Retention in care among vulnerable HIV-positive populations: the impact of socio-contextual factors

Thesis (Dr.P.H.)--Boston UniversityBackground: HIV is now manageable as a chronic disease for those who are adherent to medication and remain in care for life. However, remaining in care and achieving optimal health outcomes is challenging for many HIV-infected individuals. Examining the impact of socio-contextual factors may provide an opportunity to design interventions to improve retention in HIV care among vulnerable populations. Objectives: This study examines the relationship between retention in HIV care, social support, and stigma among two vulnerable populations of people living with HIV: racial ethnic/minorities and older Black women. Methods: I analyzed data collected from a multi-site study of six urban HIV clinics to quantitatively examine the relationship between social support, stigma, and age with retention in HIV care. I also conducted semi-structured qualitative interviews with 20 older Black women (age 50+) who were currently in care at Boston-area HIV clinics. The qualitative thematic analysis examined how the two primary domains, the role of stigma and the role of social support, were related to engagement and retention in care among the older Black women interviewed. Results: The multivariable results from the quantitative analysis showed that social support, stigma, and age were not significantly associated with retention in care. Among the older Black women I interviewed, those who did not receive social support or experienced ongoing stigma portrayed their social world as a source of potential distress that affected their ability to engage in care. However, women were able to engage in care if they could successfully limit their distress by disclosing their HIV status to someone and receiving social support. Conclusions: Despite the null results from the multivariable analysis, the qualitative findings highlight nuanced and important roles of stigma and social support among a particular vulnerable population. The negative consequences related to both stigma and low levels of social support, as revealed by the qualitative interviews, highlight their remaining importance among older HIV-infected Black women. Future research and interventions can focus on empowering patients to self-manage their HIV care as they age and reducing the effects of stigma and low social support to improve patient engagement in HIV care