Diverse processes of undervaluing, tagging, with stereotyping bring loss of status, unfair and unjust treatment, and social exclusion of persons or groups are contextually entrenched at every level. These manifest in different forms of stigma – stigma from racism; HIV-related stigma; sexism and gender related stigma; homophobia and transphobia related stigma as pathways of oppression (Logie et al, 2011). These different types of stigma occur and there is then HIV-related stigma that intermingles with other forms stigma related with the social identities ascribed (Ritter, 2017) to African women: race, gender, immigration experiences, and even their sexuality. This is called intersectional stigma, defined as, “a concern with the multiple, simultaneous and dynamic interchanges among categories of social difference as it interlinks with power and privilege, and systemic oppression and its operation at the micro (interpersonal, intrapersonal), meso (community, social networks, social norms and practices) and macro (cultural institutions, societal structures) levels (Logie et al, 2011; Loufty et al, 2105; Parker& Aggletion, ). Social exclusion is a consequence seen with stigma related social hierarchies with manifestations as psychosocial, physical and mental health factors including social isolation, anxiety, depression, suicidal ideation and harmful effects on physical and mental health as detrimental outcomes (p.19836). Loufty et al, (2015) found out that minimal interventional approaches were directed to intersectional stigma experienced by African women despite their disproportionate affectation by the HIV epidemic. Multi-level intersectional stigma intervention becomes a necessity for this group for a reduction in the burden of their health inequities. Their marginalization becomes widened, coping strategies become minimized as the barriers they face from intersectional stigma prevents them from accessing vital socio-structural supports needed for their sustaining existence.
Secondly, the interdependent and mutually constitutive relationships are experienced between the different forms of racism – intrapersonal, internalized and institutional social identities and a structural inability to access SDOH that bring mostly oppressions. These oppressions become mutually constitutive with her other identities making it almost impossible for her to the access social and health goods at multi-levels of their lives (Logie et al, 2011). In their study in Ontario, the experiences of stigma for African women at the micro-level has shown that participants hide their HIV sero-status from their parents and sexual partner for fear of disappointment and rejection due to intense shame and internalized HIV stigma; at the meso-level, the community beliefs and social norms that have expressed African woman as sexually immoral and loose as a symbolic form of HIV related stigma and a participant from Africa was able to surmise her experience at the macro level of the health care system as thus: ‘‘I was in crisis—I had to go see a doctor. When she came in she had three pairs of gloves and yet it wasn’t even a problem related to HIV! She kept her distance and could barely touch me. When she finally came closer I said: ‘If you do not remove your gloves you do not touch me!” (p.6).
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Stigma and discrimination exists as principal drivers that influence the lived experience of the SSA WLHA; invariably fueling and contributing to the continuing and widespread occurrences of HIV in Canada. Women’s human rights through their life cycle are an inalienable, integral and indivisible part of universal human rights (UN, 1995); and health is a fundamental human right (WHO, 2015). Institutionalized, personalized and internalized forms of stigma with any direct and/or indirect system of advancement becomes an indignity and injustice to the lives of people living with the HIV disease, more so, for these African women that are based on socially ascribed hierarchies, her achievements contextually are limited because their social identities limit her. Her status is a function of the sum of their ascribed and achieved actions. Furthermore, elimination of AIDS as a public health threat is being undermined as the achievement of UNAIDS (2014) 90-90-90 target that by 2020; 90% of all people living with HIV know their status, 90% of those diagnosed receive antiretroviral treatment, and 90% of those on treatment achieve viral suppression is being compromised by stigma: An ascribed social status. At the end of 2014, PHAC, (2016), reports that an estimated 80% (73% to 87%) of persons living with HIV were diagnosed, 76% (70% to 82%) of persons diagnosed with HIV were on treatment, and 89% (84% to 93%) of persons on treatment had suppressed viral load. Stigma, possibly, drives this as challenges associated with social determinants of health and access and retention in health services are encumbered (Logie et al, 2011; PHAC, 2016).
The extent of the social integration of African women against the backdrop of their well-being becomes an unjustifiable challenge. Even with their HIV sero-positivity, her gender relations and roles which are socially constructed are a rote for the developmental processes (Wangari, ) needed for their survival in their host country. For the most part, they are the original migrant and known as the first-generation migrant while the children are known as the second-generation migrants (Anthias, 2012). There can arise issues of challenging concepts of transnational framework and social integration for her progenies due to negative capabilities as the primary care giver (p. 103). Highlighting a qualitative study of WLHA in Ontario, PHAC, (2013) elucidated the fears of a parent to losing custody of their children to social welfare,
“I was very depressed, I was upset. Because like children and family services said ok, you’re sick and if you don’t have family how are you going to take care of your daughter? And how are you going to take care of your son? And that really bothered me because when I was diagnosed they didn’t care and then when I got sick all of a sudden, my daughter was taken away from me and then my son and that really hurt me” (p. 35).
This can reduce the level of social attachment of these African women to social institutions as structural attitudes, societal beliefs and norms with values cannot govern their life due to an inherent internalized fear and stigma. It is obvious that the impact of a child’s life course due to detachment from her main primary care-giver, may institute a life pattern of barrage of emotional instability. Though some level of fluidity exists in social identities; such as migration status, education or housing but fixed situations; such as race, early child experiences of an adult (Anthias, 2012; Piggott & Orkin, 2018).
Even with the violence and social profiling, these women are expected by the originating culture to keep silent and take it in their stride (Brown-Speights et al, 2017; Etowa et al 2007; Etowa et al, 2017). In addition to their gender, the complex intersections with her diverse identities deleteriously heightens these women’s daily experiences and impinge on her well-being. As women, and potentially mothers and/or care-givers, these mutually constituted vulnerabilities oppressively manifest as racism, gender inequality, classism and HIV-related stigma; impacts to their access to social and health care with a poor quality of care that translates to poor individual and population health outcomes (Caiola, 2014). With the sensitivity and stigmatizing challenges associated with HIV (Worthington et al, 2013) for Africans; it worsens further their ability, as African women, to access to social products and resources (trainings, health, education, legal services, police services, jobs, and earnings for savings potentialities, social supports - both internally with her nuclear and extended families and network of communities) intersects with these social influences to impact on their life as immigrants. These social influences intersect with their immigration experiences to determines her social locations, quality of health status and their life (Hankivsky et al, 2010). Understanding these intersecting webs of complex social problems are related to inequities and disparities she experiences daily. These intersectional SDOH are meant to aid their settlement and integration as immigrants; such as accessibility, affordability and availability of health care services like mental health services, counselling sessions; social support; access to socio-economic opportunities that will aid education, economy and job opportunities; access to public community spaces for promotional and communication processes with safety, neighborhood exclusion; and availability of economic resources to meet their daily needs like affordable quality housing and cost-effective nutritious foods. Nevertheless, their inaccessibility to these social determinants of health shows socio-structural marginalization due to social policies that constrains them due to their immigration status and experiences.
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