illicit substances experienced additional barriers in their efforts to prioritise regular, nutritious meals. Leah discussed the complex interaction between HIV treatment regimens, substance use, and eating:

As soon as they had [HIV medication] available to me, I took them. But there was some days that I didn’t take them because there was not enough food, or because I forgot about them because I was using [illicit drugs]. I was too high to even eat…I have to eat three hundred to five hundred calories, to take my medicine. Which is a tough thing when I was in withdrawal.

[Leah, cisgender, Indigenous]

Optimal ARV effectiveness is predicated on taking medication with food. Leah’s experiences indicate that intersecting barriers related to food security, poverty and substance use undermined her efforts to effectively manage her health and HIV diagnosis.

Women identified a range of health concerns that affected their ability to eat. In addition to nausea due to HIV medication, the desire to eat also interacted with other HIV-related health complications. Luna, a cisgender White woman, described how thrush made it difficult for her to eat. She also described how not being able to afford new dentures limited her ability to chew fresh vegetables.

A number of WLWH recounted experiences of stigma from healthcare providers regarding their food choices. Participants received advice from physicians, dieticians and other healthcare workers about their weight that ignored structural constraints to health and wellness, including intersections of HIV, housing instability, poverty and the availability of cooking equipment. WLWH reported that healthcare workers made suggestions that were too expensive or were otherwise unavailable. Patricia said:

It’s frustrating when doctors make assumptions. [M]y own doctor keeps saying to me, ‘It’s your weight, you have to lose weight’ ‘Just try this’ but when you’re on a fixed income, it’s not easy to just go and get good foods that can be pricey… she tries to suggest certain things I can’t afford to do. Like, joining a gym, I can’t afford to do that…I’m not rich and by no means capable of saving that kind of money. Especially living on disability.

[Patricia, cisgender, Indigenous]

Clinicians and other healthcare providers often urge women to lose weight by consuming nutritious foods, including fruits and vegetables, which are not accessible to women living with food insecurity. In many cases, clinicians made such recommendations without an awareness of participants’ lived realities of poverty. Thus, many felt stigmatised in their interactions with healthcare professionals, due to structural constraints which affected their food security.

4. DISCUSSION

In summary, although eating well was a priority for WLWH, and closely linked to maintaining overall health, several intersecting structural and sociocultural factors, including poverty, colonialism and displacement from traditional foods, im/migration backgrounds, histories of gender-based violence and housing environments impeded food security. Most participants depended on food services, and despite the abundance of services, it remained difficult for WLWH to obtain and prepare nutritious foods. Many WLWH relied on processed foods that were less nutritious but more abundant in food services, more affordable or easier to prepare in the context of limited access to kitchen equipment and storage. WLWH also experienced stigma from medical service providers around their restricted food choices.

Existing research regarding food insecurity among PLWH indicates that poor food quality and barriers to safe and reliable food access through supportive services are significant factors in perpetuating food insecurity (Anema et al., 2016; Rawat et al., 2014; Slater & desLibris, 2012; Tarasuk et al., 2014). Furthermore, a growing body of literature shows that WLWH are disproportionately impacted by violence (Dunkle et al., 2004; Li et al., 2014; Sareen et al., 2009; Smith et al., 2018). Food security has been associated with experiences of violence among WLWH (Conroy et al., 2019). Building on this work, our findings indicate that services that fail to provide trauma informed and safe spaces to access food can further disadvantage WLWH with histories of violence and trauma and contribute to food insecurity. This context further highlights the importance of food support services that are cis and trans women-specific. Our findings demonstrate that WLWH desired trauma-aware approaches to health- and support-service delivery, including inclusive spaces with equitable decision-making. This is in line with a growing body of literature identifying key components of cis and trans women-centred care, which includes creating respectful and accepting spaces, and the use of peer and community informed practice (Carter et al., 2013).

