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ObjectiveThis study examines the association between social support and cognitive function among midlife and older MSM living with or without HIV.DesignWe analyzed longitudinal data from participants enrolled from October 2016 to March 2019 in the Patterns of Healthy Aging Study, a substudy of the Multicenter AIDS Cohort Study.MethodsWe conducted a cross-sectional analysis to estimate the association between social support and three measures of cognitive function [Trail Making Test (TMT) Part A, TMT Part B to A ratio, and Symbol Digit Modalities Tasks (SDMT)]. We also used linear mixed-effects models to estimate the association between baseline social support and cognitive function across four subsequent time points. We evaluated a multiplicative interaction term between baseline social support and time, in order to determine whether cognitive trajectories over time vary by baseline social support.ResultsSocial support was associated with lower TMT Part A scores at baseline and over the subsequent 2 years, indicating better psychomotor ability. Social support was associated with higher SDMT scores at baseline and across 2 years, indicating better information processing. We observed no association between social support and TMT B to A ratio at baseline or across 2 years, indicating no effect on set-shifting ability. Longitudinal cognition outcome trajectories did not vary by the level of baseline social support.ConclusionSocial support and cognitive function were associated in this sample over a short time period. Further research should explore causal relationships over the lifespan.

Resilience and optimism may not only have main effects on health outcomes, but may also moderate and buffer negative effects of stressors. We examined whether dispositional resilience and optimism moderate the associations between HIV-related stigma in health care settings and health-related outcomes (trust in HIV health care providers and depression symptoms) among women living with HIV (WLHIV). One thousand four hundred five WLHIV in nine US cities completed validated questionnaires for cross-sectional analyses. Higher self-reported experienced and anticipated stigma and lower resilience and optimism were associated with higher depression symptoms and with lower trust in HIV providers. Importantly, resilience moderated the effects of experienced stigma (but not of anticipated stigma): When resilience was high, the association of experienced stigma with higher depression symptoms and lower trust in HIV providers was weaker compared with when resilience was low. Further, significant moderation effects suggested that when optimism was high, experienced and anticipated stigma was both less strongly associated with depression symptoms and with lower trust in one's HIV care providers compared with when optimism was low. Thus, the effects of experienced stigma on depression symptoms and provider trust were moderated by both resilience and optimism, but the effects of anticipated stigma were moderated only by optimism. Our findings suggest that in addition to their main effects, resilience and optimism may function as buffers against the harmful effects of stigma in health care settings. Therefore, optimism and resilience may be valuable intervention targets to reduce depression symptoms or improve trust in providers among populations that experience or anticipate stigma, such as WLHIV.

ObjectiveTo test whether substance use mediates the associations between gender-based violence (GBV) and suboptimal adherence to antiretroviral therapy (ART), and GBV and poor engagement in care, among women living with HIV (WLHIV) in the United States (US).DesignWe analyzed longitudinal data collected among 1717 WLHIV in the Women's Interagency HIV Study (WIHS).MethodsFrom 2013 to 2017, WLHIV completed semi-annual assessments on GBV, substance use, and HIV treatment and care. Adjusted multilevel logistic regression models were built to estimate the impact of GBV on; suboptimal (

ObjectivesTo explore the associations between intersectional poverty, HIV, sex, and racial stigma, adherence to antiretroviral therapy (ART), and viral suppression among women with HIV (WHIV).DesignWe examined intersectional stigmas, self-report ART adherence, and viral suppression using cross-sectional data.MethodsParticipants were WHIV ( N  = 459) in the Women's Adherence and Visit Engagement, a Women's Interagency HIV Study substudy. We used Multidimensional Latent Class Item Response Theory and Bayesian models to analyze intersectional stigmas and viral load adjusting for sociodemographic and clinical covariates.ResultsWe identified five intersectional stigma-based latent classes. The likelihood of viral suppression was approximately 90% lower among WHIV who experienced higher levels of poverty, sex, and racial stigma or higher levels of all intersectional stigmas compared with WHIV who reported lower experiences of intersectional stigmas. ART adherence accounted for but did not fully mediate some of the associations between latent intersectional stigma classes and viral load.ConclusionThe negative impact of intersectional stigmas on viral suppression is likely mediated, but not fully explained, by reduced ART adherence. We discuss the research and clinical implications of our findings.

Neuropsychiatric complications are common among women with HIV (WWH). The pathophysiological mechanisms underlying these complications are not fully known but likely driven in part by immune modulation. We examined associations between T-cell activation states which are required to mount an effective immune response (activation, co-stimulation/normal function, exhaustion, senescence) and neuropsychiatric complications in WWH. 369 WWH (78% HIV RNA undetectable/

The prevalence of HIV-associated neurocognitive impairment persists despite highly effective antiretroviral therapy (ART). In this study we explore the role of internalized stigma, acceptance of negative societal characterizations, and perceptions about people living with HIV (PLWH) on neurocognitive functioning (executive function, learning, memory, attention/working memory, psychomotor speed, fluency, motor skills) in a national cohort of women living with HIV (WLWH) in the United States. We utilized observational data from a multicenter study of WLWH who are mostly African American living in low-resource settings. Neurocognitive function was measured using an eight-test battery. A multiple linear regression model was constructed to investigate the relationship between internalized stigma and overall neurocognitive functioning (mean of all neurocognitive domain standardized T-scores), adjusting for age, education, race, previous neuropsychological battery scores, illicit drug use, viral load, and years on ART. Our analysis revealed that internalized HIV-related stigma is significantly associated with worse performance on individual domain tests and overall neurocognitive performance (B = 0.27, t = 2.50, p = 0.01). This suggests HIV-related internalized stigma may be negatively associated with neurocognitive functioning for WLWH. This finding highlights a specific psychosocial factor associated with poor neurocognitive function that may be targeted to better promote the health of PLWH. Future research on the longitudinal relationship between these variables and the effects of other stigma dimensions on poor neurocognitive function would provide further insights into the pathways explaining the relationship between internalized stigma and neurocognition.

