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

Associations between interpersonal and community-level violence experiences and HIV outcomes: implications for violence screening in Ryan White Clinics

Violence experience, interpersonal and community-level, is commonly reported by people living with HIV (PLWH). Understanding the impact of the various forms of violence on HIV outcomes is critical for prioritizing violence screening and support resources in care settings. From February 2021 to December 2022, among 285 PLWH purposively sampled to attain diversity by gender, race/ethnicity, and HIV care retention status in Atlanta, Georgia, we examined interpersonal and community violence experiences and proxy measures of violence (post-traumatic stress disorder (PTSD), anxiety, depression) and their associations with HIV outcomes (engagement and retention in care and HIV viral suppression) using multivariable analysis. Participants commonly reported lifetime intimate partner violence (89%), non-partner violence (97%), hate crimes (93%), and moderate-to-severe adverse childhood events (59%). Lifetime violence experiences were not significantly linked to HIV care engagement, retention, nor durable viral suppression, but were each individually associated with PTSD, which in turn, was significantly associated lower odds of durable viral suppression (AOR 0.35, CI 0.14-0.86). Thus, the high prevalence and multiplicity of interpersonal and community-level violence experienced among PLWH in Atlanta underscores the need for universal trauma-informed approaches and supports implementation of PTSD screening to identify patients at greatest need for trauma support services.

Violence experience among cis-gender women living with HIV in Atlanta, Georgia: impact on HIV-related health and their preferences for violence screening and support

Introduction

People living with HIV (PLWH) experience multiple forms of violence at higher rates than the general population; however, research on experiences of violence among cis-gender women living with HIV (CWLH) mainly focuses on intimate partner violence (IPV), with inconsistent documentation across the literature. To begin improving trauma-informed practices in HIV care, we examined experiences of IPV, non-partner violence (NPV), hate crimes, and adverse childhood experiences (ACEs) among CWLH. We then explored experiences and preferences regarding violence screening and support services among CWLH.

Methods

As part of a larger study on violence experiences and screening among PLWH, 88 CWLH in Atlanta, Georgia, completed a cross-sectional survey on violence and mental health from February 2021 to December 2022 and provided consent for medical chart abstraction. A subgroup of 24 participants completed in-depth interviews on experiences and preferences related to violence screening. Univariate and bivariate analyses were used to assess violence prevalence and associations with mental health and chart-abstracted HIV outcomes. Thematic qualitative methods were employed for interview analysis.

Results

Every participant (100%) experienced at least one form of violence in their lifetime, which included IPV among partnered CWLH (83.33%), NPV (96.51%), hate crimes (85.23%), and ACEs (80.68%). More than half of the participants (61.36%) met diagnostic criteria for at least one mental health condition. Multiple forms of violence had high co-occurrence with post-traumatic stress disorder, depression, viral suppression, and retainment in HIV care. Qualitative analysis revealed that most interview participants had discussed violence or trauma with a healthcare professional before, reporting a mix of positive and uncomfortable experiences. Participants offered diverse perspectives on improving the violence screening process, including recommendations on how, where, by whom, when, and how frequently screenings should occur.

Conclusion

Multiple forms of violence are highly prevalent among CWLH, with several found to be associated with mental health and HIV outcomes. This highlights the necessity for a trauma-informed approach within HIV care settings. Healthcare professionals should consider the unique needs and preferences of CWLH when screening for violence and providing support services. Doing so may improve mental, physical, and overall well-being throughout the HIV care continuum.

Pathways from violence exposure to medication non-adherence: exploration of mental health symptoms and coping in people living with HIV in the U.S. South

ABSTRACTIn the current study, we examine associations between exposure to violence and antiretroviral medication adherence in persons with HIV (PWH) in a southern city in the United States. We include investigation of a variety of violence exposures including childhood sexual abuse, physical abuse, witnessing family violence, lifetime violence exposures and current stress related to violence experiences, as well as neighborhood violence exposure. We examined associations between violence exposures and adherence and mediational pathways between these variables including mental health symptoms - specifically depressive, anxiety, and posttraumatic stress symptoms - as well as coping strategies. Results suggest that physical abuse in childhood was associated with ART non-adherence, no other reported violence experiences were associated with adherence. Of the mediational paths analyzed between violence and ART adherence, only coping with substance use was significant. In post hoc analyses, we examined the mental health symptoms of depression, PTSD and anxiety as mediators between violence exposures and substance use coping. Depressive symptoms were the only significant mediational pathway. Implications for interventions to address histories of violence, depressive symptoms, coping with substance use and adherence are discussed.

HIV Outcomes Among Women Living With HIV Who Experienced Early Sexual Violence Across Four Sub-Saharan African Countries

BACKGROUND

Early experiences of sexual violence may influence HIV care and treatment outcomes among women living with HIV (WLHIV). We examined whether self-report by WLHIV of being forced into their first sexual experience was associated with awareness of HIV-positive status, being on antiretroviral therapy (ART) and being virologically suppressed.

SETTING

We conducted a secondary analysis using nationally representative, cross-sectional Population-based HIV Impact Assessment surveys from Lesotho, Malawi, Zambia, and Zimbabwe conducted from 2015 through 2017.

METHODS

Adjusted logistic regression models with survey weights and Taylor series linearization were used to measure the association between forced first sex and 3 HIV outcomes: (1) knowledge of HIV status among all WLHIV, (2) being on ART among WLHIV with known status, and (3) virological suppression among WLHIV on ART.

RESULTS

Among WLHIV, 13.9% reported forced first sex. Odds of knowledge of HIV status were not different for WLHIV with forced first sex compared with those without (adjusted odds ratio [aOR], 1.17; 95% CI: 0.95 to 1.45). Women living with HIV with forced first sex had significantly lower odds of being on ART (aOR 0.74, 95% CI: 0.57 to 0.96) but did not have lower odds of virological suppression (aOR 1.06, 95% CI: 0.80 to 1.42) compared with WLHIV without forced first sex.

CONCLUSIONS

While high proportions of WLHIV were on ART, report of nonconsensual first sex was associated with a lower likelihood of being on ART which may suggest that early life trauma could influence long-term health outcomes.

Healthcare Workers' Experiences and Challenges in Managing Gender-Based Violence Among HIV-Positive Women Living in Southern, Tanzania: A Qualitative Study

Introduction

Healthcare workers (HCW) play an important role in managing women living with HIV (WLHIV) with gender-based violence (GBV) experience, but little is known about their experience in screening and managing GBV among WLHIV. This study explored the perceptions and experience of the HCWs on screening and managing GBV cases among WLHIV.

Patients and Methods

We performed a descriptive phenomenological qualitative study to elicit the views and experience of HCW on GBV screening and management for WLHIV. The study was conducted in the semi-urban setting in Morogoro Region, Tanzania. Ten in-depth interviews (IDIs) were administered to HCW selected purposefully based on their roles at an HIV care and treatment center. Data were transcribed using patterns matching study aim and then merged into relevant themes for analysis and interpretation. NVIVO software version 12 was used for data coding and analysis.

Results

We found that HCW experienced multiple challenges in GBV screening and management, including limited capacity for GBV screening and management; inadequate training on assessment and handling GBV cases, limited resources (time, GBV guidelines and screening tools), inadequate GBV referral and monitoring systems; referral forms for GBV survivors to social support centers and follow-up mechanisms to trace survivors, mental aspects; HCWs' fear of being stressed by listening to women's' GBV traumatic experiences, HCWs' fear of causing problems to the women's families and HCW biased notions on women disclosure of GBV; the believes that women will not report their GBV experiences.

Conclusion

We identified context-specific challenges preventing HCW to deliver optimal services of GBV to WLHIV, stressing the necessity to strengthen HCW capacity and resources for GBV services and to integrate psychosocial services into HIV care. Policy and programs should be developed to support GBV screening and management for WLHIV.