Women-centred spaces are better able to provide reflexive services and supports that respond to the needs of WLWH and their roles in their families and communities. This may include operating during hours that WLWH are more able to attend, including being open past standard office hours, providing accessible services, including transportation, and allowing for, and catering to, children that WLWH may be providers for (Carter et al., 2013). Many WLWH placed significant emphasis on the sense of community and social protection afforded by women-centred services. Many who regularly accessed women-centred spaces felt a sense of community that allowed WLWH, especially those facing other barriers to health including precarious housing or intimate partner violence, to feel safe, and better cared for by their community.

As mentioned above, the main cis and trans women focused HIV support service in our setting, which had been providing women-specific supports for WLWH in downtown Vancouver for over 25 years including a lunch and grocery program, closed in April of 2017 due to loss of funding. This closure takes place in an era where funding cuts to HIV services are ever more prevalent (Canadian HIV/AIDS Legal Network, 2018). Our findings highlight that an overemphasis on pharmacological interventions whilst cutting women-specific and/or HIV-specific support services is inadequate in addressing WLWH’s experiences of intersecting structural inequalities such as poverty, housing instability and racialisation.

Research conducted across North America has highlighted the barriers PLWH experience when attempting to support good nutrition whilst reliant on social assistance, supportive housing, or when living on fixed and limited income (Anema et al., 2011, 2016; Kalichman et al., 2010). Building upon the work of Miewald et al. and Slater et al., our findings further illustrate how WLWH have limited agency in supporting a healthy diet; limitations in housing (such as restricted food storage or access to cooking facilities) and the lack of nutritious food offerings perpetuate food insecurity among those accessing food services (Miewald et al., 2010; Palar et al., 2017; Slater et al., 2015). For those living outside areas where food services or grocery stores were concentrated, especially in rural and lower income areas, a lack of transportation contributed to the dearth in grocery stores (Larsen & Gilliland, 2008). Herein, despite living in high-income settings where food is abundantly available for those of privilege, marginalised individuals, including WLWH, experience ‘food deserts’, many of which are delineated along racialised divides (Broad, 2016; Larsen & Gilliland, 2008).

Food insecurity in high-income settings tends to result in becoming overweight or experiencing obesity; however, PLWH who are food insecure may experience issues of both underweight and overweight (Sirotin et al., 2012, 2014; Tamargo et al., 2021). Weight issues were often tied to the inability of food banks to provide nutritious food, and existing research suggests WLWH experience issues with weight maintenance as a result of food insecurity (Eicher-Miller, 2020; Sirotin et al., 2014; Weiser, Fernandes, et al., 2009). Our findings highlight the tensions food and eating habits created with clinicians and how this further complicated adherence and physician relationships among WLWH. Medical professionals often failed to take lived experience and the cultural significance of food into account, offering inaccessible solutions to issues around weight management. Overall, WLWH experienced barriers both when accessing food and in creating connections with clinicians where their experiences of food insecurity were not used against them.

Previous work indicated that food insecurity among PLWH in Canada was most prevalent among women, especially those of Indigenous ancestry and those supporting children (Normén et al., 2005). Concerningly in this regard, previous research has demonstrated that medication adherence is lower among PLWH who are food insecure (Kalichman, Grebler, et al., 2014; Kalichman, Hernandez, et al., 2014). For many WLWH, especially im/migrant women, food is closely tied to their roles as caregivers (Burke et al., 2017; Ivers & Cullen, 2011). For racialised, Indigenous and im/migrant WLWH, access to culturally specific foods helped support relationships, including those with dependants, families and the broader cultural community; the absence of this food can interfere with the development and maintenance of these relationships (Burke et al., 2017; Oleschuk, 2012). Providing and preparing food can be a source of cultural and community connection and can serve as an outlet for creativity and cultural expression (Avakian, 2005; Kimura, 2013). Our findings indicated that WLWH felt a significant burden in providing food for their families and dependents, which contributed to food insecurity. Indeed, inadequate offerings both in terms of quality and quantity available through food programs placed a significant burden on WLWH who were providing for, at times, large groups of dependents.