In this mixed-methods study, we examine the relationship between provider communication and patient health literacy on HIV continuum of care outcomes among women living with HIV in the United States. We thematically coded qualitative data from focus groups and interviews (N = 92) and conducted mediation analyses with quantitative survey data (N = 1455) collected from Women's Interagency HIV Study participants. Four qualitative themes related to provider communication emerged: importance of respect and non-verbal cues; providers' expressions of condescension and judgement; patient health literacy; and unclear, insufficient provider communication resulting in diminished trust. Quantitative mediation analyses suggest that higher health literacy is associated with higher perceived patient-provider interaction quality, which in turn is associated with higher levels of trust in HIV providers, improved antiretroviral medication adherence, and reduced missed clinical visits. Findings indicate that enhancing provider communication and bolstering patient health literacy could have a positive impact on the HIV continuum of care.

Stigma in health care settings can have negative consequences on women living with HIV, such as increasing the likelihood of missed visits and reducing trust in their clinical providers. Informed by prior stigma research and considering knowledge gaps related to the effect of patient-provider race concordance, we conducted this study to assess if patient-provider race concordance moderates the expected association between HIV-related stigma in health care settings and patients' trust in their providers. Moderation analyses were conducted using Women's Interagency HIV Study data (N = 931). We found significant main effects for patient-provider race concordance. Higher experienced stigma was associated with lower trust in providers in all patient-provider race combinations [White-White: B = -0.89, standard error (SE) = 0.14, p = 0.000, 95% confidence interval, CI (-1.161 to -0.624); Black patient-White provider: B = -0.19, SE = 0.06, p = 0.003, 95% CI (-0.309 to -0.062); and Black-Black: B = -0.30, SE = 0.14, p = 0.037, 95% CI (-0.575 to -0.017)]. Higher anticipated stigma was also associated with lower trust in providers [White-White: B = -0.42, SE = 0.07, p = 0.000, 95% CI (-0.552 to -0.289); Black patient-White provider: B = -0.17, SE = 0.03, p = 0.000, 95% CI (-0.232 to -0.106); and Black-Black: B = -0.18, SE = 0.06, p = 0.002, 95% CI (-0.293 to -0.066)]. Significant interaction effects indicated that the negative associations between experienced and anticipated HIV-related stigma and trust in providers were stronger for the White-White combination compared with the others. Thus, we found that significant relationships between HIV-related experienced and anticipated stigma in health care settings and trust in providers exist and that these associations vary across different patient-provider race combinations. Given that reduced trust in providers is associated with antiretroviral medication nonadherence and higher rates of missed clinical visits, interventions to address HIV-related stigma in health care settings may improve continuum of care outcomes.

BackgroundEnding the HIV epidemic requires that women living with HIV (WLWH) have access to structurally competent HIV-related and other health care. WLWH may not regularly engage in care due to inadequate quality; however, women's perspectives on the quality of care they receive are understudied.MethodsWe conducted 12 focus groups and three in-depth interviews with Black (90%) and Latina (11%) WLWH enrolled in the Women's Interagency HIV Study in Atlanta, GA, Birmingham, AL, Brooklyn, NY, Chapel Hill, NC, Chicago, IL, and Jackson, MS from November 2017 to May 2018 (n = 92). We used a semi-structured format to facilitate discussions about satisfaction and dissatisfaction with health care engagement experiences, and suggestions for improvement, which were audio-recorded, transcribed, and coded using thematic analysis.ResultsThemes emerged related to women's health care satisfaction or dissatisfaction at the provider, clinic, and systems levels and across Institute of Medicine-defined quality of care domains (effectiveness, efficiency, equity, patient-centeredness, safety and timeliness). Women's degree of care satisfaction was driven by: 1) knowledge-based care resulting in desired outcomes (effectiveness); 2) coordination, continuity and necessity of care (efficiency); 3) perceived disparities in care (equity); 4) care delivery characterized by compassion, nonjudgment, accommodation, and autonomous decision-making (patient-centeredness); 5) attention to avoiding side effects and over-medicalization (safety); and 6) limited wait time (timeliness).ConclusionsQuality of care represents a key changeable lever affecting engage in care among WLWH. The communities most proximally affected by HIV should be key stakeholders in HIV-related quality assurance. Findings highlight aspects of the health care experience valued by WLWH, and potential participatory, patient-driven avenues for improvement.

Food insecurity (FI) contributes to HIV-related morbidity and mortality, but the mechanisms whereby FI negatively impacts HIV health are untested. We tested the hypothesis that FI leads to poor HIV clinical outcomes through nutritional, mental health, and behavioral paths. We analyzed data from Women's Interagency HIV Study (WIHS) among 1803 women living with HIV (WLWH) (8225 person-visits) collected from 2013 to 2015 biannually from nine sites across the United States participating in the WIHS. FI was measured with the US Household Food Security Survey Module. Outcomes included HIV viral nonsuppression, CD4 cell counts, and physical health status (PHS). We used longitudinal logistic and linear regression models with random effects to examine associations adjusting for covariates and path analysis to test nutritional, mental health, and behavioral paths. Increasing severity of FI was associated with unsuppressed viral load, lower CD4 counts, and worse PHS (all p