Correlation between gender-based violence and poor treatment outcomes among transgender women living with HIV in Brazil

BACKGROUND

Transgender women are disproportionately affected by both HIV and gender-based violence (GBV), defined as physical, sexual, or emotional violence perpetrated against an individual based on their gender identity/expression. While a growing body of evidence demonstrates that GBV leads to poor HIV care and treatment outcomes among cisgender women, less research has examined this association among transgender women. We assessed the impact of lifetime experiences of GBV on subsequent retention in HIV care and laboratory confirmed viral suppression among a sample of transgender women living with HIV (TWH) in Brazil.

METHODS

A pilot trial of a peer navigation intervention to improve HIV care and treatment among TWH was conducted in São Paulo, Brazil between 2018 and 2019. TWH were recruited and randomized into the intervention or control arm and participated in a baseline and 9-month follow-up survey and ongoing extraction of clinical visit, prescribing, and laboratory data. Generalized linear model regressions with a Poisson distribution estimated the relative risk (RR) for the association of lifetime physical and sexual violence reported at baseline with treatment outcomes (retention in HIV care and viral suppression) at follow-up, adjusting for baseline sociodemographic characteristics.

RESULTS

A total of 113 TWH participated in the study. At baseline, median age was 30 years, and the prevalence of lifetime physical and sexual violence was 62% and 45%, respectively. At follow-up, 58% (n = 66/113) were retained in care and 35% (n = 40/113) had evidence of viral suppression. In adjusted models, lifetime physical violence was non-significantly associated with a 10% reduction in retention in care (aRR: 0.90, 95% CI: 0.67, 1.22) and a 31% reduction in viral suppression (aRR: 0.69; 95% CI: 0.43, 1.11). Lifetime sexual violence was non-significantly associated with a 28% reduction in retention in HIV care (aRR: 0.72, 95% CI: 0.52, 1.00) and significantly associated with a 56% reduction in viral suppression (aRR: 0.44; 95% CI: 0.24, 0.79).

CONCLUSION

Our findings are among the first to demonstrate that lifetime experiences with physical and sexual violence are associated with poor HIV outcomes over time among transgender women. Interventions seeking to improve HIV treatment outcomes should assess and address experiences of GBV among this population.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03525340.

Experiences of childhood, intimate partner, non-partner, and hate crime-related violence among a sample of people living with HIV in the epicenter of the U.S. HIV epidemic

Introduction

Experiences of violence among people living with HIV (PLWH) are thought to be highly prevalent but remain inadequately captured. As a first step toward acceptable, trauma informed practices that improve engagement and retention in care for PLWH, we must acquire more comprehensive understanding of violence experiences. We examined experiences of various forms of lifetime violence: adverse childhood experiences (ACES), intimate partner violence (IPV), non-partner violence (NPV), and hate crimes among diverse sample of PLWH in Atlanta, Georgia.

Methods

Cross sectional data collected from in- and out-of-care PLWH (N = 285) receiving care/support from Ryan White Clinics (RWCs), AIDS Service Organizations (ASOs), or large safety-net hospital, February 2021-December 2022. As part of larger study, participants completed interviewer-administered survey and reported on experiences of violence, both lifetime and past year. Participant characteristics and select HIV-related variables were collected to further describe the sample. Univariate and bivariate analyses assessed participant characteristics across types of violence.

Results

High prevalence of past violence experiences across all types (ACES: 100%, IPV: 88.7%, NPV: 97.5%, lifetime hate crimes 93.2%). People assigned male at birth who identified as men experienced more violence than women, with exception of non-partner forced sex. Participants identifying as gay men were more likely to have experienced violence.

Conclusion

Among our sample of PLWH at the epicenter of the United States HIV epidemic, histories of interpersonal and community violence are common. Findings emphasize need for RWCs, ASOs, and hospital systems to be universally trained in trauma-informed approaches and have integrated onsite mental health and social support services.

A Trauma-Informed, Geospatially Aware, Just-in-Time Adaptive mHealth Intervention to Support Effective Coping Skills Among People Living With HIV in New Orleans: Development and Protocol for a Pilot Randomized Controlled Trial

BACKGROUND

In 2020, Greater New Orleans, Louisiana, was home to 7048 people living with HIV-1083 per 100,000 residents, 2.85 times the US national rate. With Louisiana routinely ranked last in indexes of health equity, violent crime rates in Orleans Parish quintupling national averages, and in-care New Orleans people living with HIV surviving twice the US average of adverse childhood experiences, accessible, trauma-focused, evidence-based interventions (EBIs) for violence-affected people living with HIV are urgently needed.

OBJECTIVE

To meet this need, we adapted Living in the Face of Trauma, a well-established EBI tailored for people living with HIV, into NOLA GEM, a just-in-time adaptive mobile health (mHealth) intervention. This study aimed to culturally tailor and refine the NOLA GEM app and assess its acceptability; feasibility; and preliminary efficacy on care engagement, medication adherence, viral suppression, and mental well-being among in-care people living with HIV in Greater New Orleans.

METHODS

The development of NOLA GEM entailed identifying real-time tailoring variables via a geographic ecological momentary assessment (GEMA) study (n=49; aim 1) and place-based and user-centered tailoring, responsive to the unique cultural contexts of HIV survivorship in New Orleans, via formative interviews (n=12; aim 2). The iOS- and Android-enabled NOLA GEM app leverages twice-daily GEMA prompts to offer just-in-time, in-app recommendations for effective coping skills practice and app-delivered Living in the Face of Trauma session content. For aim 3, the pilot trial will enroll an analytic sample of 60 New Orleans people living with HIV individually randomized to parallel NOLA GEM (intervention) or GEMA-alone (control) arms at a 1:1 allocation for a 21-day period. Acceptability and feasibility will be assessed via enrollment, attrition, active daily use through paradata metrics, and prevalidated usability measures. At the postassessment time point, primary end points will be assessed via a range of well-validated, domain-specific scales. Care engagement and viral suppression will be assessed via past missed appointments and self-reported viral load at 30 and 90 days, respectively, and through well-demonstrated adherence self-efficacy measures.

RESULTS

Aims 1 and 2 have been achieved, NOLA GEM is in Beta, and all aim-3 methods have been reviewed and approved by the institutional review board of Tulane University. Recruitment was launched in July 2023, with a target date for follow-up assessment completion in December 2023.

CONCLUSIONS

By leveraging user-centered development and embracing principles that elevate the lived expertise of New Orleans people living with HIV, mHealth-adapted EBIs can reflect community wisdom on posttraumatic resilience. Sustainable adoption of the NOLA GEM app and a promising early efficacy profile will support the feasibility of a future fully powered clinical trial and potential translation to new underserved settings in service of holistic survivorship and well-being of people living with HIV.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05784714; https://clinicaltrials.gov/ct2/show/NCT05784714.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/47151.

Implementation of trauma-informed care and trauma-responsive services in clinical settings: a latent class regression analysis

Introduction

Engagement and retention in health care is vital to sustained health among people living with HIV (PLWH), yet clinical environments can deter health-seeking behavior, particularly for survivors of interpersonal violence. PLWH face disproportionate rates of interpersonal violence; clinical interactions can provoke a re-experiencing of the sequalae of trauma from violence, called re-traumatization. Trauma-informed care (TIC) is a strengths-based approach to case that minimizes potential triggers of re-traumatization and promotes patient empowerment, increasing acceptability of care. Yet, Ryan White HIV/AIDS clinics, at which over 50% of PLWH received care, have struggled to IMPLEMENT TIC. In this analysis, we sought to (1) identify unique sub-groups of HIV clinics based on clinical attributes (i.e., resources, leadership, culture, climate, access to knowledge about trauma-informed care) and (2) assess relationships between sub-group membership and degree of implementation of TIC and trauma-responsive services offered.

