Social and Behavioral Determinants of HIV Care and Outcomes Among a Sample of African-American Women Living with HIV

Thesis (Ph.D.)--University of Washington, 2018African-American women are a vulnerable subpopulation of people living with HIV (PLWH) at risk for inadequate treatment and poor disease outcomes. The purpose of this dissertation as to investigate three aspects of social and behavioral determinants of HIV care and outcomes among African-American women living with HIV. Specifically, to: 1) evaluate the relationship between HIV-related stigma and viral suppression and explore the mediating roles of depression and nonadherence to ART 2) assess whether religiosity, social support, and ethnic identity modify the relationship between HIV-related stigma and depression, and 3) describe patterns of alcohol use and associated characteristics. We used baseline data from the Unity Study, a randomized controlled trial of an HIV-related stigma reduction intervention for African-American women living with HIV in Chicago, IL and Birmingham, AL. First, we estimated the total effect of stigma on viral suppression using logistic regression and estimated indirect and direct effects along hypothesized pathways using serial mediation analysis. Next, we used moderation analyses to estimate the modifying effects of religiosity, social support, and ethnic identity on the relationship between HIV-related stigma and depression. Finally, we compared participant characteristics across patterns of alcohol use and estimated adjusted associations using logistic regression. Among women in this sample, HIV-related stigma was common, and those who reported greater levels of HIV-related stigma were less likely to be virally suppressed; depression and ART nonadherence did not appear to account for this relationship. Still, women who reported higher levels of HIV-related stigma were more likely to report higher levels of depressive symptom severity. Religiosity buffered this relationship, but social support and ethnic identity did not. Among women in this study, half reported any alcohol use, and a quarter each screened positive for UAU and HED. Patterns of alcohol use and were associated with social characteristics (religiosity, social support, and HIV-related stigma), clinical characteristics (depression), and HIV-related clinical characteristics (ART adherence and viral suppression). African-American women living with HIV face substantial challenges but demonstrate great capacity for resilience. Effective interventions which integrate aspects of religiosity and social support are needed to reduce HIV-related stigma and any and unhealthy alcohol use. Future research should focus on better understanding the relevant mechanisms and developing and testing new interventions