Recent trauma is associated with antiretroviral failure and HIV transmission risk behavior among HIV-positive women and female-identified transgenders

Women, incarceration and HIV: a systematic review of HIV treatment access, continuity of care and health outcomes across incarceration trajectories

OBJECTIVE

The aim of this study was to systematically review the literature on gendered implications of incarceration for HIV outcomes and engagement in care for women living with HIV (WLWH).

DESIGN

We systematically searched seven bibliographic databases, for peer-reviewed English-language studies, published between 2007 and 2017 reporting on incarceration, women (transgender inclusive) and HIV.

METHODS

Articles were included for evaluation if they reported outcomes for at least one of three measures of interest: viral load, antiretroviral therapy (ART) adherence or engagement in care among WLWH along incarceration trajectories.

RESULTS

Out of 1119 studies, 24 (2%) met the inclusion criteria. Of these 24 studies, the majority (n = 23) were conducted in the USA, 19 included samples of women and men and seven studies were transgender inclusive. Our review did not reveal clear sex differences in HIV outcomes during periods of incarceration; however, studies reporting postincarceration outcomes demonstrated significant sex disparities in all three outcomes of interest. Following incarceration, women were less likely to be virally suppressed, less likely to achieve optimal ART adherence and less likely to be engaged in care.

CONCLUSION

Despite growing numbers of incarcerated WLWH globally, there is a substantial gap in research examining the impact of incarceration on HIV outcomes for WLWH. Significant sex disparities in HIV outcomes and engagement in care exist along incarceration trajectories for WLWH, especially postincarceration. For improved health outcomes, research is needed to examine the experiences of WLWH throughout incarceration trajectories to develop interventions tailored to the specific needs of WLWH both during and following incarceration.

The Inner Working of Trauma: A Qualitative Assessment of Experiences of Trauma, Intergenerational Family Dynamics, and Psychological Well-Being in Women With HIV in South Carolina

Women with HIV are more likely to have a history of traumatic and stressful life experiences. The current study examines experiences of traumatic and stressful life events, issues co-occurring with experiences of trauma, and intergenerational family dynamics regarding trauma and psychological well-being in women with HIV. The study was guided by the theoretical approach of an integrative translational model that incorporates trauma-related factors into a psychosocial framework. Data were collected from interviews with 20 women with HIV and analyzed for thematic categories. Thematic analysis indicated that traumatic life events of women with HIV included experiences of loss, sexual assault, and homelessness. Women with HIV also experienced issues co-occurring with trauma, including substance use and mental illness. The current study adds to the existing body of research by including an analysis of intergenerational family dynamics and psychological well-being. Implications for health care professionals and recommendations for translating research into practice are also discussed. [Journal of Psychosocial Nursing and Mental Health Services, 57(4), 23-31.].

Supporting the Sexual Rights of Women Living With HIV: A Critical Analysis of Sexual Satisfaction and Pleasure Across Five Relationship Types

In the context of human immunodeficiency virus (HIV), a focus on protecting others has overridden concern about women's own sexual well-being. Drawing on feminist theories, we measured sexual satisfaction and pleasure across five relationship types among women living with HIV in Canada. Of the 1,230 women surveyed, 38.1% were completely or very satisfied with their sexual lives, while 31.0% and 30.9% were reasonably or not very/not at all satisfied, respectively. Among those reporting recent sexual experiences (n = 675), 41.3% always felt pleasure, with the rest reporting usually/sometimes (38.7%) or seldom/not at all (20.0%). Sex did not equate with satisfaction or pleasure, as some women were completely satisfied without sex, while others were having sex without reporting pleasure. After adjusting for confounding factors, such as education, violence, depression, sex work, antiretroviral therapy, and provider discussions about transmission risk, women in long-term/happy relationships (characterized by higher levels of love, greater physical and emotional intimacy, more equitable relationship power, and mainly HIV-negative partners) had increased odds of sexual satisfaction and pleasure relative to women in all other relational contexts. Those in relationships without sex also reported higher satisfaction ratings than women in some sexual relationships. Findings put focus on women's rights, which are critical to overall well-being.

Correlates of Not Using Antiretroviral Therapy Among Transwomen Living with HIV: The Unique Role of Personal Competence

Purpose: This study tested three psychosocial measures for their potential to serve as counseling goals for promoting ART to transgender women living with HIV (TWLH). Methods: Among 69 TWLH, 17.4% were not taking ART; these volunteers were compared to the remainder using multivariate regression analyses. Results: Only one psychosocial measure achieved significance: Personal Competence (Adjusted Odds Ratio = 0.80, 95% CI = 0.67-0.97, P = 0.02). Because this was a continuous measure, assessed on a 7-point scale, the protective adjusted odds ratio of 0.80 represents a 20% reduction in the odds of not taking ART for each unit of increase in this construct. Conclusion: Findings suggest a potential counseling goal for TWLH not taking ART.

Relationship between intimate partner violence and antiretroviral adherence and viral suppression in pregnancy

OBJECTIVE

To determine whether intimate partner violence (IPV) during pregnancy is associated with increased risk of clinical factors that influence maternal to child transmission (MTCT) of HIV.