Methods

A total of 317 participants from 47 Ryan White Federally-funded HIV/AIDS clinics completed a quantitative survey between December 2019 and April 2020. Questions included assessment of inner setting constructs from the Consolidated Framework for Implementation Research (CFIR), perceived level of TIC implementation, and trauma-responsive services offered by each respondent's clinic. We employed latent class analysis to identify four sub-groups of clinics with unique inner setting profiles: Weak Inner Setting (n = 124, 39.1%), Siloed and Resource Scarce (n = 80, 25.2%), Low Communication (n = 49, 15.5%), and Robust Inner Robust (n = 64, 20.2%). We used multilevel regressions to predict degree of TIC implementation and provision of trauma-responsive services.

Results

Results demonstrate that clinics can be distinctly classified by inner setting characteristics. Further, inner setting robustness is associated with a higher degree of TIC implementation, wherein classes with resources (Robust Inner Setting, Low Communication) are associated with significantly higher odds reporting early stages of implementation or active implementation compared to Weak class membership. Resourced class membership is also associated with availability of twice as many trauma-responsive services compared to Weak class membership.

Discussion

Assessment of CFIR inner setting constructs may reveal modifiable implementation setting attributes key to implementing TIC and trauma-responsive services in clinical settings. Introduction.

In the era of universal test and treat in Uganda, recent intimate partner violence is not associated with subsequent ART use or viral suppression

Intimate partner violence (IPV) has been associated with delays throughout the HIV care continuum. This study explored prospective associations between experiences of past-year IPV and two HIV care outcomes in the context of current universal test and treat guidelines using two consecutive rounds of an ongoing HIV surveillance study conducted in the Rakai region of Uganda. Longitudinal logistic regression models examined associations between IPV, use of antiretroviral therapy (ART) and viral load suppression (VS), adjusting for outcome variables at baseline. To address differences in ART retention by IPV, propensity scores were used to create inverse-probability-of-treatment-and-censoring-weighted (IPTCW) models. At baseline, of 1923 women with HIV (WWH), 34.6%, 26.5%, 13.5% reported past-year verbal, physical and sexual IPV; a lower proportion of persons who experienced physical IPV (79.4%) were VS than those who did not (84.3%; p = 0.01). The proportion VS at baseline also significantly differed by exposure to verbal IPV (p = 0.03). However, in adjusted longitudinal models, IPV was not associated with lower odds of ART use or VS at follow-up. Among WWH in the Rakai region, IPV does not appear to be a barrier to subsequent ART use or VS. However, given the prevalence of IPV in this population, interventions are needed.

A Trauma-Informed HIV Intervention (LinkPositively) to Improve HIV Care Among Black Women Affected by Interpersonal Violence: Protocol for a Pilot Randomized Controlled Trial

BACKGROUND

Black women bear a disproportionate burden of HIV, accounting for nearly 60% of new diagnoses among US women. Black women living with HIV often experience mutually reinforcing epidemics, known as syndemics, including interpersonal violence and substance use. Syndemics are associated with decreased HIV care engagement and treatment adherence and worsening HIV outcomes. Few HIV services and resources are tailored to be culturally and gender-responsive and trauma informed for Black women living with HIV. Technology-based, psychoeducational, and peer navigation programs offer promising pathways to tailored HIV support and improved HIV care outcomes. Therefore, the web-based, trauma-informed intervention LinkPositively was developed in collaboration with Black women living with HIV to promote uptake of HIV care and ancillary support services.

OBJECTIVE

This study primarily determines the feasibility and acceptability of the LinkPositively intervention among Black women living with HIV affected by interpersonal violence. The secondary aim is to examine the preliminary impact of the LinkPositively intervention on retention in HIV care, antiretroviral therapy adherence, and viral suppression while evaluating the role of mechanism of change variables (eg, social support) in the associations.

METHODS

The LinkPositively trial is a pilot randomized controlled trial conducted in California, United States, among 80 adult Black women living with HIV who have experienced interpersonal violence. Core components of LinkPositively include one-on-one peer navigation with phone and SMS text message check-ins; 5 weekly one-on-one video sessions to build coping and care navigation skills; and a mobile app that contains a peer support social networking platform, an educational database with healthy living and self-care tips, a GPS-enabled HIV and ancillary care resource locator, and a medication self-monitoring and reminder system. Participants are randomly assigned to the intervention (n=40) or control (Ryan White standard of care; n=40) arm, with follow-up at 3 and 6 months. At each assessment, participants complete an interviewer-administered survey and submit hair samples for the assessment of HIV medication adherence. All research staff and investigators adhere to ethical principles and guidelines for conducting research activities. Data will be analyzed using generalized estimating equations.

RESULTS

Final development and testing of the LinkPositively app were completed in July 2021. As of May 2023, we have screened 97 women for eligibility. Of the 97 women screened, 27 (28%) were eligible and have been enrolled in the study. The dissemination of preliminary results will occur in 2024.

CONCLUSIONS

This trial will advance HIV prevention science by harnessing technology to promote engagement in HIV care while improving social support through peers and social networking-all while being trauma informed for Black women living with HIV with experiences of interpersonal violence. If shown to be feasible and acceptable, LinkPositively has the potential to improve HIV care outcomes among Black women, a marginalized key population.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/46325.

Prevalence of potentially traumatic events and symptoms of depression, anxiety, hazardous alcohol use, and post-traumatic stress disorder among people with HIV initiating HIV care in Cameroon

BACKGROUND

This study explored the relationship between specific types of potentially traumatic events (PTEs) and symptoms of mental health disorders among people with HIV (PWH) in Cameroon.

METHODS

We conducted a cross-sectional study with 426 PWH in Cameroon between 2019-2020. Multivariable log binominal regression was used to estimate the association between exposure (yes/no) to six distinct types of PTE and symptoms of depression (Patient Health Questionnaire-9 score > 9), PTSD (PTSD Checklist for DSM-5 score > 30), anxiety (Generalized Anxiety Disorder-7 scale score > 9), and hazardous alcohol use (Alcohol Use Disorders Identification Test score > 7 for men; > 6 for women).

RESULTS

A majority of study participants (96%) reported exposure to at least one PTE, with a median of 4 PTEs (interquartile range: 2-5). The most commonly reported PTEs were seeing someone seriously injured or killed (45%), family members hitting or harming one another as a child (43%), physical assault or abuse from an intimate partner (42%) and witnessing physical assault or abuse (41%). In multivariable analyses, the prevalence of PTSD symptoms was significantly higher among those who reported experiencing PTEs during childhood, violent PTEs during adulthood, and the death of a child. The prevalence of anxiety symptoms was significantly higher among those who reported experiencing both PTEs during childhood and violent PTEs during adulthood. No significant positive associations were observed between specific PTEs explored and symptoms of depression or hazardous alcohol use after adjustment.

CONCLUSIONS

PTEs were common among this sample of PWH in Cameroon and associated with PTSD and anxiety symptoms. Research is needed to foster primary prevention of PTEs and to address the mental health sequelae of PTEs among PWH.

Fertility Desire and Associations with Condomless Sex, Antiretroviral Adherence, and Transmission Potential in a Cohort of Kenyan Women Living with HIV in Sero-discordant Relationships: A Mixed Methods Study

For women living with HIV (WLH) in serodiscordant partnerships, decisions about childbearing can challenge condom use and antiretroviral adherence. In a prospective cohort of 148 WLH in serodiscordant partnerships, 58 (39%) wanted more children in the future but were not currently trying to conceive (fertility desire), and 32 (22%) were currently trying to become pregnant (fertility intent). Detection of prostate specific antigen (PSA) in vaginal secretions, a marker for recent condomless sex, was lowest in women with fertility desire and highest in women with fertility intent. Detectable viral load followed a similar pattern. Risk of HIV transmission, when condomless sex and PSA detection occurred concurrently, was three to fourfold higher at visits with fertility intent compared to visits with fertility desire. Qualitative interviews underscored the importance women place on childbearing and suggested that they had limited information about the role of antiretroviral therapy in reducing sexual HIV transmission.

