At Women’s College Hospital, we are addressing the complexity of effectively delivering reproductive health services that are impacted by science, sociocultural issues and politics. Our scientist are leading efforts to enhance access to abortion services, provide up-to-date and accessible information about emergency contraception options and enhance quality of care for women living with HIV.
Women and HIV
Despite HIV increasingly being recognized as a chronic and manageable disease, women living with HIV face unique medical, social, and political obstacles, including pervasive HIV-related stigma. Dr. Mona Loutfy founded The Women and HIV Research Program (WHRP) in 2006 and partnered with women living with HIV to address their unique clinical needs. WHRP is guided by principles of feminism, equity, anti-oppression, anti-racism and social justice, as well as the “Meaningful Engagement of Women Living with HIV/AIDS (MEWA).”
WHRP aims to accomplish three primary goals: 1) finalize a new model of care (the Women-centred HIV Care Model) aimed at optimizing the health and wellbeing of women with HIV in Canada, particularly those most affected by HIV including Indigenous women and trans women; 2) disseminate and optimize implementation of the 2018 Canadian HIV Pregnancy Planning Guidelines; and 3) mentor and train the next generation of researchers and clinicians that are focused on health equity for women with and at risk of HIV.
Abortion Care and Contraception
Ensuring that women have equal access to specialized health services, especially when it comes to their reproductive health, is fundamental to their overall well-being. Dr. Sheila Dunn is the Associate Director of Research for the Contraception and Abortion Research Team- Groupe de recherche sur l’avortement et la contraception (CART-GRAC), a national, interdisciplinary collaboration that conducts research to support health services and policies to promote equitable access to high-quality family planning knowledge, methods and services for people throughout Canada. CART research has informed federal, and provincial policies for contraception and abortion services and methods, health professional licensing policies, and national clinical guidelines.
Dr. Dunn and team have a particular research focus on mifepristone abortion or medication abortion, which became available in Canada in 2017. Currently the team is investigating how the dissemination of mifepristone to community primary care can enhance access to abortion, particularly as it relates to geographic disparities. With the CART team Dr. Dunn is also studying changes in abortion practice, safety and cost associated with mifepristone availability.
Piloting the Project ECHO Approach to optimize Women-Centred HIV Care in Ontario
Drug-drug interaction study between bictegravir/emtricitabine/tenofovir alafenamide and feminizing hormones in trans women living with HIV
Adapting & Operationalizing the Trans-Women Centered HIV Care Model
Developing a feminizing hormone therapy satisfaction questionnaire (FEM-SQ) for trans women
Areas of Focus and Key Findings
Principal Investigators: Mona Loutfy MD FRCPC, Angela Kaida PhD, Alexandra de Pokomandy MDCM, Marissa Becker MD FRCPC, Sharon Bruce PhD, Saara Greene PhD
Established in 2010, the Canadian HIV Women’s Sexual and Reproductive Health Cohort Study (CHIWOS) was the largest Canadian cohort study of women with HIV to date, enrolling 1422 women living with HIV in three Canadian provinces (Ontario, British Columbia, and Quebec) using community-based research principle between 2013 and 2017s. CHIWOS aimed to understand how women living with HIV use health and social services, and how women-specific services could address their unique needs in a supportive, inclusive, and accessible manner. Accompanying arts-based research projects were conducted to understand these aims using different research methods.