STUDY DESIGN

Retrospective cohort study of pregnant women living with HIV (WLHIV) who received prenatal care in a multidisciplinary perinatal HIV clinic (2007-2014). All women were assessed for IPV status during pregnancy by a social worker and/or health psychologist. Records were abstracted for obstetric information and factors associated with MTCT of HIV, including antenatal visit attendance, adherence to antiretroviral regimen, time until viral suppression after initiation of antiretroviral medications, HIV RNA at 36 weeks and at delivery, and preterm birth. Women who reported IPV were compared to those who did not using bivariable and multivariable logistic and linear regression analyses.

RESULTS

Of 215 women receiving care during the study period, 91.6% (N = 197) had documentation of IPV history. Of these women, 13.7% (N = 27) reported experiencing IPV during pregnancy. Women who reported IPV were less likely to be completely adherent to antiretroviral doses (38.5% vs. 62.0%, p = 0.039) and required significantly more time to achieve stable virologic suppression (16.0 vs. 8.5 weeks, p = 0.010). Time to achieve suppression remained significant in multivariable models (β 4.68, 95% CI 0.03-9.32).

CONCLUSION

IPV during a pregnancy complicated by HIV appears to be associated with decreased antiretroviral adherence. Pregnant WLHIV who reported IPV exhibited delays in achieving virologic suppression. These women represent a vulnerable population who may require additional support and interventions to reduce the risk of MTCT of HIV.

The Importance of Human Immunodeficiency Virus Research for Transgender and Gender-Nonbinary Individuals

Transgender and gender-nonbinary (trans/GNB) individuals are disproportionally affected by human immunodeficiency virus (HIV), yet they are not adequately represented in HIV research and often underserved in clinical care. By building on community strengths and addressing structural, psychological and biological challenges, we can improve the engagement of trans/GNB people in research and ultimately improve prevention, testing, and care for this population. Here, we review the current state of the science related to HIV for trans/GNB people and discuss next steps to expand research that aims to improve the lives and well-being of trans/GNB persons.

Substance Use, Violence, and Antiretroviral Adherence: A Latent Class Analysis of Women Living with HIV in Canada

We used latent class analysis to identify substance use patterns for 1363 women living with HIV in Canada and assessed associations with socio-economic marginalization, violence, and sub-optimal adherence to combination antiretroviral therapy (cART). A six-class model was identified consisting of: abstainers (26.3%), Tobacco Users (8.81%), Alcohol Users (31.9%), 'Socially Acceptable' Poly-substance Users (13.9%), Illicit Poly-substance Users (9.81%) and Illicit Poly-substance Users of All Types (9.27%). Multinomial logistic regression showed that women experiencing recent violence had significantly higher odds of membership in all substance use latent classes, relative to Abstainers, while those reporting sub-optimal cART adherence had higher odds of being members of the poly-substance use classes only. Factors significantly associated with Illicit Poly-substance Users of All Types were sexual minority status, lower income, and lower resiliency. Findings underline a need for increased social and structural supports for women who use substances to support them in leading safe and healthy lives with HIV.

Impact of Sexual Trauma on HIV Care Engagement: Perspectives of Female Patients with Trauma Histories in Cape Town, South Africa

South African women have disproportionately high rates of both sexual trauma and HIV. To understand how sexual trauma impacts HIV care engagement, we conducted in-depth qualitative interviews with 15 HIV-infected women with sexual trauma histories, recruited from a public clinic in Cape Town. Interviews explored trauma narratives, coping behaviors and care engagement, and transcripts were analyzed using a constant comparison method. Participants reported multiple and complex traumas across their lifetimes. Sexual trauma hindered HIV care engagement, especially immediately following HIV diagnosis, and there were indications that sexual trauma may interfere with future care engagement, via traumatic stress symptoms including avoidance. Disclosure of sexual trauma was limited; no women had disclosed to an HIV provider. Routine screening for sexual trauma in HIV care settings may help to identify individuals at risk of poor care engagement. Efficacious treatments are needed to address the psychological and behavioral sequelae of trauma.

Pre-exposure prophylaxis for HIV prevention in women: current perspectives

There are ~900,000 new HIV infections among women every year, representing nearly half of all new HIV infections globally. In the US, nearly one-fifth of all new HIV infections occur among women, and women from racial and ethnic minority communities experience disproportionately high rates of new HIV infections. Thus, there is a need to develop and implement effective HIV prevention strategies for women in the US and internationally, with a specific need to advance strategies in minority communities. Previous studies have demonstrated that oral HIV pre-exposure prophylaxis (PrEP), the use of antiretroviral medications by HIV-uninfected persons to prevent HIV acquisition, can reduce HIV incidence among women who are adherent to PrEP. However, to date, awareness and uptake of PrEP among women have been very limited, suggesting a need for innovative strategies to increase the knowledge of and access to PrEP among women in diverse settings. This narrative review summarizes the efficacy and safety data of PrEP in women, discusses considerations related to medication adherence for women who use PrEP, and highlights behavioral, social, and structural barriers to maximize the effectiveness of PrEP in women. It also reviews novel modalities for PrEP in women which are being developed and tested, including topical formulations and long-acting injectable agents that may offer advantages as compared to oral PrEP and proposes a community-oriented, social networking framework to increase awareness of PrEP among women. If women are provided with access to PrEP and support to overcome social and structural barriers to adhere to PrEP, this prevention strategy holds great promise to impact the HIV epidemic among women in the US and globally.