Pathways From Recent Incarceration to Antiretroviral Therapy Adherence: Opportunities for Interventions to Support Women Living With HIV Post Release From Correctional Facilities

ABSTRACT

Women living with HIV are increasingly incarcerated and experience suboptimal HIV health outcomes post release from incarceration. Drawing on cohort data with cisgender and trans women living with HIV (Sexual Health and HIV/AIDS: Women's Longitudinal Needs Assessment), we used path analysis to investigate pathways from recent incarceration to optimal antiretroviral therapy (ART) adherence. We tested direct effects between recent incarceration, mediating variables, and ART adherence, along with indirect effects between incarceration and ART adherence through each mediator. We assessed model fit using chi-square, root-mean-square error of approximation (RMSEA), and comparative fit index (CFI). Our hypothesized model fit well to the data (χ2(1)=1.100; p=.2943; CFI = 1.000; RMSEA = 0.007). Recent experiences of homelessness, criminalized substance use, and gender-based violence each fully mediated the pathway between recent incarceration and optimal ART adherence. Findings highlight the need for safe and supportive housing, supports for criminalized substance use, and trauma and violence-informed care and practice post release from incarceration.

Perceived Barriers to HIV Care and Viral Suppression Comparing Newly Diagnosed Women Living with HIV in Rural Uganda with and without a History of Intimate Partner Violence

Intimate partner violence (IPV) is associated with poor HIV care linkage and retention, medication adherence, and viral suppression. However, limited knowledge exists regarding potential mechanisms linking IPV to these outcomes. We aimed to (a) identify the top barriers to accessing HIV care experienced by women living with HIV (WLHIV) who report a history of IPV and have suppressed viral load (VL) versus unsuppressed VL and (b) understand how these barriers influence VL, comparing WLHIV with a history of IPV to WLHIV without a history of IPV. Study data come from newly diagnosed WLHIV in rural Uganda participating in the standard-of-care control arm of a randomized trial (n = 152). Descriptive results ranking mean scores from highest to lowest showed that, among women with a history of IPV, irrespective of viral suppression status, paying for transportation to come to clinic, having to wait at the clinic for long periods of time, and finding a clinic within reasonable travel distance were the top three barriers to accessing HIV care. WLHIV with a history of IPV were significantly more likely to have unsuppressed VL versus suppressed VL if they reported higher levels of difficulty finding a clinic within reasonable travel distance (RRR = 1.7, 95% CI [1.1-2.7]), getting permission to take time off from work (RRR = 1.5, 95% CI [1.0-2.9]), and finding time to come to the clinic for an appointment (RRR = 1.6, 95% CI [1.0-2.6]). The same relationships were not present among WLHIV without a history of IPV, suggesting these barriers and their effect on VL may be uniquely related to IPV. Interventions should address IPV and HIV care continuum outcomes in tandem, targeting barriers to accessing HIV care likely associated with IPV. Additional research is necessary to better understand how IPV relates to HIV care barriers and VL.

Interpersonal violence and other social-structural barriers associated with needing HIV treatment support for women living with HIV

Women living with HIV (WLWH), experience disproportionate rates of violence, along with suboptimal HIV health outcomes, despite recent advancements in HIV treatment, known as antiretroviral therapy (ART). The objectives of this study were to: (a) describe different types of support needed to take ART and (b) investigate the social and structural correlates associated with needing support for ART adherence among WLWH. Data are drawn from Sexual health and HIV/AIDS: Women's Longitudinal Needs Assessment, a community-based open research cohort with cisgender and transgender WLWH, aged 14+ who live or access HIV services in Metro Vancouver, Canada (2014-present). Baseline and semi-annual questionnaires are administered by community interviewers alongside a clinical visit with a sexual health research nurse. Bivariate and multivariable logistic regression using generalized estimating equations and an exchangeable working correlation matrix was used to model factors associated with needing supports for ART adherence. Among 276 WLWH, 51% (n = 142) reported needing support for ART adherence; 95% of participants reported lifetime gender-based violence and identified many interpersonal, structural, community, and clinical supports that would facilitate and support ART adherence. In multivariable logistic regression, participants who were Indigenous (adjusted odds ratio [AOR]: 1.70, 95% confidence intervals [CI]: 1.07-2.72), or otherwise racialized (AOR: 2.36, 95% CI : 1.09-5.12) versus white, experienced recent gender-based physical violence (AOR : 1.54, 95% CI : 1.03-2.31), lifetime post-traumatic stress disorder (AOR : 1.97, 95% CI : 1.22-3.18), and recent illicit drug use (AOR : 2.15, 95% CI : 1.43-3.22), had increased odds of needing support for ART adherence. This research suggests a need for trauma-informed, culturally safe and culturally responsive practice and services for WLWH along the HIV care continuum to support ART adherence. All services should be developed by, with, and for WLWH and tailored according to gender identity, taking into account history, culture, and trauma, including the negative impacts of settler colonialism for Indigenous people.

Lifetime sexual violence exposure in women compromises systemic innate immune mediators associated with HIV pathogenesis: A cross-sectional analysis

OBJECTIVES

Violence and HIV/AIDS syndemic highly prevalent among women impairs HIV prevention efforts. Prolonged exposure to violence results in physical trauma and psychological distress. Building on previous findings regarding genital immune dysregulation following sexual abuse exposure, we investigate here whether systemic changes occur as well.

METHODS

Using the Women's Interagency HIV Study repository, 77 women were stratified by HIV serostatus and categorized into four subgroups: (1) no sexual abuse history and lower depression score (Control); (2) no sexual abuse history but higher depression score (Depression); (3) high sexual abuse exposure and lower depression score (Abuse); (4) high sexual abuse exposure and higher depression score (Abuse + Depression). Inflammation-associated immune biomarkers (TNF-α, IL-6, IL-1α, IL-1β, TGF-β, MIP-3α, IP-10, MCP-1, and Cathepsin-B) and anti-inflammatory/anti-HIV biomarkers (Secretory leukocyte protease inhibitor, Elafin, human beta-defensin-2 (HBD-2), alpha-defensins 1-3, Thrombospondin, Serpin-A1, and Cystatin-C) were measured in plasma using enzyme-linked immunosorbent assay. Within each HIV serostatus, differences in biomarker levels between subgroups were evaluated with Kruskal-Wallis and Dunn's test with Bonferroni correction. Spearman correlations between biomarkers were assessed for each subgroup.

RESULTS

Compared to the Control and Depression groups, Abuse + Depression was associated with significantly higher levels of chemokines MIP-3α and IP-10 (p < 0.01) and lower levels of inflammatory cytokine IL-1β (p < 0.01) in the HIV-uninfected population. Human beta-defensin-2 was lowest in the Abuse + Depression group (p < 0.05 versus Depression). By contrast, among HIV-infected, Abuse and Abuse + Depression were associated with lower levels of MIP-3α (p < 0.05 versus Control) and IP-10 (p < 0.05, Abuse versus Control). Inflammatory cytokine IL-6 was higher in both Abuse groups (p < 0.05 versus Control), while Elafin was lowest in the Abuse + Depression group (p < 0.01 versus Depression).

CONCLUSION

We report compromised plasma immune responses that parallel previous findings in the genital mucosa, based on sexual abuse and HIV status. Systemic biomarkers may indicate trauma exposure and impact risk of HIV acquisition/transmission.