Notable findings of CHIWOS include:
- The women who participated in CHIWOS were diverse
- 57 percent of women perceived the care they received from primary HIV doctor or clinic had been woman-centred, but significant regional differences were evident (67 percent BC, 63 percent ON, only 37 percent QC)
- 80 percent of women agreed that women-centred HIV care is important to them
CHIWOS has grown from a study to a movement and has inspired the development of the Women Centred HIV Care Model, the Trans Women and HIV Research Initiative (TWIRI), and countless partnerships with community members and organizations. To learn more about CHIWOS, visit www.CHIWOS.ca
Principal Investigators: Mona Loutfy MD FRCPC, Mark Yudin MD, Heather Shapiro MD FRCSC, V Logan Kennedy RN, PhD(c), Vanessa Poliquin MD, Frederick Dzineku, Nicola L. Dean PhD, Shari Margolese, Alison Symington LLM, Deborah M. Money MD, Scot Hamilton PhD, Tracey Conway CYC, Sarah Khan MD
The Canadian HIV Pregnancy Planning Guidelines (CHPPG) Core Team’s mission is to work with all stakeholders across Canada to increase awareness and uptake of HIV pregnancy planning resources as a routine part of care, support, and people’s lives. We are a community of health care providers, community-service agencies, and people affected by HIV who have been championing the reproductive rights of people living with HIV for over two decades. This movement has been fuelled by the fertility desires and intentions of men and women living with HIV across Canada and is responsible for the development of Canadian HIV Pregnancy Planning Guidelines (CHPPG) in 2012 and updated in 2018. Informed by implementation science and relevant theoretical models, our team adapts various strategies and tools to support the dissemination and implementation of the CHPPG across Canada.
Principal Investigators: Mona Loutfy MD FRCPC, Wangari Tharao MA, Neora Pick MD FRCPC, Angela Kaida PhD, Alexandra de Pokomandy MDCM, Mina Kazemi MSc, Carmen Logie MSW PhD, Angela Underhill MSc PhD (c), Nadia O’Brien MPH PhD, Mary Kestler MD, Jesleen Rana MD MPH, Jay MacGillivray Reg. Mid., Denise Jaworsky MD FRCPC, Adriana Carvalhal MD MSc PhD, Tracey Conway PRA, Kath Webster PRA, Melanie Lee PRA, Shaz Islam RA, Valerie Nicholson PIRA, Mary Ndung’u BA, Karène Proulx-Boucher MA, Allison Carter MPH PhD, Rebecca Gormley MPH, CHIWOS Research Team
The comprehensive care needs of women living with HIV in Canada have not been thoroughly addressed due to the historic focus of the HIV response on men who have sex with men and the underrepresentation of women in decision-making roles. The novel Women-Centred HIV Care (WCHC) model was developed using data from the Canadian HIV Women’s Sexual and Reproductive Health Cohort Study (CHIWOS). The goal of the model is to provide healthcare personnel, both HIV specialists and primary practitioners, with a framework that will allow them to provide the best and most informed care to female HIV patients. WCHC is defined as care that supports women living with HIV to achieve the best health and wellbeing as defined by them. The WCHC model integrates 5 care components as determined by community members and CHIWOS participants and places an emphasis on flexibility of implementation to meet the needs of all women . The five care components include 1. person-centred care; 2. trauma- and violence-aware care; 3. integrated HIV care; 4. women’s health care (including sexual and reproductive health and rights); 5. mental and emotional health care (including substance use health),; and 6. peer support, leadership and capacity building.
Principal Investigators: Yasmeen Persad, Ashley Lacombe Duncan RSW, PhD, Mona Loutfy MD FRCPC, Carmen Logie PhD
The Trans Women and HIV Research Initiative (TWIRI) consists of a diverse team conducting mixed-methods research on trans women living with HIV. There is very little research being done with this important population and TWIRI takes a community-driven, interdisciplinary approach to trans health and social welfare. TWIRI is establishing a knowledge-translation (KT) plan focused on accessible, trans-specific knowledge sharing and extending the initiative’s national and international reach.
Principal Investigators: Mona Loutfy MD FRCPC, Renee Masching
To further strength-based and culturally grounded research for the wellbeing of Indigenous women living with/at risk of HIV, WHRP and The Canadian Aboriginal AIDS Network Inc (CAAN) have an agreed upon mutual desire to work together to recognize the diversity and rights of Indigenous Peoples regardless of residency, including the rights of Indigenous Peoples to access and benefit from HIV/AIDS related research, and to maintain a quality of life in a culturally appropriate manner. This has been formalized through a Memorandum of Understanding and formal partnership. This collaboration honours the OCAP principle. Ownership control access and possession (OCAP) is being used by Indigenous Peoples to highlight the right to self-determination in the area of HIV/AIDS research.