Seeking Safety Group Therapy for Co-Occurring Substance Use Disorder and PTSD among Transgender Women Living with HIV: A Pilot Study

Transgender women living with HIV experience high rates of substance use, violence, and post-traumatic stress disorder (PTSD). Seeking Safety is a manualized, present-focused, cognitive-behavioral therapy program designed to address co-occurring substance use and PTSD. Seeking Safety has evidence of efficacy in a variety of populations but had not been evaluated specifically with people living with HIV or transgender women. We pilot-tested a 12-session Seeking Safety program with a group of transgender women living with HIV who reported substance use and a history of violence. Seven transgender women living with HIV were recruited from two HIV primary care clinics in San Francisco and completed pre- and post-intervention assessments. Participants attended an average of 8 of the 12 sessions. Mean scores for all three outcome measures improved: PTSD symptom scores declined 17.5%, alcoholism screening scores declined 23.9%, and drug abuse screening scores declined 68.8%, on average. Despite the small sample, this pilot study showed Seeking Safety to be a promising intervention among transgender women living with HIV. The findings are encouraging and justify larger studies of Seeking Safety among transgender women and other people living with HIV who experience high rates of substance use and PTSD.

Using Path Analysis to Evaluate the Healthcare Empowerment Model Among Persons Living with HIV for Antiretroviral Therapy Adherence

Healthcare empowerment (HCE) is patient controlled and includes the process and state of being engaged, informed, collaborative, committed, and tolerant of uncertainty. Understanding psychosocial factors that impact HCE for persons living with HIV is critical for their treatment and care. A sample of 1494 male and female participants living with HIV in the United States with a mean age of 45.6 (standard deviation = 11.4) completed a one-time online survey about their demographic characteristics, social support, healthcare provider relationship, HIV treatment knowledge, perceived HIV-related stigma, lifetime trauma, depressive symptoms, HCE, and antiretroviral therapy (ART) adherence. A path analysis was conducted using structural equation modeling software to fit a theory-based model of HCE. Results included statistically significant direct pathways between depressive symptoms, healthcare provider relationship, lifetime trauma, and ART adherence, as well as between healthcare provider relationship, HIV treatment knowledge, and HCE. Specifically, ART adherence was positively linked to healthcare provider relationship and negatively linked to depressive symptoms and lifetime trauma. In addition, healthcare provider relationship and HIV treatment knowledge were positively associated with HCE. The indirect effects of healthcare provider relationship and HIV treatment knowledge on adherence through HCE were also significant. In particular, ART adherence was indirectly and positively affected by healthcare provider relationship and HIV treatment knowledge through HCE. Multi-level interventions are urgently needed to address the effects of these psychosocial factors on ART adherence.

The future of PrEP among transgender women: the critical role of gender affirmation in research and clinical practices

INTRODUCTION

Globally, transgender ("trans") women are one of the key populations most disproportionately impacted by HIV. Pre-exposure prophylaxis (PrEP) is the newest and most promising biomedical HIV prevention intervention to date. This paper reviews relevant literature to describe the current state of the science and describes the potential role of PrEP among trans women, including a discussion of unique considerations for maximizing the impact of PrEP for this vulnerable population.

METHODS

Available information, including but not limited to existing scientific literature, about trans women and PrEP was reviewed and critiqued based on author expertise, including PrEP clinical trials and rollout.

RESULTS

To date, PrEP demonstration projects and clinical trials have largely excluded trans women, or have not included them in a meaningful way. Data collection strategies that fail to identify trans women in clinical trials and research further limit the ability to draw conclusions about trans women's unique needs and devise strategies to meet them. Gender-affirming providers and clinic environments are essential components of any sexual health programme that aims to serve trans women, as they will largely avoid settings that may result in stigmatizing encounters and threats to their identities. While there is currently no evidence to suggest drug-drug interactions between PrEP and commonly used feminizing hormone regimens, community concerns about potential interactions may limit interest in and uptake of PrEP among trans women.

CONCLUSIONS

In scaling up PrEP for trans women, it is essential to engage trans communities, utilize trans-inclusive research and marketing strategies and identify and/or train healthcare providers to provide gender-affirming healthcare to trans women, including transition-related care such as hormone provision. PrEP implementation guidelines must consider and address trans women's unique barriers and facilitators to uptake and adherence.

