Structural equation model of intersectional microaggressions, discrimination, resilience, and mental health among black women with hiv

'Doing what I need to do': sustaining mental health, medication adherence, and engagement in care among Black women living with HIV during the COVID-19 onset of 2020

BACKGROUND

The HIV epidemic and COVID-19 are disproportionately impacting Black communities. For Black women living with HIV (BWLWH), 2020 COVID-19 mandates (e.g. stay-at-home orders) may have had implications for HIV medication adherence, engagement in care, and mental health.

METHOD

In April 2020 during COVID-19 spikes in the US, thirty Black women living with HIV in Miami, FL participated in qualitative semi-structured interviews that asked about COVID-related concerns, HIV medication adherence, engagement in care, and mental health. Interviews were audio recorded, transcribed, and coded using thematic content analysis.

RESULTS

Qualitative analyses highlighted themes around concerns (e.g. whether HIV placed them at increased risk for COVID-19, feeling confined and restricted); mental health (e.g. feeling anxious, depressed); medication adherence (adhering to HIV medication despite COVID-19); engagement in care (e.g. providers canceling appointments, being persistent in contacting providers); adaptive coping (e.g. cleaning/chores, watching series/videos, seeking/receiving social support, praying/watching virtual church services, limiting news consumption, social distancing and wearing masks); minimal use of unhelpful coping strategies (e.g. substance use, eating more unhealthy food); losses/deaths; and the need for financial, food, mental health, and community level (e.g. testing sites) resources. Additionally, survey responses to quantitative measures indicated that a significant portion of women (between 20% and 47%) had difficulties such as getting food, paying bills, getting hand sanitizer and cleaning supplies, communicating with loved ones, reduced wages/work hours, and transportation barriers.

CONCLUSION

Our findings indicate that in the context of COVID-19 stay-at-home orders BWLWH were moderately impacted, shared concerns and mental health symptoms, and voiced the shortfalls of medical providers. Further, BWLWH exhibited resilience with regard to medication adherence and the use of adaptive coping strategies while echoing the need for additional resources and structural interventions.

Innovations to Address Unmet Behavioral Health Needs in National Ending the HIV Epidemic Priority Jurisdictions

ABSTRACT

People who have behavioral health disorders are disproportionately represented among people with HIV and those likely to be diagnosed with HIV. Despite repeated calls for the past decade for the integration of behavioral health into the HIV Care Continuum, findings from priority jurisdictions show these efforts lag. We present 5 examples of efforts to integrate behavioral health services into the HIV Care Continuum, across regions and populations in Ending the HIV Epidemic priority regions. Across diverse settings, care provision-screening, assessment, referrals, and treatments-remains insufficient. Consistent, ongoing actions are needed to address the compounded consequences of the HIV and behavioral health synergistic epidemics, or syndemic. The studies in this article involved local communities, provider groups, and people with lived experience of trauma, serious mental illness, neuropsychological disorder, substance use disorder, and HIV. These example studies reveal significant unmet needs for behavioral health care and/or HIV prevention and treatment in these priority communities. A common finding among these examples was that the success of interventions hinges on the extent to which interventions are tailored to local contexts and the specific needs of historically underserved populations, including Black women, the socioeconomically disadvantaged, LGBTQIA+ individuals, and people with serious mental illness and/or substance use disorders. We suggest recommendations for how Ending the HIV Epidemic efforts can be optimized to adapt and implement integrated HIV and behavioral health care to advance national goals.

Burnout Among Service Providers for People Living with HIV: Factors Related to Coping and Resilience

Individuals who provide services for people living with HIV (PLWH) face numerous work-related challenges, including psychosocial and structural factors affecting the quality of care that they provide. Little is known about the factors that relate to burnout among service providers for PLWH. The current study seeks to examine the factors associated with burnout and the role of resilience and coping in the context of burnout. Via convenience sampling, data was collected from 28 professionals (e.g., peer counselors, HIV testers, case managers/case workers, group facilitators, or social workers) serving PLWH in the USA. Participants completed quantitative measures on sociodemographics, organizational factors, discrimination, trauma, depression, and burnout. A sub-sample of 19 participants provided in-depth qualitative data via semi-structured interviews on burnout, coping, and resilience as a buffer against the effects of burnout. Thematic content analysis revealed themes on the factors related to burnout (e.g., discrimination, limited financial and housing resources, and COVID-19), rejuvenating factors, coping with burnout, and intervention strategies. Additionally, Pearson's product moment correlations revealed significant associations between mental health variables such as depressive and posttraumatic stress disorder symptomology with (a) discrimination and microaggressions and (b) burnout. The current study highlights challenges to providing HIV care, including structural barriers and discrimination that are doubly impactful to the professionals in this sample who share identities with the PLWH whom they serve. These findings may inform the development of an intervention targeting burnout among individuals providing services to PLWH and motivate change to remove structural barriers and improve quality of care for PLWH.