Principal Investigators: Notisha Massaquoi RSW PhD, Wangari Tharao, Mary Ndung’u BW, Mona Loufty MD FRCPCP
The involvement of WHRP in the research work with African, Caribbean, Black (ACB) women living with HIV has been ongoing since 2004. It started as a partnership between Women’s Health in Women Hands (WHIWH) , an Ontario-based Community Health Centre that serves Black and racialized women who live in Toronto and the surrounding area. The first project WHIWH and WHRP partnered on was a CIHR-funded Community-based HV mixed method study asking women living with HIV across Ontario and their care providers what were the most pressing issues to research for them. WHIWH and WHRP also collaborated on several community-based research (CBR) projects related to pregnancy planning, parenting, assisted reproductive health, and infant feeding from 2005 to today. That work has changed the landscape of pregnancy and parenting with HIV to one that is normalized and celebrated. In 2011, the Canadian HIV Women’s Sexual and Reproductive Health Cohort Study (CHIWOS) was funded and the CHIWOS ACB Advisory Board (ACB-CAB) was formed. The purpose of the ACB-CAB was to bring together stakeholders committed to research with, and care of ACB women living with HIV in Canada. The ACB-CAB aimed to ensure the voices of ACB women were heard and influenced the progress and direction of CHIWOS, highlighting the unique needs and lived experiences of ACB women. The ACB-CAB contributed to tailoring programs and interventions to improve the wellbeing of ACB women living with HIV. After completing several research endeavours, including an analysis of experiences of intersecting stigmas including HIV-related stigma, sexism, and racism by CHIWOS participants, there is now a realization of the gap that exists between the original work and today’s realities for ACB women. After 10 years since the establishment of CHIWOS the movement will now be focused on a process led by and for ACB women with mentorship and support by Dr. Loutfy and the WHRP staff.
Canadian Institutes for Health Research (CIHR). Partnerships for Health System Improvement. Michael Smith Foundation, BC Women’s Hospital
Principal Investigator(s): Kendall T, Norman WV Co-investigators: Blake J, Brant R, Brooks M, Bryan S, Christilaw J, Costescu D, Dunn S, Emberley P, Foster A, Guilbert E, Kaczorowski J, Meuser J, Munro S, Renner R, Soon J, Stroulia E, Teng F, Waddington A. 492,500 CAD
In preparation for mifepristone’s availability in 2017, the Contraception and Abortion Research Team-Groupe de recherche sur l’avortement et la contraception launched the CART-Mife Study, a 4-year national implementation research project that aimed to identify and mitigate barriers to implementing mifepristone abortion practice, particularly those affecting primary care providers. The project had two interventions: 1) integrated knowledge translation with health policy-makers to mitigate health system barriers and support facilitators to adoption of mifepristone abortion by community-based healthcare providers and 2) a virtual Community of Practice (VCoP), the Canadian Abortion Providers Support-Communauté de pratique Canadienne sur l’avortement (CAPS-CPCA) online platform, that supported community-based health care providers across Canada to implement mifepristone abortion in their practices.
Principal investigators: Norman WV, Hendry B, McGrail K
Following the availability of mifepristone in Canada, administrative data was leveraged to examine abortion availability, specifically the availability of mifepristone abortion on 1) abortion access and service distribution; 2) abortion related adverse events and 3) abortion related health system costs.
