Intersectional stigma and the non-communicable disease syndemic in the context of HIV: protocol for a multisite, observational study in the USA.

INTRODUCTION: The increasing burden of non-communicable diseases, such as hypertension, diabetes and dyslipidaemia, presents key challenges to achieving optimal HIV care outcomes among ageing people living with HIV. These diseases are often comorbid and are exacerbated by psychosocial and structural inequities. This interaction among multiple health conditions and social factors is referred to as a syndemic. In the USA, there are substantial disparities by social position (ie, racial, ethnic and socioeconomic status) in the prevalence and/or control of non-communicable diseases and HIV. Intersecting stigmas, such as racism, classism and homophobia, may drive these health disparities by contributing to healthcare avoidance and by contributing to a psychosocial syndemic (stress, depression, violence victimisation and substance use), reducing success along the HIV and non-communicable disease continua of care. Our hypothesis is that marginalised populations experience disparities in non-communicable disease incidence, prevalence and control, mediated by intersectional stigma and the psychosocial syndemic. METHODS AND ANALYSIS: Collecting data over a 4 year period, we will recruit sexual minority men (planned n=1800) enrolled in the MACS/WIHS Combined Cohort Study, a long-standing mixed-serostatus observational cohort in the USA, to investigate the following specific aims: (1) assess relationships between social position, intersectional stigma and the psychosocial syndemic among middle-aged and ageing sexual minority men, (2) assess relationships between social position and non-communicable disease incidence and prevalence and (3) assess relationships between social position and HIV and non-communicable disease continua of care outcomes, mediated by intersectional stigma and the psychosocial syndemic. Analyses will be conducted using generalised structural equation models using a cross-lagged panel model design. ETHICS AND DISSEMINATION: This protocol is approved as a single-IRB study (Advarra Institutional Review Board: Protocol 00068335). We will disseminate results via peer-reviewed academic journals, scientific conferences, a dedicated website, site community advisory boards and forums hosted at participating sites.

Impacts of Medicaid Expansion on Health Insurance and Coverage Transitions among Women with or at Risk for HIV in the United States.

BACKGROUND: As employment, financial status, and residential location change, people can gain, lose, or switch health insurance coverage, which may affect care access and health. Among Women's Interagency HIV Study participants with HIV and participants at risk for HIV attending semiannual visits at 10 U.S. sites, we examined whether the prevalence of coverage types and rates of coverage changes differed by HIV status and Medicaid expansion in their states of residence. METHODS: Geocoded addresses were merged with dates of Medicaid expansion to indicate, at each visit, whether women lived in Medicaid expansion states. Age-adjusted rate ratios (RRs) and rate differences of self-reported insurance changes were estimated by Poisson regression. RESULTS: From 2008 to 2018, 3,341 women (67% Black, 71% with HIV) contributed 43,329 visits at aged less than 65 years (27% under Medicaid expansion). Women with and women without HIV differed in their proportions of visits at which no coverage (14% vs. 19%; p < .001) and Medicaid enrollment (61% vs. 51%; p < .001) were reported. Women in Medicaid expansion states reported no coverage and Medicaid enrollment at 4% and 69% of visits, respectively, compared with 20% and 53% of visits for those in nonexpansion states. Women with HIV had a lower rate of losing coverage than those without HIV (RR, 0.81; 95% confidence interval [CI], 0.70 to 0.95). Compared with nonexpansion, Medicaid expansion was associated with lower coverage loss (RR, 0.62; 95% CI, 0.53 to 0.72) and greater coverage gain (RR, 2.32; 95% CI, 2.02 to 2.67), with no differences by HIV status. CONCLUSIONS: Both women with HIV and women at high risk for HIV in Medicaid expansion states had lower coverage loss and greater coverage gain; therefore, Medicaid expansion throughout the United States should be expected to stabilize insurance for women and improve downstream health outcomes.

A new smoking cessation 'cascade' among women with or at risk for HIV infection.