Alcohol Use and Human Immunodeficiency Virus (HIV) Infection: Current Knowledge, Implications, and Future Directions

Alcohol use is common among people living with human immunodeficiency virus (HIV). In this narrative review, we describe literature regarding alcohol's impact on transmission, care, coinfections, and comorbidities that are common among people living with HIV (PLWH), as well as literature regarding interventions to address alcohol use and its influences among PLWH. This narrative review identifies alcohol use as a risk factor for HIV transmission, as well as a factor impacting the clinical manifestations and management of HIV. Alcohol use appears to have additive and potentially synergistic effects on common HIV-related comorbidities. We find that interventions to modify drinking and improve HIV-related risks and outcomes have had limited success to date, and we recommend research in several areas. Consistent with Office of AIDS Research/National Institutes of Health priorities, we suggest research to better understand how and at what levels alcohol influences comorbid conditions among PLWH, to elucidate the mechanisms by which alcohol use is impacting comorbidities, and to understand whether decreases in alcohol use improve HIV-relevant outcomes. This should include studies regarding whether state-of-the-art medications used to treat common coinfections are safe for PLWH who drink alcohol. We recommend that future research among PLWH include validated self-report measures of alcohol use and/or biological measurements, ideally both. Additionally, subgroup variation in associations should be identified to ensure that the risks of particularly vulnerable populations are understood. This body of research should serve as a foundation for a next generation of intervention studies to address alcohol use from transmission to treatment of HIV. Intervention studies should inform implementation efforts to improve provision of alcohol-related interventions and treatments for PLWH in healthcare settings. By making further progress on understanding how alcohol use affects PLWH in the era of HIV as a chronic condition, this research should inform how we can mitigate transmission, achieve viral suppression, and avoid exacerbating common comorbidities of HIV and alcohol use and make progress toward the 90-90-90 goals for engagement in the HIV treatment cascade.

A Prospective Study of Intimate Partner Violence as a Risk Factor for Detectable Plasma Viral Load in HIV-Positive Women Engaged in Transactional Sex in Mombasa, Kenya

We conducted a prospective cohort study to evaluate intimate partner violence (IPV) as a risk factor for detectable plasma viral load in HIV-positive female sex workers (FSWs) on antiretroviral therapy (ART) in Kenya. IPV in the past year was defined as ≥1 act of physical, sexual, or emotional violence by the index partner (i.e. boyfriend/husband). The primary outcome was detectable viral load (≥180 copies/ml). In-depth interviews and focus groups were included to contextualize results. Analyses included 195 women (570 visits). Unexpectedly, IPV was associated with significantly lower risk of detectable viral load (adjusted relative risk 0.21, 95 % CI 0.05-0.84, p-value = 0.02). Qualitative findings revealed that women valued emotional and financial support from index partners, despite IPV. IPV was not a major barrier to ART adherence. The observed association between IPV and lower risk of detectable viral load in FSWs may be due to unmeasured personal and relationship factors, warranting further research.

A Report of the Women's Health Congress Workshop on The Health of Women of Color: A Critical Intersection at the Corner of Sex/Gender and Race/Ethnicity

Women of color face unique health challenges that differ significantly from those of other women and men of color. To bring these issues to light, the National Institutes of Health (NIH) Office of Research on Women's Health sponsored a preconference workshop at the 23rd Annual Women's Health Congress, which was held in Washington, DC, in April 2015. The workshop featured presentations by NIH intramural and extramural scientists who provided insight on the disparities of a wide range of conditions, including cancer, cardiovascular disease, the risk of HIV infection, and disability in an aging population. In this study, we highlight the major points of each presentation and the ensuing discussion.

PTSD co-morbid with HIV: Separate but equal, or two parts of a whole?

Approximately 30 million people currently live with HIV worldwide and the incidence of stress-related disorders, such as post-traumatic stress disorder (PTSD), is elevated among people living with HIV as compared to those living without the virus. PTSD is a severely debilitating, stress-related psychiatric illness associated with trauma exposure. Patients with PTSD experience intrusive and fearful memories as well as flashbacks and nightmares of the traumatic event(s) for much of their lives, may avoid other people, and may be constantly on guard for new negative experiences. This review will delineate the information available to date regarding the comorbidity of PTSD and HIV and discuss the biological mechanisms which may contribute to the co-existence, and potential interaction of, these two disorders. Both HIV and PTSD are linked to altered neurobiology within areas of the brain involved in the startle response and altered function of the hypothalamic-pituitary-adrenal axis. Collectively, the data highlighted suggest that PTSD and HIV are more likely to actively interact than to simply co-exist within the same individual. Multi-faceted interactions between PTSD and HIV have the potential to alter response to treatment for either independent disorder. Therefore, it is of great importance to advance the understanding of the neurobiological substrates that are altered in comorbid PTSD and HIV such that the most efficacious treatments can be administered to improve both mental and physical health and reduce the spread of HIV.

'I am not a man': Trans-specific barriers and facilitators to PrEP acceptability among transgender women

The frequent conflation of transgender ('trans') women with 'men who have sex with men (MSM)' in HIV prevention obscures trans women's unique gender identities, social and behavioural vulnerabilities, and their disproportionately high rates of HIV infection. Pre-exposure prophylaxis (PrEP) is an efficacious biomedical HIV prevention approach. However, trans women are underrepresented in PrEP research, and are often aggregated with MSM without consideration for their unique positions within sociocultural contexts. This study examined PrEP acceptability among trans women via three focus groups and nine individual interviews (total N = 30) in San Francisco. While knowledge of PrEP was low, interest was relatively high once participants were informed. Due to past negative healthcare experiences, ability to obtain PrEP from a trans-competent provider was cited as essential to PrEP uptake and adherence. Participants noted that PrEP could address situations in which trans women experience reduced power to negotiate safer sex, including sex work. Trans-specific barriers included lack of trans-inclusive marketing of PrEP, prioritisation of hormone use, and medical mistrust due to transphobia. Findings underscore the importance of disaggregating trans women from MSM in HIV prevention strategies to mitigate disparate risk among this highly vulnerable population.

