POST-TRAUMATIC STRESS DISORDER (PTSD) AMONG WOMEN LIVING WITH HIV: AN EXAMINATION OF CONTEXT, CHANGE, AND EFFECT ON HIV OUTCOMES

Statement of problem or theory: This dissertation focuses on posttraumatic stress disorder (PTSD) among U.S. women living with HIV. There is a high prevalence of recent PTSD in this population (30%), yet little is known about its characteristics, change over time, and relationship to HIV care outcomes. PTSD may itself negatively affect HIV care outcomes. Methods: I used data from 1,098 women living with HIV across the US who were participating in an ongoing longitudinal cohort study and provided data on severity of their PTSD symptoms. Conceptualizing PTSD as a latent variable, I applied latent variable methods (latent class analysis, latent class regression, and latent transition analysis) to group participants by PTSD symptom severity and patterns, examine associated sociodemographic and psychosocial characteristics, explore HIV outcomes over time associated with latent class membership, and investigate change in PTSD over time. Results: Participants had a low overall socioeconomic status and high prevalence of lifetime violence experience with 54.7% having experienced severe physical abuse, 42.1% having experienced sexual assault, and 38.9% experiencing psychological abuse. Over one-fifth (21.3%) experienced all three types of abuse. Latent class analysis results supported a model where participants were split into three groups – high, medium, and low severity - differing only by PTSD symptom severity and not by symptom pattern or configuration. Socioeconomic status and violence experience differentiated PTSD latent classes. Specifically, sociodemographic characteristics associated with membership in the high or medium class included race, country of birth, employment, education, housing, sexual identity, and income. Those in the high or medium classes were more likely to have experienced violence, and those in the high severity class were more likely to have experienced recent violence. Participants in the high or medium PTSD severity class had poorer medication adherence and worse HIV outcomes (less likely to have an undetectable viral load, more likely to have a CD4 count consistent with AIDS). However, medication adherence explained the differences in detectable viral load and CD4 counts consistent with an AIDS diagnosis between PTSD classes. Examining PTSD latent class stability, I found that latent class membership changed over time with a higher proportion of participants moving to a higher disturbance class than to a lower disturbance class. These changes were predicted by demographic characteristics, prior violence experience, and economic hardship. In particular, participants whose PTSD symptoms appeared between the baseline and time 1 were more likely to be of Hispanic ethnicity; bisexual, lesbian/gay or other (non-heterosexual) orientation; unemployed; have less than a high school education; have experienced physical assault, particularly by a family member; and have experienced psychological abuse from a partner. Participants whose PTSD symptoms were maintained or worsened were more likely than their counterparts to have experienced sexual assault before the age of 18. Participants who recovered from PTSD during this study were more likely to be employed, less likely to have a low income, and less likely to have been sexually assaulted before the age of 18. Conclusions: Women living with both PTSD and HIV conditions are suffer disproportionately from past or ongoing experiences of violence and trauma coupled with low socioeconomic status including unemployment, low educational attainment, low income, and unstable housing. Programs that address HIV should not only be trauma-informed and incorporate mental health treatment but also respond to patients’ or clients’ basic needs, such as housing and employment. The results of this research also point to several important, future research questions to further characterize PTSD among WLHIV, as well as address PTSD. These areas of inquiry include how PTSD manifests among other populations living with HIV, such as youth or non-heterosexual individuals; the role of medication adherence in the pathway between trauma and poor HIV outcomes; effective PTSD treatment modalities tailored to WLHIV; and evaluating PTSD and HIV outcomes within programs that can incorporate HIV care, mental health treatment, and social services