OBJECTIVES: The aim of this study was to define a smoking cessation 'cascade' among USA women with and without HIV and examine differences by sociodemographic characteristics. DESIGN: An observational cohort study using data from smokers participating in the Women's Interagency HIV Study between 2014 and 2019. METHODS: We followed 1165 women smokers with and without HIV from their first study visit in 2014 or 2015 until an attempt to quit smoking within approximately 3 years of follow-up, initial cessation (i.e. no restarting smoking within approximately 6 months of a quit attempt), and sustained cessation (i.e. no restarting smoking within approximately 12 months of a quit attempt). Using the Aalen-Johansen estimator, we estimated the cumulative probability of achieving each step, accounting for the competing risk of death. RESULTS: Forty-five percent of smokers attempted to quit, 27% achieved initial cessation, and 14% achieved sustained cessation with no differences by HIV status. Women with some post-high school education were more likely to achieve each step than those with less education. Outcomes did not differ by race. Thirty-six percent [95% confidence interval (95% CI): 31-42] of uninsured women attempted to quit compared with 47% (95% CI: 44-50) with Medicaid and 49% (95% CI: 41-59) with private insurance. CONCLUSION: To decrease smoking among USA women with and without HIV, targeted, multistage interventions, and increased insurance coverage are needed to address shortfalls along this cascade.

Quality of care for Black and Latina women living with HIV in the U.S.: a qualitative study.

BACKGROUND: Ending the HIV epidemic requires that women living with HIV (WLWH) have access to structurally competent HIV-related and other health care. WLWH may not regularly engage in care due to inadequate quality; however, women's perspectives on the quality of care they receive are understudied. METHODS: We conducted 12 focus groups and three in-depth interviews with Black (90%) and Latina (11%) WLWH enrolled in the Women's Interagency HIV Study in Atlanta, GA, Birmingham, AL, Brooklyn, NY, Chapel Hill, NC, Chicago, IL, and Jackson, MS from November 2017 to May 2018 (n = 92). We used a semi-structured format to facilitate discussions about satisfaction and dissatisfaction with health care engagement experiences, and suggestions for improvement, which were audio-recorded, transcribed, and coded using thematic analysis. RESULTS: Themes emerged related to women's health care satisfaction or dissatisfaction at the provider, clinic, and systems levels and across Institute of Medicine-defined quality of care domains (effectiveness, efficiency, equity, patient-centeredness, safety and timeliness). Women's degree of care satisfaction was driven by: 1) knowledge-based care resulting in desired outcomes (effectiveness); 2) coordination, continuity and necessity of care (efficiency); 3) perceived disparities in care (equity); 4) care delivery characterized by compassion, nonjudgment, accommodation, and autonomous decision-making (patient-centeredness); 5) attention to avoiding side effects and over-medicalization (safety); and 6) limited wait time (timeliness). CONCLUSIONS: Quality of care represents a key changeable lever affecting engage in care among WLWH. The communities most proximally affected by HIV should be key stakeholders in HIV-related quality assurance. Findings highlight aspects of the health care experience valued by WLWH, and potential participatory, patient-driven avenues for improvement.

Neighborhood Poverty and Control of HIV, Hypertension, and Diabetes in the Women's Interagency HIV Study.

Neighborhoods with high poverty rates have limited resources to support residents' health. Using census data, we calculated the proportion of each Women's Interagency HIV Study participant's census tract (neighborhood) living below the poverty line. We assessed associations between neighborhood poverty and (1) unsuppressed viral load [VL] in HIV-seropositive women, (2) uncontrolled blood pressure among HIV-seropositive and HIV-seronegative hypertensive women, and (3) uncontrolled diabetes among HIV-seropositive and HIV-seronegative diabetic women using modified Poisson regression models. Neighborhood poverty was associated with unsuppressed VL in HIV-seropositive women (> 40% versus ≤ 20% poverty adjusted prevalence ratio (PR), 1.42; 95% confidence interval (CI) 1.04-1.92). In HIV-seronegative diabetic women, moderate neighborhood poverty was associated with uncontrolled diabetes (20-40% versus ≤ 20% poverty adjusted PR, 1.75; 95% CI 1.02-2.98). Neighborhood poverty was associated with neither uncontrolled diabetes among HIV-seropositive diabetic women, nor uncontrolled hypertension in hypertensive women, regardless of HIV status. Women living in areas with concentrated poverty may need additional resources to control health conditions effectively.

Towards ending the US HIV epidemic by 2030: Understanding social determinants of health and HIV in Mississippi.