Addressing the Intersection of HIV and Intimate Partner Violence Among Women with or at Risk for HIV in the United States

In 2012, the White House established a working group in recognition of the need to understand and address the intersection of human immunodeficiency virus (HIV) infection and violence against women and girls. This report describes the Centers for Disease Control and Prevention (CDC)'s efforts for addressing intimate partner violence and HIV among women and provides suggestions for future prevention efforts. CDC's current efforts are focused on understanding these often co-occurring public health problems, identifying effective interventions, and ensuring that states and communities have the capacity and resources to implement prevention approaches based on the best available evidence. Additional research is needed on effective strategies for integrating violence prevention and HIV programming into health services targeting adolescent girls and women who experience intimate partner violence or are at risk for HIV.

Safer disclosure of HIV serostatus for women living with HIV who experience or fear violence: a systematic review

Introduction

Supporting individuals as they disclose their HIV serostatus may lead to a variety of individual and public health benefits. However, many women living with HIV are hesitant to disclose their HIV status due to fear of negative outcomes such as violence, abandonment, relationship dissolution and stigma.

Methods

We conducted a systematic review of studies evaluating interventions to facilitate safer disclosure of HIV status for women living with HIV who experience or fear violence. Articles, conference abstracts and programme reports were included if they reported post-intervention evaluation results and were published before 1 April 2015. Searching was conducted through electronic databases for peer-reviewed articles and conference abstracts, reviewing websites of relevant organizations for grey literature, hand searching reference lists of included studies and contacting experts. Systematic methods were used for screening and data abstraction, which was conducted in duplicate. Study quality (rigor) was assessed with the Cochrane risk of bias tool.

Results

Two interventions met the inclusion criteria: the Safe Homes and Respect for Everyone cluster-randomized trial of combination HIV and intimate partner violence (IPV) services in Rakai, Uganda, and the South Africa HIV/AIDS Antenatal Post-Test Support study individual randomized trial of an enhanced counselling intervention for pregnant women undergoing HIV testing and counselling. Both programmes integrated screening for IPV into HIV testing services and trained counsellors to facilitate discussions about disclosure based on a woman's risk of violence. However, both were implemented as part of multiple-component interventions, making it impossible to isolate the impact of the safer disclosure components.

Conclusions

The existing evidence base for interventions to facilitate safe HIV serostatus disclosure for women who experience or fear violence is limited. Development and implementation of new approaches and rigorous evaluation of safe disclosure outcomes is needed to guide programme planners and policy makers.

HIV and gender-based violence: welcome policies and programmes, but is the research keeping up?

The global HIV policy arena has seen a surge of interest in gender-related dimensions of vulnerability to HIV and violence. UNAIDS and other prominent actors have named gender-based violence a key priority, and there seems to be genuine understanding and commitment to addressing gender inequalities as they impact key populations in the AIDS response. In the quest for evidence-informed interventions, there is usually a strong connection between the research conducted and the policies and programmes that follow. Regarding gender, HIV and violence, is this the case? This discussion paper asks whether the relevant peer-reviewed literature is suitably representative of all affected populations--including heterosexual men, transgender men and women, women who have sex with women, and men who have sex with men--as well as whether the literature sufficiently considers gender norms and dynamics in how research is framed. Conclusions about violence in the context of heterosexual relationships, and with specific attention to heterosexual women, should not be presented as insights about gender-based violence more generally, with little attention to gender dynamics. Research framed by a more comprehensive understanding of what is meant by gender-based violence as it relates to all of the diverse populations affected by HIV would potentially guide policies and programmes more effectively.

Intimate partner violence and engagement in HIV care and treatment among women: a systematic review and meta-analysis

OBJECTIVE

We aimed to estimate the odds of engagement in HIV care and treatment among HIV-positive women reporting intimate partner violence (IPV).

DESIGN

We systematically reviewed the literature on the association between IPV and engagement in care. Data sources included searches of electronic databases (PubMed, Web of Science, CINAHL and PsychoInfo), hand searches and citation tracking.

METHODS

Two reviewers screened 757 full-text articles, extracted data and independently appraised study quality. Included studies were peer-reviewed and assessed IPV alongside engagement in care outcomes: antiretroviral treatment (ART) use; self-reported ART adherence; viral suppression; retention in HIV care. Odds ratios (ORs) were pooled using random effects meta-analysis.

RESULTS

Thirteen cross-sectional studies among HIV-positive women were included. Measurement of IPV varied, with most studies defining a 'case' as any history of physical and/or sexual IPV. Meta-analysis of five studies showed IPV to be significantly associated with lower ART use [OR 0.79, 95% confidence interval (95% CI) 0.64-0.97]. IPV was associated with poorer self-reported ART adherence in six studies (OR 0.48, 95% CI 0.30-0.75) and lower odds of viral load suppression in seven studies (OR 0.64, 95% CI 0.46-0.90). Lack of longitudinal data and measurement considerations should temper interpretation of these results.

CONCLUSION

IPV is associated with lower ART use, half the odds of self-reported ART adherence and significantly worsened viral suppression among women. To ensure the health of HIV-positive women, it is essential for clinical programmes to address conditions that impact engagement in care and treatment. IPV is one such condition, and its association with declines in ART use and adherence requires urgent attention.