Bidirectional Violence Is Associated with Poor Engagement in HIV Care and Treatment in Malawian Couples

Growing evidence suggests that intimate partner violence (IPV) is a barrier to engagement in HIV care. Bidirectional IPV-being both a perpetrator and victim-may be the most common pattern of IPV, yet no research has examined its effect on engagement in care, which could identify couples in most need of interventions. Married couples (N = 211) with at least one partner on antiretroviral therapy were recruited from HIV clinic waiting rooms in Zomba, Malawi. Partners completed separate surveys on physical, sexual, and emotional IPV, medication adherence, and appointment attendance. We created categorical variables indicating no violence, perpetrator-only, victim-only, and bidirectional violence. Generalized estimating equation regression models tested for associations between IPV and engagement in care. The bidirectional pattern represented 25.4%, 35.5%, and 34.0% of all physical, sexual, and emotional IPV. Physical IPV victimization-only (adjusted odds ratio [AOR]: 0.28, 95% confidence interval [CI]: 0.08, 0.92) was associated with lower adherence, but the association was stronger for bidirectional physical IPV (AOR: 0.10, 95% CI: 0.02, 0.51). Bidirectional sexual IPV was also associated with lower adherence (AOR: 0.14, 95% CI: 0.02, 0.80). Bidirectional physical IPV (AOR: 4.04, 94% CI: 1.35, 12.14) and emotional IPV (AOR: 3.78, 95% CI: 1.78, 8.05) were associated with missing 1+ appointment. Interventions to address the health effects of bidirectional IPV, which may be greater than victim-only or perpetrator-only IPV, should intervene with both partners to break cycles of violence. Couple-based interventions may be a viable option by intervening on both partners' trauma and aggression simultaneously.

Current intimate partner violence and associated factors among sero-positive women attending Adama town ART Clinics, Central Ethiopia 2019

BACKGROUND

Intimate partner violence against women is a behavior within an intimate relationship that causes physical, sexual, or psychological harm to the victim. It is well recognized as a gross violation of human rights and affects the health of women, families, and the community at large. However, the level to which Human Immuno Deficiency virus sero-positive women are experiencing recent intimate partner violence and its associated factors have not been well investigated as the majority of the study done so far were focused on the study of lifetime violence and violence among women in the general population. The study was conducted to determine the prevalence and factors associated with current intimate partner violence among sero-positive women.

METHODS

A facility-based cross-sectional study was conducted from March 2019 to April 2019 among 396 sero-positive women visiting anti-retroviral therapy (ART) units of Adama town public health facilities. A systematic random sampling technique was used to select individual participants. Validated World Health Organization (WHO) tools were used to collect information on the outcomes and key independent variables. The collected data were entered into Epidata version 4.4.6 and analyzed using SPSS version 24. Descriptive statistics were used to compute summary statistics and proportion. Variables at a cut-off value of 0.25 on bivariate analysis and 0.05 during multivariate logistic regression were used to identify factors associated with recent intimate partner violence.

RESULT

The response rate in this study was 100% since all women approached took part in this study. The prevalence of current intimate partner violence was 32.3% while lifetime intimate partner violence (IPV) was 45.5%. Exposure to coerced first sexual intercourse [AOR = 3.0 (1.73, 5.44)], male multi-partnership [AOR = 2.2 (1.21, 4.06)], believing in the husband's right to sex [AOR = 2.3 (1.29, 4.12)], contraceptive use [AOR = 3.33 (1.67, 6.62)], and having farmer partner [AOR = 3.9 (1.43, 10.79)] were significantly associated with current intimate partner violence.

CONCLUSION

One-in-three women reported at least 2 or more forms of violence from their intimate partner. Individual-level factors (Exposure to coerced first sexual intercourse, partner's occupation, contraceptive use, and believing in husband's right to sex and relationship factor (Male multi-partnership) were significantly associated with recent intimate partner violence. Combined efforts are required to avert intimate partner violence among women on ART while targeting risky sexual behavior practiced among male partner factors significantly associated with violence.

'So hurt and broken': A qualitative study of experiences of violence and HIV outcomes among Zambian youth living with HIV

Emerging data show associations between violence victimisation and negative HIV outcomes among youth in sub-Saharan Africa. We conducted in-depth interviews with adolescents and young adults living with HIV (aged 15-24 years) in Ndola, Zambia, to better understand this relationship. We purposively selected 41 youth (24 females, 17 males) with varied experiences of violence and virologic results. Analysis used thematic coding. Two-thirds of participants said violence affected their medication adherence, clinic attendance, and/or virologic results. They focused on the negative effects of psychological abuse from family members in homes and peers at schools, which were the most salient forms of violence raised, and sexual violence against females. In contrast, they typically depicted physical violence from caregivers and teachers as a standard discipline practice, with few impacts. Youth wanted HIV clinic settings to address verbal abuse and emotional maltreatment, alongside physical and sexual violence, including through peer mentoring. Violence - especially verbal and emotional forms - must be recognised as a potential barrier to HIV self-management among youth living with HIV in the region. Further testing of clinic, home, and school-based interventions may be critical to reducing levels of violence and improving HIV outcomes in this vulnerable but resilient population.Trial registration: ClinicalTrials.gov identifier: NCT04115813.

Mental Health Mediates the Association Between Gender-Based Violence and HIV Treatment Engagement in US Women

BACKGROUND

Gender-based violence (GBV) is associated with poorer engagement in HIV care and treatment. However, there is a dearth of research on the psychological (eg, mental health) and structural (eg, food insecurity) factors that mediate and moderate this association. GBV could lead to poor mental health, which in turn affects adherence, whereas food insecurity could worsen the effect of GBV on engagement in care. This study uses data from the Women's Interagency HIV Study to address these gaps.

METHODS

Women completed 6 assessments from 2013 to 2016 on GBV, mental health, food insecurity, adherence to antiretroviral therapy, and missed HIV care appointments in the past 6 months. Multilevel logistic regression models estimated associations between GBV and engagement in care and whether associations were mediated by depression, generalized anxiety disorder (GAD), and posttraumatic stress disorder (PTSD) and moderated by food insecurity.

RESULTS

GBV was associated with higher odds of suboptimal adherence (adjusted odds ratio: 1.88; 95% confidence interval: 1.24 to 2.87) and missed appointments (adjusted odds ratio: 1.76; 95% confidence interval: 1.16 to 2.67). The association between GBV and adherence was mediated by depressive symptoms, GAD, and PTSD, accounting for 29.7%, 15.0%, and 16.5%, respectively, of the total association. The association between GBV and missed appointments was mediated by depression and GAD, but not PTSD, with corresponding figures of 25.2% and 19.7%. Associations did not differ by food insecurity.

CONCLUSIONS

GBV is associated with suboptimal engagement in care, which may be explained by mental health. Interventions should address women's mental health needs, regardless of food insecurity, when improving engagement in HIV care.

Comparison of HIV Viral Suppression Between a Sample of Foreign-Born and U.S.-Born Women of Color in the United States

We investigate the association between nativity status (U.S.- vs foreignborn) and viral suppression among women of color (WOC) with HIV (HIV +) and whether this association was modified by education and housing.

METHODS

Data were from 549 HIV + WOC, who participated in the Health Resources and Services Administration-funded WOC Initiative 2009-2013. We used generalized estimating equation models to quantify the association between the respondents' nativity status and viral suppression.

RESULTS

After adjusting for covariates, foreign-born WOC were 2.2 times (95% confidence interval: 1.25, 3.85) more likely to achieve viral suppression than U.S.-born WOC. This association was not modified by education or housing status.

CONCLUSIONS

Despite facing barriers to care, foreign-born WOC were more likely to achieve viral suppression than U.S.-born WOC. Programs aiming to end the HIV epidemic and reduce HIV disparities in the U.S. should consider these findings as they provide a more nuanced understanding of HIV + WOC.

Intimate partner violence and the HIV care and treatment cascade among adolescent girls and young women in DREAMS, South Africa

Supplemental Digital Content is Available in the Text.

Background:

Intimate partner violence (IPV) may affect the HIV-treatment cascade.

Setting:

Four high HIV-prevalence DREAMS health districts in South Africa.

Methods:

Secondary analysis of cross-sectional data collected March 2017–June 2018, using random household sample of young (12–24 years) girls and women. Face-to-face interviews assessed IPV and HIV-status knowledge, and finger-prick blood draws assessed ART (antiretroviral therapy) uptake and viral suppression. We used logistic regression to estimate crude and adjusted effects of IPV on HIV knowledge, ART uptake, and viral suppression.

