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.

Extreme weather events and HIV: development of a conceptual framework through qualitative interviews with people with HIV impacted by the California wildfires and their clinicians.

BACKGROUND: People with HIV (PWH) are disproportionately vulnerable to the impacts of wildfires, given the need for frequent access to healthcare systems, higher burden of comorbidities, higher food insecurity, mental and behavioral health challenges, and challenges of living with HIV in a rural area. In this study, we aim to better understand the pathways through which wildfires impact health outcomes among PWH. METHODS: From October 2021 through February 2022, we conducted individual semi-structured qualitative interviews with PWH impacted by the Northern California wildfires and clinicians of PWH who were impacted by wildfires. The study aims were to explore the influence of wildfires on the health of PWH and to discuss measures at the individual, clinic, and system levels that helped to mitigate these impacts. RESULTS: We interviewed 15 PWH and 7 clinicians. While some PWH felt that surviving the HIV epidemic added to their resilience against wildfires, many felt that the wildfires compounded the HIV-related traumas that they have experienced. Participants outlined five main routes by which wildfires negatively impacted their health: (1) access to healthcare (medications, clinics, clinic staff), (2) mental health (trauma; anxiety, depression, or stress; sleep disturbances; coping strategies), (3) physical health (cardiopulmonary, other co-morbidities), (4) social/economic impacts (housing, finances, community), and (5) nutrition and exercise. The recommendations for future wildfire preparedness were at the (1) individual-level (what to have during evacuation), (2) pharmacy-level (procedural, staffing), and (3) clinic- or county-level (funds and vouchers; case management; mental health services; emergency response planning; other services such as telehealth, home visits, home laboratory testing). CONCLUSIONS: Based on our data and prior research, we devised a conceptual framework that acknowledges the impact of wildfires at the community-, household-, and individual-level with implications for physical and mental health outcomes among PWH. These findings and framework can help in developing future interventions, programs, and policies to mitigate the cumulative impacts of extreme weather events on the health of PWH, particularly among individuals living in rural areas. Further studies are needed to examine health system strengthening strategies, innovative methods to improve access to healthcare, and community resilience through disaster preparedness. TRIAL REGISTRATION: N/A.

Social Determinants of Adherence to Treatment for Tuberculosis Infection and Disease Among Children, Adolescents, and Young Adults: A Narrative Review.

Global efforts to eliminate tuberculosis (TB) must address the unique barriers that children (ages 0 through 9 years) and adolescents/young adults (AYA; ages 10 through 24 years) face in adhering to treatment for TB infection and disease. We conducted a narrative review to summarize current knowledge on the social determinants of treatment adherence among these age groups to guide efforts and policy to address their unique needs. Our findings revealed that research on TB treatment adherence among children and AYA is still in its nascent stage. The current literature revealed structural/community-, health system-, household-, and individual-level factors that influence treatment adherence and varied with developmental stage. There is a need to develop multilevel interventions to address the unique challenges that children and AYA face in adhering to TB treatment.

Examining Mediators of the Relationship Between Community Mobilization and HIV Incidence Among Young South African Women Participating in the HPTN 068 Study Cohort.

We previously demonstrated that village community mobilization (CM) was associated with reduced HIV incidence among adolescent girls and young women (AGYW) in South Africa. Little remains known about the mechanisms linking CM to HIV incidence. Using longitudinal data from 2292 AGYW in the HPTN 068 cohort (2011-2017), we examined whether school attendance, pro-social engagement, and hope for the future mediated the relationship between CM and HIV incidence. CM was measured at the village-level via two population-based surveys (2012 and 2014). Mediators and incident HIV infection were measured through HPTN 068 surveys and HIV testing. Mediation analyses were conducted using Mplus 8.5, adjusting for village-level clustering and covariates. Hope for the future mediated the relationship between CM and HIV incidence (indirect effect-RR 0.98, bias-corrected 95% CI 0.96, 0.99). Pro-social engagement and school attendance did not demonstrate indirect effects. CM reduces AGYW's HIV acquisition risk, in part, by engendering hope.

Emotional Violence is Associated with Increased HIV Risk Behavior Among South African Adolescent Girls and Young Women in the HPTN 068 Cohort.