BackgroundFood insecurity is a well-established determinant of suboptimal, self-reported antiretroviral therapy (ART) adherence, but few studies have investigated this association using objective adherence measures. We examined the association of food insecurity with levels of ART concentrations in hair among women living with human immunodeficiency virus (WLHIV) in the United States.MethodsWe analyzed longitudinal data collected semiannually from 2013 through 2015 from the Women's Interagency HIV Study, a multisite, prospective, cohort study of WLHIV and controls not living with HIV. Our sample comprised 1944 person-visits from 677 WLHIV. Food insecurity was measured using the US Household Food Security Survey Module. ART concentrations in hair, an objective and validated measure of drug adherence and exposure, were measured using high-performance liquid chromatography with mass spectrometry detection for regimens that included darunavir, atazanavir, raltegravir, or dolutegravir. We conducted multiple 3-level linear regressions that accounted for repeated measures and the ART medication(s) taken at each visit, adjusting for sociodemographic and clinical characteristics.ResultsAt baseline, 67% of participants were virally suppressed and 35% reported food insecurity. In the base multivariable model, each 3-point increase in food insecurity was associated with 0.94-fold lower ART concentration in hair (95% confidence interval, 0.89 to 0.99). This effect remained unchanged after adjusting for self-reported adherence.ConclusionsFood insecurity was associated with lower ART concentrations in hair, suggesting that food insecurity may be associated with suboptimal ART adherence and/or drug absorption. Interventions seeking to improve ART adherence among WLHIV should consider and address the role of food insecurity.

ObjectiveConsidering the association between internalized HIV-related stigma and treatment adherence, an intervention addressing HIV treatment adherence may have the added benefit of reducing internalized stigma. The 'integrating ENGagement and Adherence Goals upon Entry' (iENGAGE) intervention was developed to facilitate adjustment to living with HIV among individuals newly engaged in HIV care. We evaluated the effects of this intervention on internalized stigma and examined whether the effect is moderated by depressive symptoms and coping styles.DesignThe iENGAGE intervention was tailored individually to improve information, motivation, and behavioral skills to promote treatment adherence and viral suppression. Three hundred and seventy-one participants initiating HIV care at four sites in the United States were randomly assigned to either the intervention receiving four face-to-face sessions or standard of care control arm.MethodsBaseline and 48-week follow-up assessments were conducted, which included validated measures of internalized HIV-related stigma, depressive symptoms, and coping mechanisms (behavioral disengagement and self-blame) as secondary outcomes. A repeated measures ANOVA evaluated the effect of the intervention on change in internalized HIV stigma. Furthermore, the moderating effects of depressive symptoms and coping mechanisms on the decrease in internalized stigma were examined.ResultsThe decrease in internalized stigma from baseline to 48 weeks was significantly larger in the intervention arm compared with the control arm. This effect was significantly moderated by baseline levels of depressive symptoms and self-blame.ConclusionThe multifaceted iENGAGE intervention is effective in reducing internalized stigma for new-to-HIV care individuals, especially with higher depressive symptoms or when using higher levels of self-blame coping.

Resilience is defined as the ability and process to transform adversity into opportunities for growth and adaptation. Resilience may be especially important for people living with HIV (PLWH), who are susceptible to anxiety and depressive disorders, which are commonly linked to risk behaviors (i.e., alcohol and drug abuse), poor adherence to medical regimens, increased risk of morbidity and mortality, and related stigma and discrimination. To date, few studies have examined the impact of resilience on health-related behaviors and outcomes among PLWH, particularly among minority women living with HIV (WLWH) who are dealing with multiple stressors impacting their health. This study used a convergent parallel mixed-methods design to collect, analyze, and integrate qualitative and quantitative data from a subsample of WLWH enrolled in the Women's Interagency HIV Study (WIHS). The aims of the study were to (1) qualitatively examine the resilience perspectives of 76 marginalized WLWH, and; (2) quantitatively assess the associations of resilience with HIV health outcomes-adherence to antiretroviral therapy and viral suppression-in the context of differing levels of internalized HIV-related stigma and depressive symptoms (n = 420). Findings from this mixed-methods study suggest that resilience is an important resource that can aid WLWH in coping constructively with adversity by capitalizing on intrapersonal traits and states, interpersonal and institutional resources, and spiritual and/or religious practices. Given the complex medical and social needs of marginalized WLWH, intervention strategies should focus on mitigating psychosocial burdens of stigma and depression, in addition to building resilience.

BackgroundFood insecurity, which disproportionately affects marginalized women in the United States, is associated with depressive symptoms. Few studies have examined relations of food insecurity with other mental health outcomes.ObjectiveThe aim of this study was to investigate the associations of food insecurity with symptoms of generalized anxiety disorder (GAD), stress, and posttraumatic stress disorder (PTSD) in the Women's Interagency HIV Study (WIHS), a prospective cohort study of women with or at risk of HIV in the United States.MethodsParticipants were 2553 women with or at risk of HIV, predominantly African American/black (71.6%). Structured questionnaires were conducted during April 2013-March 2016 every 6 mo. Food security (FS) was the primary predictor, measured using the Household Food Security Survey Module. We measured longitudinal outcomes for GAD (GAD-7 score and a binary GAD-7 screener for moderate-to-severe GAD). Only cross-sectional data were available for outcomes measuring perceived stress (PSS-10 score) and PTSD (PCL-C score and a binary PCL-C screener for PTSD). We examined associations of FS with the outcomes through use of multivariable linear and logistic regression, including lagged associations with GAD outcomes.ResultsAfter adjusting for sociodemographic and health-related factors including HIV serostatus, current marginal, low, and very low FS were associated with increasingly higher GAD-7 scores, and with 1.41 (95% CI: 1.10, 1.80; P