Results:

Of 18,230 adolescent girls and young women, 8413 (46%) reported ever having had sex, of whom 1118 (13%) were HIV positive. The 90:90:90 benchmarks were 61% knew their status, 86% had ART present in their blood sample, and 91% were virally suppressed. Among the entire sample of young women living with HIV, 65.6% were virally suppressed. Past year IPV was reported by 15%. In adjusted models, IPV trended toward increasing the odds that a young woman was aware she was living with HIV [adjusted odds ratios (aOR) = 1.40, 2.00–9.98, P = 0.067]. There was no association between IPV and reduced treatment use (aOR = 0.73, 0.41–1.29). IPV was independently associated with reduced viral suppression (aOR = 0.30, 0.13–0.66).

Conclusions:

Addressing the role of IPV in undermining the treatment cascade for adolescent and young women is a critical issue for HIV programming.

Intersections of food insecurity, violence, poor mental health and substance use among US women living with and at risk for HIV: Evidence of a syndemic in need of attention

Background

Food insecurity and intimate partner violence (IPV) are associated with suboptimal HIV prevention and treatment outcomes, yet limited research has explored how food insecurity and IPV intersect to influence HIV-related behaviors. To fill this gap, we conducted a qualitative study with women living with or at risk for HIV in the United States.

Methods

We conducted 24 in-depth interviews with women enrolled in the San Francisco and Atlanta sites of the Women’s Interagency HIV study (WIHS). Participants were purposively sampled so half were living with HIV and all reported food insecurity and IPV in the past year. Semi-structured interviews explored experiences with food insecurity and IPV, how these experiences might be related and influence HIV risk and treatment behaviors. Analysis was guided by an inductive-deductive approach.

Results

A predominant theme centered on how food insecurity and IPV co-occur with poor mental health and substance use to influence HIV-related behaviors. Women described how intersecting experiences of food insecurity and IPV negatively affected their mental health, with many indicating using substances to “feel no pain”. Substance use, in turn, was described to perpetuate food insecurity, IPV, and poor mental health in a vicious cycle, ultimately facilitating HIV risk behaviors and preventing HIV treatment adherence.

Conclusions

Food insecurity, IPV, poor mental health and substance use intersect and negatively influence HIV prevention and treatment behaviors. Findings offer preliminary evidence of a syndemic that goes beyond the more widely studied “SAVA” (substance use, AIDS, and violence) syndemic, drawing attention to additional constructs of mental health and food insecurity. Quantitative research must further characterize the extent and size of this syndemic. Policies that address the social and structural drivers of this syndemic, including multi-level and trauma-informed approaches, should be implemented and evaluated to assess their impact on this syndemic and its negative health effects.

Recent sexual violence exposure is associated with immune biomarkers of HIV susceptibility in women

PROBLEM

HIV/AIDS and sexual violence act synergistically and compromise women's health. Yet, immuno-biological mechanisms linking sexual violence and increased HIV susceptibility are poorly understood.

METHODS

We conducted a cross-sectional pilot study of HIV-uninfected women, comparing 13 women exposed to forced vaginal penetration within the past 12 weeks (Exposed) with 25 Non-Exposed women. ELISA assays were conducted for 49 biomarkers associated with HIV pathogenesis in plasma and cervicovaginal lavage (CVL). Differences between Exposed and Non-Exposed were analyzed by linear and logistic regression, using propensity score weighting to control for age, race, socioeconomic status, menstrual cycle, and contraceptive use.

RESULTS

In CVL, Exposed women had significantly reduced chemokines MIP-3α (p < .01), MCP-1 (p < .01), and anti-HIV/wound-healing thrombospondin-1 (p = .03). They also had significantly increased inflammatory cytokine IL-1α (p < 0.01) and were more likely to have detectable wound-healing PDGF (p = .02). In plasma, Exposed women had reduced chemokines MIP-3α (p < .01) and IL-8 (p < .01), anti-inflammatory cytokine TGF-β (p = .02), anti-HIV/antimicrobial HBD-2 (p = .02), and wound-healing MMP-1 (p = 0.02). They also had increased thrombospondin-1 (p < .01) and Cathepsin B (p = .01). After applying the stringent method of false discovery rate adjustment, differences for IL-1α (p = .05) and MCP-1 (p = .03) in CVL and MIP-3α (p = .03) in plasma remained significant.

CONCLUSIONS

We report systemic and mucosal immune dysregulation in women exposed to sexual violence. As these biomarkers have been associated with HIV pathogenesis, dysregulation may increase HIV susceptibility.

Past-Year Violence Victimization is Associated with Viral Load Failure Among HIV-Positive Adolescents and Young Adults

We examined the relationship between past-year violence victimization and viral load (VL) failure among consecutively-sampled male and female adolescents and young adults, aged 15-24, in four HIV clinics in Ndola, Zambia. Measures of past-year physical violence, psychological abuse, and forced sex were adapted from the ICAST-C and WHO Multi-Country Study. Using logistic regression, we derived associations between VL failure (≥ 1000 copies/mL) and: any victimization; cumulative victimization; and types and perpetrators of violence. Among 272 youth (59.2% female, 72.8% perinatally infected), 73.5% (n = 200) experienced past-year violence and 36.8% (n = 100) had VL failure. Higher odds of VL failure were observed for participants who reported high frequency of any violence versus no violence victimization (adjusted OR, aOR: 3.58; 95% CI 1.14-11.27), high frequency of psychological abuse versus no psychological abuse (aOR: 3.32; 95% CI 1.26-8.70), any versus no violence from a family member other than a parent/caregiver for physical violence (aOR: 2.18, 95% CI 1.05-4.54) and psychological abuse (aOR: 2.50; 95% CI 1.37-4.54), and any versus no physical violence from a friend/peer (aOR: 2.14, 95% CI 1.05-4.36). Past-year violence victimization was associated with VL failure when considering the frequency, type, and perpetrator of violence. Programs addressing violence among youth living with HIV may be critical to improving viral suppression and preventing onward transmission.

LinkPositively: A Trauma-Informed Peer Navigation and Social Networking WebApp to Improve HIV Care among Black Women Affected by Interpersonal Violence

In the U.S., Black women living with HIV/AIDS (WLHA) are affected disproportionately by interpersonal violence, which often co-occurs with adverse mental health and/or substance use, and exacerbates existing poor HIV care outcomes. Peer navigation has been successful in improving HIV care; however, HIV clinics often lack resources for sustainability and may not account for socio-structural barriers unique to Black WLHA. To address this gap, we developed LinkPositively, a culturally-tailored, trauma-informed WebApp for Black WLHA affected by interpersonal violence to improve HIV care outcomes. Using focus group data from nine Black WLHA and peer navigators, we developed LinkPositively. Core components include: virtual peer navigation to facilitate skill-building to cope with barriers and navigate care; social networking platform for peer support; educational and self-care tips; GPS-enabled resource locator for HIV care and support service agencies; and medication self-monitoring/reminder system. If efficacious, LinkPositively will shift the HIV prevention and care paradigm for Black WLHA.

Application of the Consolidated Framework for Implementation Research to Facilitate Violence Screening in HIV Care Settings: a Review of the Literature

PURPOSE OF REVIEW

This review summarizes the literature on violence screening practices within HIV care settings globally as well as identified salient multi-level barriers and facilitators for adopting and implementing violence screening within HIV care. We utilized the Consolidated Framework for Implementation Research (CFIR) to systematically identify multi-level factors related to violence screening within HIV services.

RECENT FINDINGS

Across the 15 articles included, several highly salient CFIR constructs emerged as particularly relevant for violence screening adoption and implementation within HIV including inner setting factors, outer setting factors, as well as select constructs specific to characteristics of the violence screening process, the individuals charged with screening, and violence screening execution. This review underscores the importance of considering CFIR constructs to bolster successful violence screening implementation in HIV care settings. We describe several potential implementation strategies to overcome the most salient barriers identified across this limited body of summarized research.