Limited research has explored how emotional intimate partner violence (IPV) shapes HIV risk behaviors. Using cross-sectional data from the HPTN 068 post-trial visit (N = 1942), we assessed the association between emotional IPV and its sub-domains (verbal abuse and threats) with condomless sex, transactional sex, and frequent alcohol use among young women in South Africa. In adjusted multivariable logistic regression models, any emotional IPV and verbal IPV were associated with increased odds of condomless sex (aOR: 1.47; 95% CI: 1.15, 1.87; and aOR: 1.48; 95% CI: 1.15, 1.89), transactional sex (aOR: 2.32; 95% CI: 1.74, 3.08; and aOR: 2.02; 95% CI: 1.51, 2.71) and alcohol use (aOR: 1.88; 95% CI: 1.39, 2.53; and aOR: 1.87; 95% CI: 1.37, 2.55). Threats were associated with transactional sex (aOR: 3.67; 95% CI: 2.62, 5.14). Future research should examine this relationship over-time and HIV prevention programs should consider and address emotional IPV.

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.

Shifting gender norms to improve HIV service uptake: Qualitative findings from a large-scale community mobilization intervention in rural South Africa.

BACKGROUND: Interventions to improve HIV service uptake are increasingly addressing inequitable and restrictive gender norms. Yet comparatively little is known about which gender norms are most salient for HIV testing and treatment and how changing these specific norms translates into HIV service uptake. To explore these questions, we implemented a qualitative study during a community mobilization trial targeting social barriers to HIV service uptake in South Africa. METHODS: We conducted 55 in-depth interviews in 2018, during the final months of a three-year intervention in rural Mpumalanga province. Participants included 25 intervention community members (48% women) and 30 intervention staff/community-opinion-leaders (70% women). Data were analyzed using an inductive-deductive approach. RESULTS: We identified three avenues for gender norms change which, when coupled with other strategies, were described to support HIV service uptake: (1) Challenging norms around male toughness/avoidance of help-seeking, combined with information on the health and preventive benefits of early antiretroviral therapy (ART), eased men's fears of a positive diagnosis and facilitated HIV service uptake. (2) Challenging norms about men's expected control over women, combined with communication and conflict resolution skill-building, encouraged couple support around HIV service uptake. (3) Challenging norms around women being solely responsible for the family's health, combined with information about sero-discordance and why both members of the couple should be tested, encouraged men to test for HIV rather than relying on their partner's results. Facility-level barriers such as long wait times continued to prevent some men from accessing care. CONCLUSIONS: Despite continued facility-level barriers, we found that promoting critical reflection around several specific gender norms, coupled with information (e.g., benefits of ART) and skill-building (e.g., communication), were perceived to support men's and women's engagement in HIV services. There is a need to identify and tailor programming around specific gender norms that hinder HIV service uptake.

Mobility for sex work and recent experiences of gender-based violence among female sex workers in Iringa, Tanzania: A longitudinal analysis.

Female sex workers are highly mobile, which may influence their risk of experiencing physical and sexual violence. However, there remains a paucity of research, particularly longitudinal, from Sub-Saharan Africa exploring mobility and gender-based violence among female sex workers. To address this gap, this study examined the longitudinal relationship between work-related mobility and recent experience of physical or sexual gender-based violence from a client or partner among female sex workers in Iringa, Tanzania. A secondary data analysis was conducted using baseline and 18-month follow-up data from Project Shikamana, a community empowerment-based combination HIV prevention intervention. Responses from 387 female sex workers aged 18 years and older participating in both baseline and follow-up were analyzed. Unadjusted and adjusted Poisson regression models with robust variance estimations, accounting for clustering of female sex workers' responses over time, were fit. Final models adjusted for socio-demographic characteristics and aspects of participants' living situations and work environments. Recent physical or sexual violence from a client or partner was common (baseline: 40%; follow-up: 29%). Twenty-six percent of female sex workers at baseline, and 11% at follow-up, had recently traveled outside of Iringa for sex work. In the final adjusted longitudinal model, female sex workers recently mobile for sex work had a 25% increased risk of any recent experience of physical or sexual gender-based violence when compared with their non-mobile counterparts (adjusted incidence rate ratio: 1.25; 95% CI: 1.03-1.53; p<0.05). Interventions must identify ways-such as mobile support services, linkages and referrals to health and other social services while traveling, or the use of mobile or digital technology-to address mobile female sex workers' unique needs while traveling. Future quantitative and qualitative research is needed to understand the context of female sex workers' mobility and how and why mobility influences risk environments and experiences of gender-based violence.