A Pilot Randomized Control Trial of the Striving Towards EmPowerment and Medication Adherence (STEP-AD) Intervention for Black Women Living with HIV

Black women living with HIV (BWLWH) face adversities associated with lower HIV medication adherence, viral non-suppression, and mental health symptoms (e.g., post-traumatic stress disorder) such as trauma/violence, racism, HIV-related discrimination/stigma, and gender-related stressors. We developed the first intervention based in cognitive behavioral therapy and culturally congruent coping for BWLWH to increase medication adherence and decrease PTSD symptoms by enhancing resilience, self-care, engagement in care, and coping for trauma, racism, HIV-related discrimination/stigma, and gender-related stressors. A pilot randomized control trial was conducted with BWLWH and histories of trauma who were at risk for their HIV viral load remaining or becoming detectable (i.e., below 80% medication adherence, detectable viral load in the past year, and/or missed HIV-related appointments). 119 BWLWH were assessed at baseline and 70 met inclusion criteria, completed one session of Life-Steps adherence counseling, and were randomized to either nine sessions of STEP-AD (Striving Towards EmPowerment and Medication Adherence) or ETAU (enhanced treatment as usual consisting of biweekly check-ins). Women completed a post intervention follow up assessment (3 months post baseline) and 3-month post intervention follow-up (6 months post baseline). Via STATA the difference-in-difference methodology with mixed models compared STEP-AD to ETAU on changes in outcomes over time. BWLWH in STEP-AD compared to E-TAU had significantly higher ART adherence (estimate = 9.36 p = 0.045) and lower likelihood of being clinically diagnosed with PTSD (OR = .07, estimate = - 2.66, p = 0.03) as well as borderline significance on higher CD4 count (estimate = 161.26, p = 0.05). Our findings suggest preliminary efficacy of STEP-AD in improving ART adherence, mental health, and immune function.

Black Women's Experiences Along the HIV Care Continuum in the United States: A Scoping Review

Purpose

The prevalence of HIV among Black women is higher than the prevalence among other ethnic groups. Although antiretroviral therapy reduces HIV transmission and mortality, Black women still face health disparities when it comes to receiving health care. The purpose of this scoping review is to synthesize research regarding health disparities and health inequities faced by Black women living with HIV (BWLH).

Methods

We searched three scholarly databases, PsychNet, MEDLINE, and CINAHL, and 18 peer-reviewed complete studies that met the inclusion criteria.

Results

Several themes emerged from the literature, including discrimination, poverty, mental and physical health, health care, and social support. Each theme had a role in the progression of BWLH along the HIV care continuum.

Conclusion

Black women continue to be disproportionately affected by HIV, which involves active engagement in HIV care to sustain viral suppression to prevent the spread of the virus. Factors continue to exist that contribute to health disparities and inequities, such as discrimination, internal and enacted HIV-related stigma, and poverty. Thematic findings in this review indicate that patient-centered care and support systems can positively impact BWLH experiences along the HIV continuum.

Gendered Racial Microaggressions, Self-silencing, Substance Use, and HIV Outcomes Among Black Women Living with HIV: A Structural Equation Modeling Approach

To better understand factors that may contribute to HIV outcomes experienced by Black women living with HIV (BWLWH), the present study examined the relationships among gendered racial microaggressions (GRM; subtle daily insults due to racism and sexism), self-silencing, substance use, antiretroviral therapy (ART) medication adherence, and viral suppression using structural equation modeling and path analysis. Self-silencing and substance use were examined as potential mediators. Participants were 119 BWLWH residing in South Florida. Results of this study showed that GRM was directly and positively associated with self-silencing and indirectly and negatively associated with medication adherence via self-silencing. GRM was directly related to higher alcohol use disorder severity. Self-silencing was directly and negatively associated with medication adherence. Medication adherence was directly and negatively related to viral suppression. The model fit the data well. Identifying the negative consequences of GRM in conjunction with self-silencing and substance use may help inform prevention and intervention strategies to improve mental health and HIV-related outcomes among BWLWH.

Systems Connected to Inequities in Access to Kidney Transplantation and the Value of Intersectionality

Patients from minoritized backgrounds based on race/ethnicity, gender, sexuality, and other social identities are more likely to experience inequities in access in kidney transplantation. Although these inequities have been reported over the decades, limited research focuses on the experiences of patients with intersecting minoritized social statuses and the mechanisms that contribute to their reduced access to transplantation. Intersectionality, a framework for understanding the ways in which multiple social identities represent interacting systems of oppression and privilege, offers a nuanced approach for understanding the experiences of patients diagnosed with end-stage organ disease with intersecting social identities. This article outlines complex systems that perpetuate inequities by highlighting the value of intersectionality in studying disparate outcomes to transplant and providing recommendations for the transplant community. This article aligns with the ESOT call for action to promote equity in transplantation worldwide.