Resilience Moderates the Association Between Childhood Sexual Abuse and Depressive Symptoms Among Women with and At-Risk for HIV

Childhood sexual abuse (CSA) places women at risk for HIV infection and once infected, for poor mental health outcomes, including lower quality of life and depressive symptoms. Among HIV-positive and demographically matched HIV-negative women, we investigated whether resilience and HIV status moderated the relationships between CSA and health indices as well as the relationships among CSA, depressive symptoms, and health-related quality of life (HRQOL). Participants included 202 women (138 HIV+, 64 HIV-, 87 % African American) from the Women's Interagency HIV Study Chicago CORE Center site. Results indicated that in both HIV-positive and HIV-negative women, higher resilience significantly related to lower depressive symptoms and higher HRQOL. CSA related to higher depressive symptoms only for women scoring low in resilience. Interventions to promote resilience, especially in women with a CSA history, might minimize depressive symptoms and poor HRQOL among HIV-positive and HIV-negative women.

Differences in housing, health, and well-being among HIV-positive women living in poverty

The social context of living in poverty has a direct and indirect impact on a woman's health and well-being. This cross-sectional study investigates the relationship between housing and adherence to treatment, emotional wellness, environmental safety, physical health status, and risk behaviors among HIV-positive women receiving services from an AIDS service organization in the mid-South. Significant differences were found between stably housed and unstably housed women on the dependent outcome variables. Results suggest that housing services for HIV-positive women may be an effective way to increase their health and well-being as well as prevent transmission to others.

Trauma history in African-American women living with HIV: effects on psychiatric symptom severity and religious coping

Women living with HIV (WLHIV) have rates of post-traumatic stress disorder (PTSD) up to 5 times higher than the general population. Individuals living with HIV and a concurrent diagnosis of PTSD have poorer HIV-related outcomes; however, the prevalence and impact of PTSD on African-American WLHIV seeking mental health treatment is unknown. The aim of this study is to examine the associations between PTSD symptoms with psychiatric symptom severity and psychological/religious coping strategies in African-American WLHIV who are seeking mental health treatment. This is a cross-sectional study of 235 African-American WLHIV attending an urban community mental health clinic. Bivariate analyses were conducted to evaluate associations between a PTSD symptoms scale (PSS≥21 versus PSS<21) and (1) psychiatric severity, (2) coping strategies, and (3) religious coping strategies. Thirty-six percent reported symptoms consistent with PTSD (PSS≥21). These women were significantly more likely to have worse mental health symptoms and were more likely to employ negative psychological and religious coping strategies. On the contrary, women with a PSS<21 reported relatively low levels of mental health symptoms and were more likely to rely on positive psychological and religious coping strategies. Over one-third of African-American WLHIV attending an outpatient mental health clinic had symptoms associated with PTSD. These symptoms were associated with worse mental health symptoms and utilization of dysfunctional religious and nonreligious coping strategies. Untreated PTSD in WLHIV predicts poorer HIV-related health outcomes and may negatively impact comorbid mental health outcomes. Screening for PTSD in WLHIV could identify a subset that would benefit from evidence-based PTSD-specific therapies in addition to mental health interventions already in place. PTSD-specific interventions for WLHIV with PTSD may improve outcomes, improve coping strategies, and allow for more effective treatment of comorbid mental health disorders.

Violence screening and viral load suppression among HIV-positive women of color

Recent research suggests intimate partner violence (IPV) is commonly experienced by many people living with HIV/AIDS, which can complicate their care. We introduce a novel approach to screening for history of violence among 102 women of color living with HIV and receiving care at an outpatient public health clinic. Using a composite measure composed of data from a variety of screening tools, we were able to determine that 70.6% of the women had a history of violence using the composite measure, and that 43% screened positive using multiple screening tools. Although overall viral load suppression rate was high at 81.4%, women with a history of violence were less likely to be virally suppressed when compared to those without such a history (76.4% versus 93.3%, p<0.05). Our findings suggest using a variety of screening questions at entry and at follow-up care appointments may be key to identifying and supporting women survivors who may not disclose violence when first asked. Future research should foster further development, analysis, and use of a variety of screening tools such as those used in this study.

Intimate partner violence and human immunodeficiency virus risk among black and Hispanic women

BACKGROUND

Approximately 80% of new HIV infections among U.S. women are among black/African American and Hispanic women. HIV risk may be associated with intimate partner violence (IPV); data regarding IPV for women in high-HIV prevalence areas are scarce.

PURPOSE

To examine prevalence and correlates of IPV among women.

METHODS

Heterosexual women and their male partners in cities with high HIV prevalence were enrolled. During 2006-2007, participants completed interviews about HIV risk factors and IPV (physical violence or forced sex) experiences. Data were analyzed during 2012-2013 using multivariate logistic regression to identify individual- and partner-level IPV correlates.