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.

Point-of-Care Test for Assessing Tenofovir Adherence: Feasibility and Recommendations from Women in an Oral PrEP Program in Kenya and Their Healthcare Providers.

Oral pre-exposure prophylaxis (PrEP) is a highly effective HIV prevention modality when taken as recommended. Women in sub-Saharan Africa may have adherence challenges that remain undisclosed to providers. Real-time measures that identify non-adherence can allow for immediate exploration of adherence challenges, counseling and interventions. We conducted a formative qualitative study in Kenya to explore oral PrEP experiences and reactions to a point-of-care urine test (UT) identifying recent (past 4 days) non-adherence to tenofovir-based PrEP among female PrEP users (25 in-depth interviews; 4 focus groups) and health care provider (10 key informant interviews). Findings indicate that use of the UT would be highly feasible in the context of regular PrEP care, largely acceptable to clients and providers, and could improve adherence. Clients emphasized the need for transparent client-centered strategies in delivering results. This formative study informs the development of tools to implement this point-of-care UT in future interventional studies and clinical settings.

Perceived Neighborhood-Level Drivers of Food Insecurity Among Aging Women in the United States: A Qualitative Study.

BACKGROUND: Aging populations in the United States exhibit high rates of food insecurity and chronic illness. Few studies have explored the neighborhood-level drivers of food insecurity among such populations, and how they intersect with experiences of aging. OBJECTIVE: The aim of this study was to explore how aging women experience food insecurity in the United States, and the neighborhood-level factors that influence these experiences. DESIGN: Semistructured qualitative interviews were conducted to elicit participants' perceptions of how their neighborhood influenced their experiences with food security and aging. PARTICIPANTS/SETTING: Thirty-eight food-insecure women aged 50 years and older were purposively sampled from the Northern California, Georgia, and North Carolina sites of the Women's Interagency Human Immunodeficiency Virus Study. Interviews were conducted between November 2017 and July 2018 at the three Women's Interagency Human Immunodeficiency Virus Study sites. STATISTICAL ANALYSIS: Three researchers thematically analyzed the data using an inductive-deductive approach. RESULTS: Participants described neighborhood-level drivers of food insecurity that centered around three themes: accessibility of food from traditional food stores, the role of food aid institutions, and the intersection of aging with the food environment. Participants explained that food insecurity was related to limited access to food stores largely due to long distances and poor public transportation in Georgia and North Carolina, and high food prices in Northern California. Most participants described being dependent on food aid programs, but found this difficult due to poor quality food and long wait times. Aging-related issues emerged as a cross-cutting theme, with fatigue, poor strength, and chronic illness amplifying barriers to accessing food. CONCLUSIONS: Findings from this study reveal the structural barriers that aging women face in accessing healthy food within their neighborhoods, and how experiences with aging and chronic illnesses exacerbate these barriers. Although future programs should address common neighborhood-level barriers such as the accessibility and affordability of healthy foods, they should also be tailored to aging women and the local context.

Cultural Adaptation of an Intervention to Reduce Hazardous Alcohol Use Among People Living with HIV in Southwestern Uganda.

Hazardous drinking by persons living with HIV (PLHIV) is a well-established determinant of sub-optimal HIV care and treatment outcomes. Despite this, to date, few interventions have sought to reduce hazardous drinking among PLHIV in sub-Saharan Africa (SSA). We describe an iterative cultural adaptation of an evidence-based multi-session alcohol reduction intervention for PLHIV in southwestern Uganda. The adaptation process included identifying core, theoretically informed, intervention elements, and conducting focus group discussions and cognitive interviews with community members, HIV clinic staff and patients to modify key intervention characteristics for cultural relevance and saliency. Adaptation of evidence-based alcohol reduction interventions can be strengthened by the inclusion of the target population and key stakeholders in shaping the content, while retaining fidelity to core intervention elements.

Exploring the role of social capital in managing food insecurity among older women in the United States.

