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Table 2 Common barriers in Canada and Kenya

From: Barriers to and facilitators of accessing HIV services for street-involved youth in Canada and Kenya

Level

Theme

Illustrative Quotes

Societal Level

Intersectional Stigma and Discrimination

“[They] feel like they’re targeted, that they don’t get the same care, and that they’re treated as second-class citizens.” (CS, London)

“For trans youth of colour it’s extremely difficult because there’s so much inherent transphobia in the service provided.” (CS, Montreal)

Public Policy Level

Inadequate Access to Basic Needs

“It becomes a privilege to then think about your medical needs and your mental health needs. It’s more about, ‘Where am I going to be safe? What am I going to do to be warm and to have something over my head, to find a meal?’…I don’t think that people are having the luxury to think about, ‘I’m going to go get my blood work done. I’m going to go get tested,’ you know?” (HCP, Toronto)

Limited Community-Based Funding

“The one-size-fits-all model doesn’t work but the program didn’t have enough capacity to tailor specifically for that one group.” (CS, Toronto)

“I’ve had to cut so many programs because we’re in deficit actually…we went from two tokens to one….we had to cut some of our meals or dinners and it’s empty here those nights because they have to find somewhere else to eat and that pulls at my heart strings. It bothers me so much.” (HCP, Toronto)

Legal Documentation

“STI testing here, we can do without a health card, but anything beyond that, they’re going to need it, and certainly, if they test positive for something like HIV and need treatment, of course they need it.” (HCP, London)

“[They] feel like that is a huge thing for trans people especially if their IDs have their dead name on it or their previous gender, they don’t want to be misgendered when they go into a clinic.” (CS, Toronto)

Lack of Health Insurance

“If it’s not covered under OW’s prescription benefits plan, they can’t afford it…. even something like Ontario Trillium benefits is possible, but there’s a large wait for applications to be processed for them to be able to access all covered medications. And if there’s no generic one and they have to pay for it, they just won’t do it.” (CS, London)

Institutional Level

Lack of Diversity and Inclusive Education and Training

“I feel like the harm reduction scene in general is very white, very male dominated and if you’re not from those identities it can kind of feel isolating or people might not feel as welcome to access the services there.” (CS, Toronto)

“Even within our own team, the people who don’t really know much about PrEP… I think there’s a lot of work that needs to happen around educating people.” (HCP, Toronto)

Restrictive Service Provision

“The other barrier is…you find there is a queue in the facility or hospital which will take you a lot of time that’s time wastage.” (CS, Eldoret)

“It’s hard to find a doctor that takes patients…and so I always go to the emergency, but they treat me like I’m just a piece of shit” (SIY, London)

Inadequate HIV Education Outreach

“STI and HIV testing facilities at some community-based organizations were separated by gender so “someone who might be non-binary might not be sure which drop-in to go to in that case” (CS, Toronto).

Interpersonal Level

Ineffective Communication from Service Providers

“They talk down to us…They don’t let you finish your thoughts, like if you just say two of the 10 symptoms and they go, “Oh that’s this”, I’m like,

“You didn’t even hear the other eight”…They don’t really care.” (SIY, London)

“The doctor sort of explained [HIV], but didn’t get too far into detail, which didn’t help me at all.” (SIY, Toronto)

Intrapersonal Level

Lack of Trust and Associated Fear

“I know that like science and everyone says that like HIV is not a death sentence but it kind of feels like it. It’s a heavy fucking load to hear like, you’ve got HIV so, like they’ll get tested for it and then even just the wait for the results is like am I going to die or am I not going to die? It’s like I think a lot of people are like I already have enough shit that I’m dealing with, I don’t want to hear that… like I really don’t have a house to live in I also don’t want to hear that I’m not doing well health like health wise.” (SIY, Toronto)

“There is a belief that when you don’t know you are not stressed but once you get tested that is your end so that is believe which may contribute for them not to go for testing.” (CS, Kitale)

Low Perception of Need for Healthcare

“You can’t blame someone for catching a cold…no one does that, no one is out here blaming people for catching a cold…Healthcare professionals need to understand that people aren’t willingly uneducated, it’s not random. It isn’t surprising that the information never got to those people. Actually, this information is kept from those people, and it’s a responsibility that healthcare workers have. It’s not the individual’s fault that people don’t have this information, and they shouldn’t be expected to go and get it.” (SIY, Montreal)

Lack of Self-Esteem

“I would have unprotected sex with someone, and I was like ‘that’s what you deserve to live with.’”(SIY, Montreal)

High risk behaviours

“Someone with really severe mental health and high substance use is going to be unwilling to take their medication, or unable to take their medication. So you can say to that individual hey, you want your ARV today and by and large they’ll say yes, but we may not be able to find that individual, they may be substance using so heavily that today is not a good day for them….I’ve had some instances where someone is so heavily substance using that they may not know where they put their medication, or they may get a month’s worth of medication and it’s like still at the pharmacy” (HCP, London)