title: The impact of criminalization of HIV non-disclosure on the healthcare engagement of women living with HIV in Canada: a comprehensive review of the evidence.
abstract: BACKGROUND
  In 2012, the Supreme Court of Canada ruled that people living with HIV (PLWH) must disclose their HIV status to sexual partners prior to sexual activity that poses a "realistic possibility" of HIV transmission for consent to sex to be valid. The Supreme Court deemed that the duty to disclose could be averted if a person living with HIV both uses a condom and has a low plasma HIV-1 RNA viral load during vaginal sex. This is one of the strictest legal standards criminalizing HIV non-disclosure worldwide and has resulted in a high rate of prosecutions of PLWH in Canada. Public health advocates argue that the overly broad use of the criminal law against PLWH undermines efforts to engage individuals in healthcare and complicates gendered barriers to linkage and retention in care experienced by women living with HIV (WLWH).
  
  
  METHODS
  We conducted a comprehensive review of peer-reviewed and non-peer-reviewed evidence published between 1998 and 2015 evaluating the impact of the criminalization of HIV non-disclosure on healthcare engagement of WLWH in Canada across key stages of the cascade of HIV care, specifically: HIV testing and diagnosis, linkage and retention in care, and adherence to antiretroviral therapy. Where available, evidence pertaining specifically to women was examined. Where these data were lacking, evidence relating to all PLWH in Canada or other international jurisdictions were included.
  
  
  CONCLUSIONS
  Evidence suggests that criminalization of HIV non-disclosure may create barriers to engagement and retention within the cascade of HIV care for PLWH in Canada, discouraging access to HIV testing for some people due to fears of legal implications following a positive diagnosis, and compromising linkage and retention in healthcare through concerns of exposure of confidential medical information. There is a lack of published empirical evidence focused specifically on women, which is a concern given the growing population of WLWH in Canada, among whom marginalized and vulnerable women are overrepresented.
  
  
  CONCLUSIONS
  The threat of HIV non-disclosure prosecution combined with a heightened perception of surveillance may alter the environment within which women engage with healthcare services. Fully exploring the extent to which HIV criminalization represents a barrier to the healthcare engagement of WLWH is a public health priority.
authors.affiliation: Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada.|BC Centre for Excellence in HIV/AIDS, St Paul's Hospital, Vancouver, BC, Canada.
authors.forename: Sophie E
authors.initials: SE
authors.lastname: Patterson
authors.affiliation: BC Centre for Excellence in HIV/AIDS, St Paul's Hospital, Vancouver, BC, Canada.|Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.
authors.forename: M-J
authors.initials: MJ
authors.lastname: Milloy
authors.affiliation: Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.
authors.forename: Gina
authors.initials: G
authors.lastname: Ogilvie
authors.affiliation: School of Social Work, McMaster University, Hamilton, ON, Canada.
authors.forename: Saara
authors.initials: S
authors.lastname: Greene
authors.affiliation: Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada.
authors.forename: Valerie
authors.initials: V
authors.lastname: Nicholson
authors.affiliation: British Columbia Civil Liberties Association, Vancouver, BC, Canada.
authors.forename: Micheal
authors.initials: M
authors.lastname: Vonn
authors.affiliation: Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada.|BC Centre for Excellence in HIV/AIDS, St Paul's Hospital, Vancouver, BC, Canada.
authors.forename: Robert
authors.initials: R
authors.lastname: Hogg
authors.affiliation: Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada; angela_kaida@sfu.ca.
authors.forename: Angela
authors.initials: A
authors.lastname: Kaida
mesh_terms: D002170:Canada; D000066479:Criminal Behavior; D005260:Female; D015658:HIV Infections / Q000175:diagnosis* / Q000523:psychology; D006297:Health Services Accessibility; D006801:Humans; D055118:Medication Adherence; D011634:Public Health; D012650:Self Disclosure; D012725:Sexual Behavior; D012747:Sexual Partners
keywords: Canada; HIV; HIV non-disclosure; criminalization; women