Relationships that traverse sociodemographic categories may improve community attitudes toward marginalized groups and potentially protect members of those groups from stigma and discrimination. The present study evaluated whether internalized HIV stigma and perceived HIV-related discrimination in health care settings differ based on individual- and neighborhood-level characteristics of women living with HIV (WLHIV). We also sought to extend previous conceptual and empirical work to explore whether perceived HIV-related discrimination mediated the association between neighborhood racial diversity and internalized HIV stigma. A total of 1256 WLHIV in the Women's Interagency HIV Study (WIHS) attending 10 sites in metropolitan areas across the United States completed measures of internalized HIV stigma and perceived HIV-related discrimination in health care settings. Participants also provided residential information that was geocoded into Federal Information Processing Standard (FIPS) codes and linked with census-tract level indicators. In cross-sectional analyses, greater neighborhood racial diversity was associated with less internalized HIV stigma and less perceived HIV-related discrimination regardless of individual race. Neighborhood median income was positively associated with internalized HIV stigma and perceived discrimination, while individual income was negatively associated with perceptions of stigma and discrimination. In an exploratory mediation analysis, neighborhood racial diversity had a significant indirect effect on internalized HIV stigma through perceived HIV-related discrimination. An indirect effect between neighborhood income and internalized stigma was not supported. These findings suggest that greater neighborhood racial diversity may lessen HIV stigma processes at the individual level and that HIV stigma-reduction interventions may be most needed in communities that lack racial diversity.

Among places where people living with HIV experience and anticipate HIV-related stigma, stigma in health care settings may be particularly harmful. Utilizing an exploratory sequential mixed methods approach, we conducted interviews (n = 76) and questionnaires (N = 460) with older adult women living with HIV enrolled in the Women's Interagency HIV Study in Birmingham, AL; Jackson, MS; Atlanta, GA; and San Francisco, CA. Interviews addressed facilitators and barriers to HIV treatment adherence, including HIV-related stigma. Qualitative data were coded using thematic analysis. Questionnaires assessed self-reported antiretroviral therapy (ART) adherence and experienced and anticipated HIV-related stigma from various sources (i.e., health care personnel, family, partner, and community). Covariate-adjusted logistic regression analyses examined total and mediated effects of stigma on ART adherence. Interviewees described fears and experiences of stigma in health care settings; including privacy violations, disrespect for patient autonomy, and reproductive coercion; and how these influenced their adherence to HIV treatment recommendations. Experienced and anticipated HIV-related stigma in health care settings were associated with suboptimal (or

BackgroundOne mechanism through which social stigma of HIV affects health outcomes for people living with HIV (PLWH) is through internalization of stigma. However, this transformation of social stigma in the community into internalized stigma may not be of the same magnitude for all PLWH. We examined the moderating effects of 3 personality traits-fear of negative social evaluation, attachment-related anxiety, and dispositional resilience-in transforming perceived stigma in the community into internalized stigma. Furthermore, we investigated downstream effects of these moderated associations on depressive symptoms and antiretroviral treatment (ART) adherence.Setting/methodsIn study 1, data from 203 PLWH in the Southeast United States were analyzed controlling for age, sex, education, race, and time on ART. In study 2, data from 453 women in a multisite study were analyzed controlling for age, education, race, time on ART, and substance use.ResultsIn both studies, fear of negative evaluation and attachment-related anxiety moderated the effect of perceived HIV stigma in the community on internalized HIV stigma: People higher on those moderating variables had stronger associations between perceived stigma in the community and internalized stigma. In study 2, resilience was assessed and also moderated the effect of perceived HIV stigma in the community on internalized stigma. In moderated mediation models, fear of negative evaluation, attachment-related anxiety, and resilience moderated the indirect effect of perceived HIV stigma in the community on ART adherence and depression through internalized stigma.ConclusionsInterventions to assuage internalization of HIV stigma should focus on bolstering attachment-related security, social competence, and resilience.

BackgroundFood insecurity and mental health negatively affect the lives of women in the United States. Participants in the Women's Interagency HIV Study (WIHS) provided the opportunity to understand the association of food insecurity with depression and mental well-being over time.ObjectiveWe investigated the association between current and persistent food insecurity and depression among women at risk of or living with HIV in the United States.MethodsWe used longitudinal data from the WIHS, a prospective cohort study in women at risk of or living with HIV from multiple sites in the United States. Participants completed 6 semiannual assessments from 2013 to 2016 on food security (FS; high, marginal, low, and very low) and mental health (i.e., depressive symptoms and mental well-being). We used multiple regression analysis to estimate the association between these variables.ResultsAmong 2551 participants, 44% were food insecure and 35% reported depressive symptoms indicative of probable depression. Current marginal, low, and very low FS were associated with 2.1-, 3.5-, and 5.5-point (all P

BackgroundChronic inflammation is associated with AIDS-defining and non-AIDS-defining conditions. Limited research has considered how food insecurity influences chronic inflammation among people living with human immunodeficiency virus (HIV). We examined whether food insecurity was associated with higher levels of inflammation among women living with HIV (WWH) in the United States.MethodsWe analyzed cross-sectional data collected in 2015 from 421 participants on antiretroviral therapy from the Women's Interagency HIV Study. The exposure was any food insecurity. The outcome was inflammation, measured by proinflammatory cytokine interleukin-6 (IL-6) and tumor necroses factor receptor 1 (TNFR1) levels. We conducted multivariable linear regressions, adjusting for sociodemographic, clinical, and nutritional factors.ResultsNearly one-third of participants (31%) were food insecure and 79% were virally suppressed (