In addition, our findings reveal a distinct lack of access to culturally specific foods for Black/African women and Indigenous women, which included food items such as dried and smoked fish, speciality meats, fresh fruits and vegetables and foods used for ceremony or religious celebration. Indigenous and Black/African women are vastly overrepresented among PLWH in Canada and rates of new infections continue to be highest among Indigenous and Black/African women (Bourgeois et al., 2017). Whilst Indigenous and Black/African women experience HIV at disproportionate rates, our findings indicate that food support programs did not address the unique cultural needs of these women. Given the burden of HIV among Indigenous and Black/African women, there is a significant need for services that are responsive to these women, including greater emphasis on culturally aware food programming.

4.1. Limitations

This study has limitations. Findings from this study reflect the setting and supportive infrastructure available to WLWH living in Metro Vancouver and this study may not be reflective of other settings. More work is needed to better understand how trans participants navigate food security and what gender-safe supports look like for gender diverse PLWH. Previous work in this setting has shown that trans, two spirit and gender diverse people experience additional gender-related exclusion and barriers to accessing supportive services, especially in ‘women-only’ environments (Lyons et al., 2015). More research is needed in order to evaluate the barriers to gender-safe food programming for trans, two-spirit and gender diverse PLWH.

5. CONCLUSION

Lived experiences of structural inequalities and persistent funding cuts to food programming and HIV support services exacerbate food insecurity, especially for the most marginalised WLWH. Increasingly, in order to destigmatise HIV, it is being conceptualised as a disease ‘like any other’ (Krüsi et al., 2018; Moyer & Hardon, 2014). Whilst this is generally seen as a positive development, this shift has been used by governments to justify decreases in HIV-specific programming and funding (Canadian HIV/AIDS Legal Network, 2018). Whilst food services may help support food security, their limitations, including restrictive hours and limited nutritious offerings, support a call for increased personal financial means, including increased social assistance, disability payments, unemployment insurance or a guaranteed liveable income to allow WLWH to purchase food that is accessible and meets their dietary and cultural needs. More broadly, recognizing and addressing the social and structural disparities that exist for WLWH in high-income setting are essential for addressing food insecurity and ultimately optimal health among this population.

What is known about this topic:

  • Food security is a critical determinant of health.

  • Food insecurity disproportionately impacts women and people living with HIV.

  • A lack of nutritious food worsens health outcomes for people living with HIV (PLWH).

What this paper adds:

  • Gendered barriers impede full realisation of existing food support services for women living with HIV (WLWH).

  • Women living with HIV need trauma-informed and gender-safe spaces for accessing food and food services that are reflexive to cultural food needs.

  • Women-centred services help mitigate some of the barriers to traditional food services for women living with HIV, but more gender-aware food programming is needed.

ACKNOWLEDGEMENTS

We thank all those who contributed their time and expertise to this project, particularly participants, community partners, the SHAWNA Positive Women’s Advisory Board and Community Advisory Board and the SHAWNA team members: Sarah Moreheart, Lulu Gurney, and Barbara Borden. We also acknowledge Brittney Udall, Jennifer Morris, Peter Vann, Maya Henriquez, Megan Bobetsis and Jenn McDermid for their research and administrative support. This research was supported by the Canadian Institutes of Health Research through a Community-based Research Grant (384667) and a Foundation Grant (FDN-143349). AK is supported through a Michael Smith Foundation for Health Research Scholar Award. KS is partially supported by a Canada Research Chair in Global Sexual Health and HIV/AIDS and Michael Smith Foundation for Health Research Scholar Award. AS is supported by a Fredrick Banting and Charles Best Master’s Award (CGS-M). The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript.

Footnotes

CONFLICTS OF INTEREST

The authors declare no conflicts of interest with regards to the authorship, research and publication of this article.

ETHICAL APPROVAL

Ethical approval was obtained from the Providence Healthcare and University of British Columbia’s Behavioural Review Ethics Board (H14-01073).

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