Long-term consequences of interpersonal violence experiences on treatment engagement and health status in people living with HIV

OBJECTIVE

To examine the impact of previous interpersonal violence (IPersV) experiences on long-term healthcare engagement and health outcomes in a large Canadian HIV-cohort.

DESIGN

People living with HIV (PLHIV) were screened for IPersV, and their healthcare outcomes over the nine subsequent years were analyzed.

METHODS

A total of 1064 PLHIV were screened for past and present IPersV experiences through semistructured interviews. Follow-up included core treatment engagement (e.g. clinic visits) and health-status variables (HIV viral load, CD4+ T-cell count, mortality, comorbidities), analyzed descriptively and with longitudinal Cox regressions.

RESULTS

At intake, 385 (36%) PLHIV reported past or present IPersV including childhood (n = 224, 21%) or adulthood experiences (n = 161, 15%) and were offered conventional social work support. Over 9 years, individuals with any IPersV experiences were 36% more likely to discontinue care, 81% more likely to experience viremia, 47% more likely to experience a drop in CD4+ cell counts below 200/μl, and 65% more likely to die compared with patients not reporting IPersV (P < 0.05). Outcomes were similar when adjusted for sociodemographic factors. Childhood IPersV in particular was linked to several of the outcomes, with higher rates of discontinuation of care, viremia, and mortality related to mental health/addiction or HIV-related complications.

CONCLUSION

IPersV is associated with an increased risk over time of healthcare discontinuation, poorer long-term HIV-related health outcomes, and increased mortality, especially for patients victimized in childhood. Apart from targeted IPersV screening to initiate conventional supports (e.g. through social work), increased efforts to engage vulnerable populations in their long-term care seems warranted.

Longitudinal association between intimate partner violence and viral suppression during pregnancy and postpartum in South African women

OBJECTIVE

We examined the longitudinal association between women's exposure to intimate partner violence (IPV) and HIV viral load during pregnancy and postpartum.

DESIGN

Secondary analysis of an HIV-positive cohort enrolled during pregnancy at a South African antenatal clinic.

METHODS

Viral load was assessed at 10 study visits and analyzed continuously as log10 copies/ml and suppression at less than 50 copies/ml. IPV was measured at three timepoints using behaviorally specific items. We used multivariate logistic regression to examine the association between IPV and viral suppression, and cross-lagged dynamic panel modeling (DPMs) to estimate the longitudinal association between IPV (lagged by 3-6 months) and log10 viral load.

RESULTS

Of 471 women, 84% were virally suppressed by 6 weeks postpartum and 67% at 12 months postpartum. One-third reported IPV exposure. IPV victimization was not associated with viral suppression at delivery, but was associated with a reduced odds of viral suppression at 12 months postpartum (aOR = 0.48, 95% CI = 0.27-0.85). Findings were robust to sensitivity analyses at different timepoints and clinical cut-points. In DPMs, lagged IPV exposure was associated with higher log10 viral load after controlling for past viral load, duration on ART, age, alcohol use, and gestation at study enrolment. Each standardized increase in IPV intensity was associated with higher log10 viral load (standardized coefficient = 0.12, 95% CI = 0.05-0.23).

CONCLUSION

Although viral suppression was widely achieved during pregnancy, suppression rates declined postpartum in this South African cohort. These data suggest IPV is longitudinally associated with elevated viral load postpartum. Interventions for reducing exposure to IPV are important for the health of women and may improve HIV care and treatment.

HIV Pathogenesis in the Human Female Reproductive Tract

PURPOSE OF REVIEW

Women remain disproportionately affected by the HIV/AIDS pandemic. The primary mechanism for HIV acquisition in women is sexual transmission, yet the immunobiological factors that contribute to HIV susceptibility remain poorly characterized. Here, we review current knowledge on HIV pathogenesis in women, focusing on infection and immune responses in the female reproductive tract (FRT).

RECENT FINDINGS

We describe recent findings on innate immune protection and HIV target cell distribution in the FRT. We also review multiple factors that modify susceptibility to infection, including sex hormones, microbiome, trauma, and how HIV risk changes during women's life cycle. Finally, we review current strategies for HIV prevention and identify barriers for research in HIV infection and pathogenesis in women. A complex network of interrelated biological and sociocultural factors contributes to HIV risk in women and impairs prevention and cure strategies. Understanding how HIV establishes infection in the FRT can provide clues to develop novel interventions to prevent HIV acquisition in women.

Recent Incarceration as a Primary Barrier to Virologic Suppression Among Women Living with HIV: Results from a Longitudinal Community-Based Cohort in a Canadian Setting

Women living with HIV (WLWH) are disproportionately represented among incarcerated populations yet there is a paucity of research on how incarceration shapes HIV treatment outcomes for women. Data is drawn from SHAWNA (Sexual health and HIV/AIDS: Women's Longitudinal Needs Assessment), a longitudinal community-based open research cohort with cis and trans WLWH in Metro Vancouver, Canada (2010-2017). Multivariable logistic regression using generalized estimating equations (GEE) longitudinally modeled the effect of incarceration on virologic suppression (HIV plasma VL < 50 copies/mL), adjusting for potential confounders. Amongst 292 WLWH, the majority (74%) had been incarcerated in their lifetime and 17% were incarcerated over the study period. Exposure to recent incarceration was independently correlated with reduced odds of virologic suppression (AOR: 0.42, 95% CI 0.22-0.80). This study suggests critical need for research and interventions to better address factors shaping ART adherence and retention in care for WLWH, both within correctional centres and following release from prison.

Violence and other social structural factors linked to incarceration for women living with HIV in Metro Vancouver: need for trauma-informed HIV care in prisons and post-Release

Despite women living with HIV (WLWH) being disproportionately criminalized and overrepresented within correctional facilities, there remains limited longitudinal research with WLWH examining factors that make WLWH vulnerable to incarceration. Data are drawn from SHAWNA (Sexual health and HIV/AIDS: Women's Longitudinal Needs Assessment), a community-based research cohort with cisgender and transgender WLWH in Metro Vancouver, Canada. Multivariable logistic regression using generalized estimating equations (GEE) and an exchangeable working correlation matrix was used to prospectively model correlates of recent incarceration exposure over a seven-year period. Amongst 289 WLWH, 76% had been incarcerated in their lifetime, and 17% had experienced recent incarceration. In multivariable GEE analysis, younger age (AOR: 0.92 per year older, 95% CI: 0.89-0.96), recent homelessness (AOR: 2.81, 95% CI: 1.46-5.41), recent gender-based (physical and/or sexual) violence (AOR: 2.26, 95% CI: 1.20-4.22) and recent opioid use (AOR: 1.83, 95% CI: 1.00-3.36), were significantly associated with recent incarceration. Lifetime exposure to gender-based violence by police (AOR: 1.97, CI: 0.97-4.02) was marginally associated with increased odds of recent incarceration. This research suggests a critical need for trauma-informed interventions for WLWH during and following incarceration. Interventions must be gender specific, include housing and substance use supports, and address the impact of gender-based violence.

Intimate partner violence polyvictimisation and HIV among coupled women in Zambia: Analysis of a population-based survey

Women in sub-Saharan Africa are disproportionately at risk for the dual epidemics of intimate partner violence (IPV) and HIV. Little is known about how specific violence profiles affect women's HIV risk, limiting effective intervention. We analysed couples' data from the Zambia Demographic and Health Survey 2013-2014 to evaluate relationships among IPV, male partner HIV status and women's HIV status. We considered the individual and combined effects of physical, sexual, emotional, and high controlling behaviour violence and accumulated violence exposure, respectively. Among partnered women, 48.9% (n = 2,812) experienced IPV victimisation, of whom 52.1% (n = 1,465) reported polyvictimisation (experiencing two or more violence types). Female HIV prevalence was 13.2%. Adjusted for demographics, HIV was significantly higher for women who experienced three (17.3%, aPR 1.33, 95%CI: 1.04-1.69, p = 0.02) or four (22.1%, aPR 1.66, 95%CI: 1.23-2.26, p ≤ 0.01) types versus no IPV. Violence including emotional and/or high controlling victimisation was associated with female HIV infection (aPR: 1.31, 95%CI: 1.09-1.57, p = 0.01). Physical and/or sexual violence victimisation in the absence of other victimisation was not associated with HIV (aPR: 0.92, 95%CI:0.73-1.15, p = 0.46). IPV and HIV interventions are incomplete without addressing emotional and controlling IPV and the role of coercive relationship dynamics in transmission risk.