Background and aimsFew longitudinal studies have examined the relationship between food insecurity and substance use. We aimed to investigate this relationship using longitudinal data among women with or at risk for HIV in the United States.DesignWomen's Interagency HIV Study (WIHS), a prospective cohort study.SettingNine sites across the United States.ParticipantsA total of 2553 women with or at risk for HIV.MeasurementsSemi-annual structured interviews were conducted during April 2013-March 2016. Food security (FS) was the primary predictor, measured using the Household Food Security Survey Module. Outcomes were: any illicit substance use except cannabis; licit or illicit cannabis use; stimulant use (crack, cocaine, or methamphetamine); opioid use (heroin or methadone in a non-prescribed way); and prescription drug misuse (prescription narcotics, amphetamines, or tranquilizers in a non-prescribed way) since the last visit. We used multivariable logistic regression with random effects to examine longitudinal associations of current and previous FS with the outcomes simultaneously, adjusting for socio-demographic factors, HIV serostatus, physical health and health insurance.FindingsAverage number of visits was 4.6. At baseline, 71% of participants were HIV-seropositive, 44% reported marginal, low, or very low FS, and 13% were using illicit substances. In adjusted analyses, current low and very low FS were significantly associated with 1.59 [95% confidence interval (CI) = 1.02, 2.46; P = 0.039] and 2.48 (95% CI = 1.52, 4.04; P

BackgroundTreatment adherence and viral suppression remain suboptimal in the United States. Attachment insecurity may be one understudied factor affecting adherence. According to attachment theory, people develop generalized internal working models of interpersonal relationships, which shape their perceptions of the availability of others at times of stress and how they handle stressors as an individual. Two dimensions of attachment insecurity are attachment-related avoidance (avoidance of intimacy with others and avoidance of negative emotions) and attachment-related anxiety (feeling unable to deal with stressors without others' help). For people living with chronic stressful health conditions that require life-long self-management, attachment-related avoidance and attachment-related anxiety may diminish the ability to cope with stressors as an individual leading to negative health outcomes.MethodsWe examined cross-sectional associations of the 2 attachment-related insecurity dimensions with antiretroviral treatment (ART) adherence, HIV visit adherence, CD4 cell counts, and viral suppression. Survey and clinical data from 453 women living with HIV in 4 US cities were analyzed controlling for age, education, income, time on ART, illicit drug use, and race.ResultsAttachment-related avoidance was the only unique predictor of suboptimal ART adherence, viral failure, and low CD4 count, and attachment-related anxiety was the only unique predictor of missed HIV care visits. These effects were over and above the effects of all covariates. ART adherence mediated the association of attachment-related avoidance with both viral failure and low CD4 counts.ConclusionsInterventions may need to focus on the vulnerable subpopulation with high attachment insecurity and incorporate existing strategies that address insecure attachment models.

Food insecurity, internalized HIV stigma, and depressive symptoms are independently associated with poor HIV outcomes. Food insecurity, stigma, and depression may be interrelated among women living with HIV (WLHIV). We hypothesized that food insecurity would be independently associated with internalized stigma and depressive symptoms among WLHIV in the United States (US), and would partially account for associations between stigma and depressive symptoms. We tested hypotheses using regression models and partial correlation analysis with cross-sectional data among 1317 WLHIV from the Women's Interagency HIV Study. In adjusted models, greater food insecurity was associated with internalized HIV stigma and depressive symptoms (all p

Chronic pain is an important and understudied comorbidity in people living with HIV (PLWH). We conducted a pilot trial of Skills TO Manage Pain (STOMP), an innovative social cognitive theory-based pain self-management intervention tailored to PLWH, to assess feasibility, acceptability, and preliminary efficacy. Eligibility criteria included being HIV+, ≥ moderate pain for ≥ 3 months and a score of ≥ 4 on the three-item PEG pain severity and interference scale. Participants were randomized in a 1:1 fashion to STOMP or a usual care comparison. Among 22 participants randomized to STOMP, median session attendance was 9/12 (75%). Of 19 STOMP participants surveyed, 13 reported being "much better" overall since beginning treatment. Brief pain inventory-total scores decreased by 2 points in the intervention group and 0.9 in the control group (p = 0.11). STOMP is feasible, acceptable, and shows preliminary evidence of efficacy and promise for a full-scale trial.

Attitudes and behavior that devalue individuals based upon their HIV status (HIV-related stigma) are barriers to HIV prevention, treatment, and wellbeing among women living with HIV. Other coexisting forms of stigma (e.g., racism, sexism) may worsen the effects of HIV-related stigma, and may contribute to persistent racial and gendered disparities in HIV prevention and treatment. Few studies examine perceptions of intersectional stigma among women living with HIV. From June to December 2015, we conducted 76 qualitative interviews with diverse women living with HIV from varied socioeconomic backgrounds enrolled in the Women's Interagency HIV Study (WIHS) in Birmingham, Alabama; Jackson, Mississippi; Atlanta, Georgia; and San Francisco, California. Interview guides facilitated discussions around stigma and discrimination involving multiple interrelated identities. Interviews were audio-recorded, transcribed verbatim, and coded using thematic analysis. Interviewees shared perceptions of various forms of stigma and discrimination, most commonly related to their gender, race, and income level, but also incarceration histories and weight. Women perceived these interrelated forms of social marginalization as coming from multiple sources: their communities, interpersonal interactions, and within systems and structures. Our findings highlight the complexity of social processes of marginalization, which profoundly shape life experiences, opportunities, and healthcare access and uptake among women living with HIV. This study highlights the need for public health strategies to consider community, interpersonal, and structural dimensions across intersecting, interdependent identities to promote the wellbeing among women living with HIV and to reduce social structural and health disparities.