Women-Centred HIV Care (WCHC)
- Peer Reviewed Manuscript – (https:// doi: 10.1177/2325958221995612)
- WCHC Toolkits for Clinician’s and Community Members - https://cep.health/clinical-products/hiv/
- Previously Recorded Webinars (EN/FR) - https://www.catie.ca/women-centred-hiv-care-toolkits-webinar-for-women-living-with-hiv-and-community-based-service
- Canadian Fertility & Andrology Society (CFAS)
- Canadian Aboriginal AIDS Network (CAAN)
- Women’s Health In Women’s Hands (WHIWH)
- Community AIDS Treatment Information Exchange (CATIE)
- The Ontario HIV Treatment Network (OHTN)
- Women and HIV/AIDS Initiative
Abortion and Contraception
The Canadian HIV Women’s Sexual and Reproductive Health Cohort
- Operationalizing CBR (doi: 10.1186/s12874-016-0190-7)
- CHIWOS Cohort Profile (https://doi.org/10.1371/journal.pone.0184708)
- Access and engagement in HIV care (doi: 10.1080/09540121.2017.1338658)
- Food and housing insecurity (DOI: 10.1007/s10461-018-2119-0)
- Posttraumatic stress symptoms (https://doi.org/10.1371/journal.pone.0200526)
- Cervical cancer screening (DOI:10.9778/cmajo.20180151)
- HIV-related stigma, racial discrimination and gender discrimination (https://doi.org/10.1016/j.ypmed.2017.12.018)
- Mental health among transgender women living with HIV (https://doi.org/10.1080/09540121.2020.1737640)
- Substance use and violence (10.1007/s10461-017-l1863-x)
- Pregnancy after diagnosis (https://doi.org/10.1371/journal.pone.0180524)
- Alcohol consumption (doi: 10.1007/s10461-019-02454-3.)
The Canadian HIV Pregnancy Planning Guidelines (CHPPG)
- Canadian HIV Pregnancy Planning Guidelines
- Clinical practice guide for HIV care providers published in JAMMI (DOI:10.3138/jammi.2019-0013)
- Clinical practice guide for pregnancy care providers published by JOGC (DOI:https://doi.org/10.1016/j.jogc.2020.09.022)
- CFAS companion guidelines on management and preventing blood-borne viral infection transmission in assisted reproduction (https://cfas.ca/clinical-practice-guidelines.html)
Trans Women HIV Research Initiative
- HIV care among transgender women living with HIV (doi:10.1111/hiv.13261)
- ‘Transgender Education for Affirmative and Competent HIV and Healthcare (TEACHH)’ (doi:10.1136/bmjopen-2019-034144)
- Barriers to HIV prevention, treatment and support (doi:10.1111/hsc.13234)
- Mental health (doi:10.1080/09540121.2020.1737640)
- Gender-affirming healthcare experiences (doi:10.1071/SH19011)
- HIV Care Cascade (doi:10.1089/apc.2019.0013)
Abortion Care and Access
- Renner RM, Ennis M, Contandriopoulos D, Guilbert E, Dunn S, Kaczorowski J, Darling EK, Albert A, Styffe C, Norman WV. Abortion services and providers in Canada in 2019: Results of a national survey. CMAJ Open Sep 2022, 10 (3) E856-E864; DOI: 10.9778/cmajo.20210232.
- Dunn S, Munro S, Devane C, Guilbert E, Jeong D, Stroulia E, Soon JA, Norman WV. A virtual community of practice to support physician uptake of a novel abortion practice: A mixed methods case study. J Med Internet Res 2022;24(5):e34302
- Schummers L, McGrail K, Darling EK, Dunn S, Gayowsky A, Kaczorowski J, Norman, WV. A more accurate approach to define abortion cohorts using linked administrative data: an application to Ontario, Canada. International Journal of Population Data Science 2022; 7(1). doi: 10.23889/ijpds.v7i1.1700.
- Ennis M, Renner R, Guilbert E, Norman WV, Pymar H, Kean L, Carson A, Martin-Misener, Dunn S. Provision of first-trimester medication abortion in 2019: Results from the Canadian Abortion Provider Survey. Contraception 2022; doi: https://doi.org/10.1016/j.contraception.2022.03.020
- Schummers, L., McGrail K., Darling E K, Dunn S, Gayowsky A, Kaczorowski J, Norman WV. (2022) “A more accurate approach to define abortion cohorts using linked administrative data: an application to Ontario, Canada”, International Journal of Population Data Science, 7(1). doi: 10.23889/ijpds.v7i1.1700
- Schummers L, Darling EK, Dunn S, McGrail K, Carson A, Gayowsky A, Law MR, Laba TL, Kaczorowski J, Norman WV. Abortion safety and use with normally prescribed mifepristone in Canada. NEJM 2022; 386:57-67.