Gender Disparities in Traumatic Life Experiences and Antiretroviral Therapy Adherence Among People Living with HIV in South Carolina

People living with HIV are at increased risk for experiencing trauma, which may be linked to reduced adherence to antiretroviral therapy (ART), making it more difficult to achieve and maintain viral suppression. The current study sought to assess whether traumatic life experiences were associated with lower ART adherence among a diverse sample of people living with HIV in South Carolina. A cross-sectional survey was completed by 402 individuals receiving HIV care from a large immunology center. Principal component analysis revealed three primary categories of trauma experience (extreme violence/death-related trauma, physical and sexual assault, and accidental/disaster-related trauma). Multivariable logistic regression models using complete case analysis and multiple imputation were used to determine the associations between experiencing each trauma category and ART adherence. Complete case analysis showed that overall, participants who reported exposure to any trauma were 58% less likely to be adherent to their ART (adjusted OR 0.42; 95% CI 0.21-0.86) compared to respondents who did not experience trauma. Participants exposed to extreme violence/death-related trauma were 63% less likely to be adherent to their ART (adjusted OR 0.37; 95% CI 0.15-0.95) compared to respondents who did not experience trauma. Participants exposed to physical and sexual assault were 65% less likely (adjusted OR 0.35; 95% CI 0.16-0.77) and those who reported experiencing accidental/disaster-related trauma were 56% less likely (adjusted OR 0.44; 95% CI 0.21-0.93) to report being ART adherent compared to participants who did not experience trauma. Analyses with multiple imputation yielded similar findings as the complete case analyses. When the data were analyzed separately by gender, the associations between overall trauma, extreme violence/death-related trauma, and physical and sexual assault were statistically significant for men using complete case and multiple imputation analyses. There were no statistically significant associations between trauma and ART adherence among women. Findings highlight the need to adopt trauma-informed approaches and integrate trauma- and gender-specific interventions into HIV clinical care in the Southern United States.

Gender-based violence and engagement in biomedical HIV prevention, care and treatment: a scoping review

BACKGROUND

While gender-based violence (GBV) has been shown to increase women's risk of HIV acquisition, the role of GBV in the HIV testing to care continuum is less clear. Clarifying how GBV may act as a barrier to accessing HIV services, treatment and care - such as anti-retroviral treatment (ART) or pre-exposure prophylaxis (PrEP) - will not only provide insights into how to best meet individual women's HIV care needs, but also inform public health oriented HIV epidemic control strategies.

METHODS

Through a comprehensive scoping review, we synthesized and analyzed existing evidence regarding the influence of GBV on engagement in PrEP and the HIV care continuum among women living with HIV, including members of key populations (female sex workers, transgender women and women who use drugs). We explored PubMed, Scopus and Web of Science for peer-reviewed studies published in 2003-2017. Of the 279 sources identified, a subset of 51 sources met the criteria and were included in the scoping review.

RESULTS

Studies were identified from 17 countries. The majority of studies utilized quantitative cross-sectional designs (n = 33), with the rest using longitudinal (n = 4), qualitative (n = 10) or mixed methods (n = 4) designs. Taken together, findings suggest that GBV impedes women's uptake of HIV testing, care, and treatment, yet this can vary across different geographic and epidemic settings. Substantial gaps in the literature do still exist, including studies on the impact of GBV on engagement in PrEP, and research among key populations.

CONCLUSIONS

This scoping review contributes to our knowledge regarding the role GBV plays in women's engagement in PrEP and the HIV care continuum. Findings reveal the need for more longitudinal research to provide insights into the causal pathways linking GBV and HIV care and treatment outcomes. Research is also needed to illuminate the impact of GBV on PrEP use and adherence as well as the impact of GBV on engagement along the HIV care continuum among key populations. It is critical that programs and research keep pace with these findings in order to reduce the global burden of GBV and HIV among women.

A Critical Review and Commentary on the Challenges in Engaging HIV-Infected Latinos in the Continuum of HIV Care

Antiretroviral therapy for treatment of HIV infection has become increasingly effective. Persistent poor HIV outcomes in racial and ethnic minority populations in the US call for a closer examination into why Latinos are at significant risk for acquiring and dying from HIV. To improve clinical outcomes and achieve an AIDS-free generation, HIV research must address disparities in HIV outcomes in Latinos, the largest ethnic/racial minority population in the US. Immigrant status as well as cultural factors influence HIV care utilization and are essential to highlight for effective intervention development in Latinos. A better understanding of these individual and contextual factors is critical to developing tailored approaches to engaging Latinos in HIV care. Based on a comprehensive literature review, we offer a framework for understanding what is needed from clinical practice and research to improve engagement in HIV care for US-based Latinos. These findings may have implications for other minority populations.

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.

Barriers to Viral Suppression Among Female Sex Workers: Role of Structural and Intimate Partner Dynamics

OBJECTIVE

Despite global evidence that sex workers (SWs) are disproportionately impacted by HIV, data on HIV treatment outcomes among SWs living with HIV remains sparse. This study examined the correlates of undetectable plasma viral load (pVL) among street- and off-street SWs living with HIV and on antiretroviral therapy (ART) in Metro Vancouver, Canada.

METHODS

Analyses drew on data (2010-2014) from a longitudinal cohort of SWs (An Evaluation of Sex Workers Health Access) and confidential linkages with the Drug Treatment Program (DTP) data on ART dispensation and outcomes. Bivariate and multivariable generalized linear mixed-effects models were used to identify longitudinal correlates of undetectable pVL (<50 copies/mL).

RESULTS

Of the 72 SWs living with HIV who had ever used ART, 38.9% had an undetectable pVL at baseline. Although 84.7% had undetectable pVL at least once over the study period, 18.1% exhibited sustained undetectable pVL. In multivariable generalized linear mixed-effects model analyses, ≥95% pharmacy refill adherence (adjusted odds ratio (AOR) = 4.21; 95% confidence interval (CI) 2.16 to 8.19) and length of time since diagnosis (AOR = 1.06; 95% CI: 1.00 to 1.13) were positively correlated with undetectable pVL. Having an intimate male partner (AOR = 0.35; 95% CI: 0.16 to 0.78) and being homelessness were negatively correlated with undetectable pVL (AOR = 0.22; 95% CI: 0.10 to 0.47).

DISCUSSION/CONCLUSIONS

There is a need to more closely consider the social and structural contexts that shape SWs' experiences on ART and impact treatment outcomes, including the gendered power dynamics within intimate partnerships. Future research on HIV care among SWs is urgently needed, alongside structural and community-led interventions to support SWs' access to and retention in care.

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.

A Review of Recent Literature on Trauma Among Individuals Living with HIV

Persons living with HIV (PLWH) report disproportionately high levels of exposure to traumatic events in childhood and adulthood. Traumatic experiences are associated with negative health and behavioral outcomes. Current research in this area seeks to further explicate the myriad health effects of trauma on PLWH and the pathways through which trauma operates. In this paper, we review articles published in English between January 2014 and June 2015 that examine traumatic experiences among PLWH, including intimate partner violence (IPV), domestic abuse, child abuse, and other forms of violence. A selection of studies examining trauma among PLWH and its associations with mental health, antiretroviral medication adherence, clinical outcomes, HIV disclosure, and sexual risk behaviors were included. Studies describing trauma coping strategies and interventions were also included. We conclude with recommendations for care of trauma-exposed PLWH and directions for future research.