Chronic pain is an important comorbidity among individuals with HIV. Behavioral interventions are widely regarded as evidence-based, efficacious non-pharmacologic interventions for chronic pain in the general population. An accepted principle in behavioral science is that theory-based, systematically-developed behavioral interventions tailored to the unique needs of a target population are most likely to be efficacious. Our aim was to use Intervention Mapping to systematically develop a Social Cognitive Theory (SCT)-based intervention for chronic pain tailored to individuals with HIV that will improve pain intensity and pain-related functional impairment. Our Intervention Mapping process was informed by qualitative inquiry of 24 patients and seven providers in an HIV primary care clinic. The resulting intervention includes group and one-on-one sessions and peer and staff interventionists. We also developed a conceptual framework that integrates our qualitative findings with SCT-based theoretical constructs. Using this conceptual framework as a guide, our future work will investigate the intervention's impact on chronic pain outcomes, as well as our hypothesized proximal mediators of the intervention's effect.

BackgroundChronic pain is a common, disabling, and costly comorbidity, particularly in people living with HIV (PLWH). This study developed and pilot tested a pain self-management intervention for chronic pain tailored to PLWH called Skills TO Manage Pain (STOMP).ObjectivesGiven the additional resources needed to deliver STOMP in HIV clinical settings, an important objective of the pilot study was to assess not only STOMP's preliminary efficacy, but also its cost-effectiveness.Research design and subjectsThe present study draws from a 44-participant, 2-arm randomized pilot trial of the STOMP intervention vs usual care among PLWH and at least moderate chronic pain (Clinicaltrials.gov: NCT02824562). Cost-effectiveness is presented as the incremental cost-effectiveness ratio (ICER). Costs were considered from the clinic perspective over a 1-year time horizon using real costs from the pilot trial. It was conservatively assumed there would be no costs savings. The Standard Gamble (SG) method was used to directly measure utilities.ResultsThirty-six participants met inclusion criteria for the present analyses. Mean age was 52 years; 61% were female and 86% were black. The total cost of STOMP was $483.83 per person. Using the SG method, the change in QALYs was 0.15, corresponding to an ICER of $3,225.ConclusionsSTOMP's cost/QALY is substantially lower than the $50,000 to $100,000/QALY benchmark often used to indicate cost-effectiveness. Although based on a pilot trial and, therefore, preliminary, these findings are promising, and suggest the importance of cost analyses in future STOMP trials.

There is insufficient research on the impact of perceived discrimination in healthcare settings on adherence to antiretroviral therapy (ART), particularly among women living with HIV, and even less is known about psychosocial mechanisms that may mediate this association. Cross-sectional analyses were conducted in a sample of 1356 diverse women living with HIV enrolled in the Women's Interagency HIV Study (WIHS), a multi-center cohort study. Indirect effects analysis with bootstrapping was used to examine the potential mediating roles of internalized stigma and depressive symptoms in the association between perceived discrimination in healthcare settings and ART adherence. Perceived discrimination in healthcare settings was negatively associated with optimal (95% or better) ART adherence (adjusted odds ratio (AOR) = 0.81, p = 0.02, 95% confidence interval (CI) [0.68, 0.97]). Furthermore, internalization of stigma and depressive symptoms mediated the perceived discrimination-adherence association: Serial mediation analyses revealed a significant indirect effect of perceived discrimination in healthcare settings on ART adherence, first through internalized HIV stigma, and then through depressive symptoms (B = - 0.08, SE = 0.02, 95% CI [- 0.12, - 0.04]). Perceiving discrimination in healthcare settings may contribute to internalization of HIV-related stigma, which in turn may lead to depressive symptoms, with downstream adverse effects on ART adherence among women. These findings can guide the design of interventions to reduce discrimination in healthcare settings, as well as interventions targeting psychosocial mechanisms that may impact the ability of women living with HIV to adhere to ART regimens.

Women in the general population experience more food insecurity than men. Few studies have examined food insecurity's impact on HIV treatment outcomes among women. We examined the association between food insecurity and HIV outcomes in a multi-site sample of HIV-infected women in the United States (n = 1154). Two-fifths (40%) of participants reported food insecurity. In an adjusted multivariable Tobit regression model, food insecurity was associated with 2.08 times higher viral load (95% confidence interval (CI): 1.04, 4.15) and lower CD4+ counts (- 42.10, CI: - 81.16, - 3.03). Integration of food insecurity alleviation into HIV programs may improve HIV outcomes in women.

Disability benefits have become an increasingly prominent source of cash assistance for impoverished American citizens over the past two decades. This development coincided with cuts and market-oriented reforms to state and federal welfare programs, characteristic of the wider political-economic trends collectively referred to as neoliberalism. Recent research has argued that contemporary discourses on 'disability fraudsters' and 'malingerers' associated with this shift represent the latest manifestation of age-old stigmatization of the 'undeserving poor'. Few studies, however, have investigated how the system of disability benefits, as well as these stigmatizing discourses, shapes the lived experience of disabling physical illness in today's United States. Here we present qualitative data from 64 semi-structured interviews with low-income individuals living with HIV and/or type 2 diabetes mellitus to explore the experience of long-term, work-limiting disability in the San Francisco Bay Area. Interviews were conducted between April and December 2014. Participants explained how they had encountered what they perceived to be excessive, obstructive, and penalizing bureaucracy from social institutions, leading to destitution and poor mental health. They also described being stigmatized as disabled for living with chronic ill health, and simultaneously stigmatized as shirking and malingering for claiming disability benefits as a result. Notably, this latter form of stigma appeared to be exacerbated by the bureaucracy of the administrating institutions. Participants also described intersections of health-related stigma with stigmas of poverty, gender, sexual orientation, and race. The data reveal a complex picture of poverty and intersectional stigma in this population, potentiated by a convoluted and inflexible bureaucracy governing the system of disability benefits. We discuss how these findings reflect the historical context of neoliberal cuts and reforms to social institutions, and add to ongoing debate around the future of public social provision for impoverished and chronically ill citizens under neoliberalism.