RESULTS

Of 1,011 female respondents, 985 (97.4%) provided risk factor and demographic data. Most were non-Hispanic black/African American (82.7%); living at or below poverty (86.7%); and tested HIV-negative (96.8%). IPV-physical violence was reported by 29.1%, and IPV-forced sex by 13.7%. Being married/living with a partner (AOR=1.60, 95% CI=1.06, 2.40); non-injection drug use (AOR=1.74, 95% CI=1.22, 2.48); and ever discussing male partners' number of current sex partners (AOR=1.60, 95% CI=1.15, 2.24) were associated with IPV-physical violence. Women reporting concurrent sex partners (AOR=1.80, 95% CI=1.04, 3.13) and ever discussing number of male partners' past sex partners (AOR=1.85, 95% CI=1.13, 3.05) were associated with IPV-forced sex. Feeling comfortable asking a male partner to use condoms was associated with decreased IPV-physical violence (AOR=0.32, 95% CI=0.16,0.64) and -forced sex (AOR=0.37, 95% CI=0.16, 0.85).

CONCLUSIONS

Prevention interventions that enhance women's skills to decrease HIV and IPV risk are important strategies for decreasing racial/ethnic disparities among women.

The syndemic illness of HIV and trauma: implications for a trauma-informed model of care

BACKGROUND

People living with HIV infection are disproportionately burdened by trauma and the resultant negative health consequences, making the combination of HIV infection and trauma a syndemic illness. Despite the high co-occurrence and negative influence on health, trauma and posttraumatic sequelae in people living with HIV infection often go unrecognized and untreated because of the current gaps in medical training and lack of practice guidelines.

OBJECTIVE

We set out to review the current literature on HIV infection and trauma and propose a trauma-informed model of care to target this syndemic illness.

METHODS

We searched PubMed, PsycINFO, and Cochrane review databases for articles that contained the following search terms: HIV AND either trauma (specifically violent trauma), PTSD, intimate partner violence (IPV), abuse, or trauma-informed care. Articles were limited to primary clinical research or metanalyses published in English. Articles were excluded if they referred to HIV-associated posttraumatic stress disorder or HIV-associated posttraumatic growth.

RESULTS

We confirm high, but variable, rates of trauma in people living with HIV infection demonstrated in multiple studies, ranging from 10%-90%. Trauma is associated with (1) increased HIV-risk behavior, contributing to transmission and acquisition of the virus; (2) negative internal and external mediators also associated with poor health and high-risk HIV behavior; (3) poor adherence to treatment; (4) poor HIV-related and other health outcomes; and (5) particularly vulnerable special populations.

CONCLUSIONS

Clinicians should consider using a model of trauma-informed care in the treatment of people living with HIV infection. Its adoption in different settings needs to be matched to available resources.

Predicting long-term outcomes for children affected by HIV and AIDS: perspectives from the scientific study of children's development

The immediate and short-term consequences of adult HIV for affected children are well documented. Little research has examined the long-term implications of childhood adversity stemming from caregiver HIV infection. Through overviews provided by experts in the field, together with an iterative process of consultation and refinement, we have extracted insights from the broader field of child development of relevance to predicting the long-term consequences to children affected by HIV and AIDS. We focus on what is known about the impact of adversities similar to those experienced by HIV-affected children, and for which there is longitudinal evidence. Cautioning that findings are not directly transferable across children or contexts, we examine findings from the study of parental death, divorce, poor parental mental health, institutionalization, undernutrition, and exposure to violence. Regardless of the type of adversity, the majority of children manifest resilience and do not experience any long-term negative consequences. However, a significant minority do and these children experience not one, but multiple problems, which frequently endure over time in the absence of support and opportunities for recovery. As a result, they are highly likely to suffer numerous and enduring impacts. These insights suggest a new strategic approach to interventions for children affected by HIV and AIDS, one that effectively combines a universal lattice of protection with intensive intervention targeted to selected children and families.

An expressive therapy group disclosure intervention for women living with HIV improves social support, self-efficacy, and the safety and quality of relationships: a qualitative analysis

Women living with HIV (WLHIV) face high rates of morbidity and mortality. HIV disclosure interventions have been identified as a promising but under-evaluated approach for WLHIV to improve their health and well-being. The Medea Project is an expressive therapy group intervention that was first developed to help incarcerated women develop the confidence and skills to tell their stories publicly in theatrical performances. The intervention was subsequently adapted as a community-based disclosure intervention for WLHIV. Our study describes an analysis of the impact of the Medea Project on the lives of the WLHIV who participated. All participating WLHIV publicly disclosed their HIV status during the performances. Five impact themes emerged from the data: sisterhood, catharsis, self-acceptance, safer and healthier relationships, and gaining a voice. Our study identifies a voluntary, effective, and broadly beneficial disclosure intervention for women living with HIV.

Correlates of antiretroviral adherence and viral load among transgender women living with HIV

Transgender women are 49 times more likely to become HIV infected than other groups, yet they are drastically underserved by current treatment efforts and report lower rates of treatment adherence then other groups. The objective of this study was to explore correlates of antiretroviral (ART) adherence and viral load among HIV-positive transgender women on ART utilizing a cross-sectional survey of a convenience sample of 59 transgender women. In multivariate models of ART adherence, correlates were age, stress appraisal of transphobic experiences, importance of gender affirmation, and adherence to hormone therapy. In multivariate models of self-reported viral load, correlates were stress appraisal of transphobic experiences and being in a relationship. This study provides preliminary evidence of transgender-relevant correlates of ART adherence and viral load.