The disproportionate burden of HIV-related inequities borne by African Americans in the US South amplifies the role of social determinants of health (SDH) in shaping social patterning of illness. Despite some attention, SDH remain overlooked in a biomedically oriented, federal HIV policy. Mississippi is the poorest state with the worst HIV outcomes, nationally. Using qualitative methods, we investigated how primarily African American, HIV-positive Mississippians experienced SDH and health inequities in their daily lives. Employing grounded theory and in-depth interviews (n = 25) in an urban and rural site in 2015 yielded these findings: (1) absence of an enabling structural environment; (a) HIV-stigma constructed via social discourse; (b) lack of psycho-social support and HIV education; (c) insufficient economic and social support resources; and (2) presence of family support for coping. Due to stigma, being HIV-positive seemed to lead to further status loss; diminished social position; reduced life chances; and contractions in particular freedoms. Stigma further compounded existing inequalities - contributing to the moral, social experience of those living with HIV. Trump's plan to end HIV by 2030 creates the opportunity to rethink the biomedical-paradigm and fully engage SDH - using social science theory and methods that address multi-level social determinants in ways that are also policy-responsive.

Longitudinal assessment of abnormal Papanicolaou test rates among women with HIV.

OBJECTIVE: To describe longitudinal changes in the prevalence of abnormal Papanicolau testing among women living with HIV. DESIGN: Prospective cohort study with sequential enrollment subcohorts. METHODS: Four waves of enrollment occurred in the Women's Interagency HIV Study, the US women's HIV cohort (1994-1995, 2001-2002, 2011-2012, 2013-2015). Pap testing was done at intake, with colposcopy prescribed for any abnormality. Rates of abnormal Pap test results (atypical squamous cells of uncertain significance or worse) and cervical intraepithelial neoplasia grade 2 (CIN2) or worse were calculated. Logistic regression models assessed changes in prevalence across cohorts after controlling for severity of HIV disease and other risk factors for abnormal Pap tests. RESULTS: The unadjusted prevalence of any Pap abnormality was 679/1769 (38%) in the original cohort, 195/684 (29%) in the 2001-2002 cohort, 46/231 (20%) in the 2011-2012 cohort, and 71/449 (16%) in the 2013-2015 cohort. In multivariable analysis, compared with risk in the 1994-1995 cohort, the adjusted risk in the 2001-2002 cohort was 0.79 (95% CI 0.59-1.05), in the 2011-2012 cohort was 0.67 (95% CI 0.43-1.04), and in the 2013-2015 cohort was 0.41 (95% CI 0.27-0.62) with P for trend less than 0.0001. CONCLUSION: Rates of abnormal cytology among women with HIV have fallen during the past two decades.

Health Disparities and the Digital Divide: The Relationship between Communication Inequalities and Quality of Life among Women in a Nationwide Prospective Cohort Study in the United States.

Background: Communication inequalities can affect health-seeking behaviors yet the relationship between Internet use and overall health is inconclusive. Communication-related inequalities vary by race/ethnicity and SES but existing research primarily includes middle-class Whites. We therefore examined the relationship between communication-related inequalities-measured by daily Internet use-and health-related quality of life (QOL) using a nationwide prospective cohort study in the United States that consists of primarily low income, minority women. Methods: We examined Internet use and QOL among participants in the Women's Interagency HIV Study. Data collection occurred from October 2014-September 2015 in Chicago, New York, Washington DC, San Francisco, Atlanta, Chapel Hill, Birmingham/Jackson and Miami. We used multi-variable analyses to examine the relationship between daily Internet use and QOL. Results: The sample of 1,915 women was 73% African American and 15% Hispanic; 53% reported an annual income of ≤$12,000. Women with daily Internet use reported a higher QOL at six months, as did women with at least a high school diploma, income >$12,000, and non-White race; older women and those with reported drug use, depressive symptoms and loneliness had lower QOL. Conclusions: Overcoming communication inequalities may be one pathway through which to improve overall QOL and address public health priorities. Reducing communication-related inequalities-e.g, by providing reliable Internet access-and thus improving access to health promoting information, may lead to improved health outcomes.

Women's decision-making about self-protection during sexual activity in the deep south of the USA: a grounded theory study.