BackgroundChronic pain is a common and disabling comorbidity in individuals living with HIV. Behavioral interventions are among the most effective and safe nonpharmacologic treatments for chronic pain. However, the success of a behavioral intervention is influenced by how well it is tailored to the target population's biological, psychological, and social context. Given well-documented psychosocial vulnerabilities among persons with HIV, it is critical to develop a behavioral intervention for chronic pain tailored to this population.ObjectiveTo use qualitative methods to investigate patient preferences for the structure and delivery of a behavioral intervention for chronic pain in individuals with HIV.MethodsInterviews and focus groups were used to elicit participant preferences. A thematic analysis approach, with an initial round of open coding, was used to develop the codebook and analyze the data.ResultsQualitative data from 12 interviews and 3 focus groups with patients living with HIV and chronic pain (total N = 24) were analyzed. Emergent themes fell into four major categories: perceived value of group sessions, incorporating peer leadership, and two key elements of how the intervention should be delivered: the HIV status of group participants and views on phone-delivered intervention content.DiscussionThis study provides a framework for the structure and delivery of a behavioral intervention for chronic pain in individuals with HIV based on patient preferences. We will use these results to design our intervention, and hope that our approach informs the work of investigators in other disciplines who seek to incorporate patient preferences during intervention development.

In sub-Saharan Africa, involving male partners in the prevention of mother-to-child transmission of HIV improves maternal and infant outcomes. Male involvement is typically conceptualised as male partners attending antenatal care, which is difficult for many men. Little is known about how men view their involvement in family health within the context of HIV, particularly outside of clinic attendance. Through interviews with 35 male partners of pregnant or postpartum women living with HIV in Kenya and Zambia, this study elicited perceptions of male involvement in maternal and infant health in families affected by HIV. Men supported the importance of clinic attendance but reported conflicts with the need to work and fulfil their role as the family's financial provider. Providing money for necessities was deemed more critical for their family's health than clinic attendance. Men's involvement was conveyed through various other supportive actions, including helping with household chores and providing emotional support (showing love and reducing women's stress). Future strategies to promote male partner involvement in the prevention of mother-to-child transmission of HIV and maternal and child health should build upon the actions men view as most meaningful to promote their family's health within their real-world life circumstances and cultural context, particularly their role as financial providers. [ABSTRACT FROM AUTHOR]

Little is known about migration during pregnancy related to intimate partner violence (IPV). In this paper, we examine issues of agency in relation to pregnant women's migrations in a high HIV prevalence area of Kenya. We qualitatively explored forced migration among pregnant women, using data from in-depth interviews, focus groups and IPV screening forms. To quantitatively examine migration during pregnancy, we analysed data from a prospective study of 614 pregnant women. The qualitative data revealed that women had varied responses to violence in pregnancy, with some being able to leave the marital home voluntarily as a strategy to escape violence. Others were 'sent packing' from their marital homes when they dared to exercise autonomy, in some cases related to HIV status. Quantitative analyses revealed that pregnant women who migrated were more educated, less likely to be living with a partner and had fewer children than other women. Migration among pregnant women in Kenya illustrates the complexity of understanding women's agency in the context of IPV. The findings indicate that there is not a dichotomy between 'victim' and 'agent', but rather a complex dynamic between and within pregnant women, who may sequentially or simultaneously experience aspects of victimhood and/or agentic response.

BackgroundThe World Health Organization (WHO) recommends that HIV-infected women practice exclusive breastfeeding (EBF) for the first 6 months postpartum to reduce HIV transmission. The aim of this study was to determine the effects of HIV/AIDS knowledge and other psychosocial factors on EBF practice among pregnant and postpartum women in rural Nyanza, Kenya, an area with a high prevalence of HIV.MethodsData on baseline characteristics and knowledge during pregnancy, as well as infant feeding practices 4-8 weeks after the birth were obtained from 281 pregnant women recruited from nine antenatal clinics. Factors examined included: fear of HIV/AIDS stigma, male partner reactions, lack of disclosure to family members, knowledge of prevention of mother-to-child transmission (PMTCT) and mental health. In the analysis, comparisons were made using chi-squared and t-test methods as well as logistic multivariate regression models.ResultsThere were high levels of anticipated stigma 171(61.2%), intimate partner violence 57(20.4%) and postpartum depression 29(10.1%) and low levels of disclosure among HIV positive women 30(31.3%). The most significant factors determining EBF practice were hospital delivery (aOR = 2.1 95% CI 1.14-3.95) HIV positive serostatus (aOR 2.5 95% CI 1.23-5.27), and disclosure of HIV-positive serostatus (aOR 2.9 95% CI 1.31-6.79). Postpartum depression and PMTCT knowledge were not associated with EBF (aOR 1.1 95% CI 0.47-2.62 and aOR 1.2 95% CI 0.64-2.24) respectively.ConclusionsHealth care workers and counselors need to receive support in order to improve skills required for diagnosing, monitoring and managing psychosocial aspects of the care of pregnant and HIV positive women including facilitating disclosure to male partners in order to improve both maternal and child health outcomes.