Abuse and resilience in relation to HAART medication adherence and HIV viral load among women with HIV in the United States

Abuse is highly prevalent among HIV+ women, leading to behaviors, including lower adherence to highly active antiretroviral therapy (HAART) that result in poor health outcomes. Resilience (functioning competently despite adversity) may buffer the negative effects of abuse. This study investigated how resilience interacted with abuse history in relation to HAART adherence, HIV viral load (VL), and CD4+ cell count among a convenience sample of 138 HIV+ women from the Ruth M. Rothstein CORE Center/Cook County Health and Hospital Systems site of the Women's Interagency HIV Study (WIHS). Resilience was measured by the 10-item Connor-Davidson Resilience Scale (CD-RISC). HAART adherence (≥95% vs. <95% self reported usage of prescribed medication) and current or prior sexual, physical, or emotional/domestic abuse, were reported during structured interviews. HIV viral load (≥20 vs. <20 copies/mL) and CD4+ count (200 vs. <200 cells/mm) were measured with blood specimens. Multiple logistic regressions, controlling for age, race, income, enrollment wave, substance use, and depressive symptoms, indicated that each unit increase in resilience was significantly associated with an increase in the odds of having ≥95% HAART adherence and a decrease in the odds of having a detectable viral load. Resilience-Abuse interactions showed that only among HIV+ women with sexual abuse or multiple abuses did resilience significantly relate to an increase in the odds of ≥95% HAART adherence. Interventions to improve coping strategies that promote resilience among HIV+ women may be beneficial for achieving higher HAART adherence and viral suppression.

HIV epidemics among transgender women

PURPOSE OF REVIEW

Recent data on the high burden of HIV among transgender women have stimulated interest in addressing HIV in this vulnerable population. This review situates the epidemiologic data on HIV among transgender women in the context of the social determinants of health and describes opportunities for effective interventions.

RECENT FINDINGS

Transgender women experience unique vulnerability to HIV that can be attributed to multilevel, intersecting factors that also influence the HIV treatment and care continuum. Stigma and discrimination, lack of social and legal recognition of their affirmed gender, and exclusion from employment and educational opportunities represent fundamental drivers of HIV risk in transgender women worldwide.

SUMMARY

Interventions to improve engagement in HIV prevention, testing, care, and treatment among transgender women should build on community strengths and address structural factors as well as psychosocial and biologic factors that increase HIV vulnerability and prevent access to HIV services.

Personalized Biobehavioral HIV Prevention for Women and Adolescent Girls

Background:

Women and adolescent girls bear a significant burden of the global HIV pandemic. Both behavioral and biomedical prevention approaches have been shown to be effective. In order to foster the most effective combination HIV-prevention approaches for women and girls, it is imperative to understand the unique biological, social, and structural considerations that increase vulnerability to acquiring HIV within this population.

Primary Study Objective:

The purpose of this article is to propose novel ideas for personalized biobehavioral HIV prevention for women and adolescent girls. The central argument is that we must transcend unilevel solutions for HIV prevention toward comprehensive, multilevel combination HIV prevention packages to actualize personalized biobehavioral HIV prevention. Our hope is to foster transnational dialogue among researchers, practitioners, educators, and policy makers toward the actualization of the proposed recommendations.

Methods:

We present a commentary organized to review biological, social, and structural factors that increase vulnerability to HIV acquisition among women and adolescent girls. The overview is followed by recommendations to curb HIV rates in the target population in a sustainable manner.

Results:

The physiology of the lower female reproductive system biologically increases HIV risk among women and girls. Social (eg, intimate partner violence) and structural (eg, gender inequality) factors exacerbate this risk by increasing the likelihood of viral exposure. Our recommendations for personalized biobehavioral HIV prevention are to (1) create innovative mechanisms for personalized HIV risk—reduction assessments; (2) develop mathematical models of local epidemics; (3) prepare personalized, evidence-based combination HIV risk—reduction packages; (4) structure gender equity into society; and (5) eliminate violence (both physical and structural) against women and girls.

Conclusions:

Generalized programs and interventions may not have universal, transnational, and crosscultural implications. Personalized biobehavioral strategies are needed to comprehensively address vulnerabilities at biological, social, and structural levels.

Access to HIV Care and Support Services for African American Transwomen Living with HIV

Low access to HIV care and support has led to survival rates for transwomen that are half that of other populations at risk for HIV. Within the population, HIV disproportionately impacts African American transwomen. Interventions to increase access to HIV care and support are needed to better serve those most affected and vulnerable within the population. We conducted a study of barriers and facilitators to care and support services for African American transwomen to fill a gap in the literature to improve access for this particularly impacted population. A total of 10 in-depth interviews were conducted with African American transwomen living with HIV who lived outside the metro area of San Francisco. Three overarching thematic topics emerged-gender stigma, peer, and institutional distrust - giving insight into African American transwomen's barriers to HIV care and support services. A number of factors within these themes impacted access, such as whether organizations offered gender-related care, the geography of organizations as it relates to safe transportation and location, confidentiality and trust of peers and organizations, and trauma. Specific instrumental, institutional and emotional supports are provided that that may increase access to care and support services for African American transwomen living with HIV.