Many women continue to become infected with HIV, particularly in the Southeastern USA, despite widespread knowledge about methods to prevent its sexual transmission. This grounded theory investigation examined the decision-making process women use to guide their use or non-use of self-protective measures when engaging in sexual activity. Participants included women in the Mississippi cohort of the Women's Interagency HIV Study who were infected with or at high risk for HIV. Theoretical sampling was used to recruit a sample of 20 primarily African American women aged between 26 and 56 years, living in rural and urban areas. Data were analysed using constant comparative method to generate a theory of the process that guided women's self-protective decisions. Three key themes were identified: (1) sexual silence, an overall context of silence around sexuality in their communities and relationships; (2) the importance of relationships with male partners, including concepts of 'love and trust', 'filling the void' and 'don't rock the boat'; and (3) perceptions of risk, including 'it never crossed my mind', 'it couldn't happen to me' and 'assumptions about HIV'. These themes impacted on women's understandings of HIV-related risk, making it difficult to put self-protection above other interests and diminishing their motivation to protect themselves.

Health Insurance Type and Control of Hypertension Among US Women Living With and Without HIV Infection in the Women's Interagency HIV Study.

BACKGROUND: Health care access is an important determinant of health. We assessed the effect of health insurance status and type on blood pressure control among US women living with (WLWH) and without HIV. METHODS: We used longitudinal cohort data from the Women's Interagency HIV Study (WIHS). WIHS participants were included at their first study visit since 2001 with incident uncontrolled blood pressure (BP) (i.e., BP ≥140/90 and at which BP at the prior visit was controlled (i.e., <135/85). We assessed time to regained BP control using inverse Kaplan-Meier curves and Cox proportional hazard models. Confounding and selection bias were accounted for using inverse probability-of-exposure-and-censoring weights. RESULTS: Most of the 1,130 WLWH and 422 HIV-uninfected WIHS participants who had an elevated systolic or diastolic measurement were insured via Medicaid, were African-American, and had a yearly income ≤$12,000. Among participants living with HIV, comparing the uninsured to those with Medicaid yielded an 18-month BP control risk difference of 0.16 (95% CI: 0.10, 0.23). This translates into a number-needed-to-treat (or insure) of 6; to reduce the caseload of WLWH with uncontrolled BP by one case, five individuals without insurance would need to be insured via Medicaid. Blood pressure control was similar among WLWH with private insurance and Medicaid. There were no differences observed by health insurance status on 18-month risk of BP control among the HIV-uninfected participants. CONCLUSIONS: These results underscore the importance of health insurance for hypertension control-especially for people living with HIV.

Impact of Health Insurance, ADAP, and Income on HIV Viral Suppression Among US Women in the Women's Interagency HIV Study, 2006-2009.

BACKGROUND: Implementation of the Affordable Care Act motivates assessment of health insurance and supplementary programs, such as the AIDS Drug Assistance Program (ADAP) on health outcomes of HIV-infected people in the United States. We assessed the effects of health insurance, ADAP, and income on HIV viral load suppression. METHODS: We used existing cohort data from the HIV-infected participants of the Women's Interagency HIV Study. Cox proportional hazards models were used to estimate the time from 2006 to unsuppressed HIV viral load (>200 copies/mL) among those with Medicaid, private, Medicare, or other public insurance, and no insurance, stratified by the use of ADAP. RESULTS: In 2006, 65% of women had Medicaid, 18% had private insurance, 3% had Medicare or other public insurance, and 14% reported no health insurance. ADAP coverage was reported by 284 women (20%); 56% of uninsured participants reported ADAP coverage. After accounting for study site, age, race, lowest observed CD4, and previous health insurance, the hazard ratio (HR) for unsuppressed viral load among those privately insured without ADAP, compared with those on Medicaid without ADAP (referent group), was 0.61 (95% CI: 0.48 to 0.77). Among the uninsured, those with ADAP had a lower relative hazard of unsuppressed viral load compared with the referent group (HR, 95% CI: 0.49, 0.28 to 0.85) than those without ADAP (HR, 95% CI: 1.00, 0.63 to 1.57). CONCLUSIONS: Although women with private insurance are most likely to be virally suppressed, ADAP also contributes to viral load suppression. Continued support of this program may be especially critical for states that have not expanded Medicaid.