BackgroundDue to rising rates of opioid addiction and overdose among individuals on chronic opioid therapy, aberrant drug-related behaviors (ADRBs) are an important and challenging issue. Our objective was to qualitatively investigate the documentation of ADRBs in the medical record.MethodsManually abstracted provider notes from an HIV primary care clinic were analyzed using content analysis methods.ResultsCategories of ADRBs identified included patients requesting opioids, obtaining nonprescribed opioids, and becoming emotional about opioids. We also identified several types of provider language used when documenting ADRBs, including purely descriptive language and emotional language such as labeling, frustration, and concern, and responses such as setting conditions for opioid prescription and action-oriented language.ConclusionsThe impact of including emotional language in the medical record is unknown. Development of instruments that can be used to facilitate ADRB documentation, as well as evidence-based approaches to addressing ADRBs, is needed.

IntroductionWithin healthcare settings, HIV-related stigma is a recognized barrier to access of HIV prevention and treatment services and yet, few efforts have been made to scale-up stigma reduction programs in service delivery. This is in part due to the lack of a brief, simple, standardized tool for measuring stigma among all levels of health facility staff that works across diverse HIV prevalence, language and healthcare settings. In response, an international consortium led by the Health Policy Project, has developed and field tested a stigma measurement tool for use with health facility staff.MethodsExperts participated in a content-development workshop to review an item pool of existing measures, identify gaps and prioritize questions. The resulting questionnaire was field tested in six diverse sites (China, Dominica, Egypt, Kenya, Puerto Rico and St. Christopher & Nevis). Respondents included clinical and non-clinical staff. Questionnaires were self- or interviewer-administered. Analysis of item performance across sites examined both psychometric properties and contextual issues.ResultsThe key outcome of the process was a substantially reduced questionnaire. Eighteen core questions measure three programmatically actionable drivers of stigma within health facilities (worry about HIV transmission, attitudes towards people living with HIV (PLHIV), and health facility environment, including policies), and enacted stigma. The questionnaire also includes one short scale for attitudes towards PLHIV (5-item scale, α=0.78).ConclusionsStigma-reduction programmes in healthcare facilities are urgently needed to improve the quality of care provided, uphold the human right to healthcare, increase access to health services, and maximize investments in HIV prevention and treatment. This brief, standardized tool will facilitate inclusion of stigma measurement in research studies and in routine facility data collection, allowing for the monitoring of stigma within healthcare facilities and evaluation of stigma-reduction programmes. There is potential for wide use of the tool either as a stand-alone survey or integrated within other studies of health facility staff.

Home-based couples HIV testing and counseling and HIV self-testing (HIVST) for pregnant women can promote HIV status disclosure and male partner testing; however, cost data are lacking. We examined a home-based couples intervention (HBCI) and HIVST intervention costs per couple (unit cost) during pregnancy and postpartum in Kenya. This randomized controlled trial is comparing HBCI and HIVST for couples among pregnant women attending antenatal care clinics in two counties in southwestern Kenya. We used micro-costing to estimate the unit cost per couple receiving the intervention as the total of direct and indirect costs for each study arm in 2019 US$. We used a one-month window to conduct a time and motion study to determine personnel effort and resources. We then compared the unit cost by arm, identified key cost drivers, and conducted sensitivity analyses for cost uncertainties. At base-case, the unit cost was $129.01 and $41.99, respectively, for HBCI and HIVST. Personnel comprised half of the unit cost for both arms. Staff spent more time on activities related to participant engagement in HBCI (accounting for 6.4% of the unit cost) than in HIVST (2.3%). Staff training was another key cost driver in HBCI (20.1% of the unit cost compared to 12.5% in HIVST). Sensitivity analyses revealed that the unit cost ranges were $104.64-$154.54 for HBCI and $30.49-$56.59 for HIVST. Our findings may guide spending decisions for future HIV prevention and treatment programs for pregnant couples in resource-limited settings such as Kenya. • Home-based couples human immunodeficiency virus (HIV) testing and counseling and HIV self-testing for pregnant couples can promote HIV status disclosure and male partner testing and improve maternal and child health; nevertheless, cost data are lacking. • In southwestern Kenya, the program implementation cost per couple was $129 for home-based couples HIV testing and counseling and $42 for HIV self-testing. • These findings may serve as important inputs for upcoming economic evaluation research and guide spending decisions for future HIV prevention and treatment programs for pregnant couples in resource-limited settings, such as Kenya. [ABSTRACT FROM AUTHOR]

Lifetime traumatic events are prevalent among people with HIV and consistently associated with deleterious HIV outcomes. Yet, little is known about the impact of recent stressful events on health outcomes among Black women with HIV (WWH). This cross-sectional study assessed the prevalence of recent stressful events and lifetime traumatic events and their association with HIV outcomes in Black WWH (n = 200) in the Southeastern United States. We evaluated the association between stressful events and HIV outcomes using chi-square tests and unadjusted and adjusted logistic regression analyses. In the unadjusted analyses, missed visits were associated with higher odds of recent stressful events (odds ratio [OR] 1.10, 95% confidence interval [CI] 1.04–1.16) and lifetime traumatic events (OR 1.15, 95% CI 1.05–1.26). In the adjusted analysis, exposure to recent stressful events was independently associated with missed visits (adjusted OR 1.08, 95% CI 1.01–1.15). Interventions addressing recent stressful events are warranted. [ABSTRACT FROM AUTHOR]