Food insecurity, which affects 37 million individuals in the United States (U.S.) and disproportionately burdens women, minorities and older adults, is a well-established determinant of poor health. Previous studies suggest social capital, defined as the material and social benefits arising from relationships among individuals within and between groups, may be protective against food insecurity. Drawing on this evidence, calls have been made for interventions and policies to promote social capital to address food insecurity. However, limited research has explored in-depth how social capital shapes the lived experience of food insecurity in the U.S. We explored how older women from three settings in the U.S. used forms of social capital to navigate their food environments. Between November 2017-July 2018, we conducted 38 semi-structured interviews with food-insecure women aged 50 years or older enrolled in the Northern California, Georgia, and North Carolina sites of the Women's Interagency HIV study, an ongoing cohort study of women living with and at risk of HIV. Interviews were analyzed using an inductive-deductive approach. Women from the three sites explained how they drew upon different forms of capital to access food. Women in Georgia and North Carolina depended on support from members within their social group (bonding social capital) to address food insecurity but described limited opportunities to build relationships with members from other social groups (bridging social capital) or representatives of institutions (linking social capital). In contrast, women from Northern California frequently used bridging and linking social capital to access food but described limited bonding social capital. Findings show how the role of social capital in protecting against food insecurity is diverse, complex, and structurally determined. Intervention implications are discussed.

A conceptual model for understanding the rapid COVID-19-related increase in food insecurity and its impact on health and healthcare.

Food insecurity, a well-established determinant of chronic disease morbidity and mortality, is rapidly increasing due to the coronavirus disease 2019 (COVID-19) pandemic. We present a conceptual model to understand the multiple mechanisms through which the economic and public health crises sparked by COVID-19 might increase food insecurity and contribute to poor health outcomes in the short- and long-term. We hypothesize that, in the short-term, increased food insecurity, household economic disruption, household stress, and interruptions in healthcare will contribute to acute chronic disease complications. However, the impact of the pandemic on food security will linger after social-distancing policies are lifted and the health system stabilizes, resulting in increased risk for chronic disease development, morbidity, and mortality among food-insecure households in the long-term. Research is needed to examine the impact of the pandemic-related increase in food insecurity on short- and long-term chronic health outcomes, and to delineate the underlying causal mechanisms. Such research is critical to inform the development of effective programs and policies to address food insecurity and its downstream health impacts during COVID-19 and future pandemics.

Food Insecurity Is Associated With Lower Levels of Antiretroviral Drug Concentrations in Hair Among a Cohort of Women Living With Human Immunodeficiency Virus in the United States.

BACKGROUND: Food insecurity is a well-established determinant of suboptimal, self-reported antiretroviral therapy (ART) adherence, but few studies have investigated this association using objective adherence measures. We examined the association of food insecurity with levels of ART concentrations in hair among women living with human immunodeficiency virus (WLHIV) in the United States. METHODS: We analyzed longitudinal data collected semiannually from 2013 through 2015 from the Women's Interagency HIV Study, a multisite, prospective, cohort study of WLHIV and controls not living with HIV. Our sample comprised 1944 person-visits from 677 WLHIV. Food insecurity was measured using the US Household Food Security Survey Module. ART concentrations in hair, an objective and validated measure of drug adherence and exposure, were measured using high-performance liquid chromatography with mass spectrometry detection for regimens that included darunavir, atazanavir, raltegravir, or dolutegravir. We conducted multiple 3-level linear regressions that accounted for repeated measures and the ART medication(s) taken at each visit, adjusting for sociodemographic and clinical characteristics. RESULTS: At baseline, 67% of participants were virally suppressed and 35% reported food insecurity. In the base multivariable model, each 3-point increase in food insecurity was associated with 0.94-fold lower ART concentration in hair (95% confidence interval, 0.89 to 0.99). This effect remained unchanged after adjusting for self-reported adherence. CONCLUSIONS: Food insecurity was associated with lower ART concentrations in hair, suggesting that food insecurity may be associated with suboptimal ART adherence and/or drug absorption. Interventions seeking to improve ART adherence among WLHIV should consider and address the role of food insecurity.

Essential elements of a community empowerment approach to HIV prevention among female sex workers engaged in project Shikamana in Iringa, Tanzania.

Globally, female sex workers bear a disproportionate burden of HIV, with those in sub-Saharan Africa being among the most affected. Community empowerment approaches have proven successful at preventing HIV among this population. These approaches facilitate a process whereby sex workers take collective ownership over programmes to address the barriers they face in accessing their health and human rights. Limited applications of such approaches have been documented in Africa. We describe the community empowerment process among female sex workers in Iringa, Tanzania, in the context of a randomised controlled trial of a community empowerment-based model of combination HIV prevention. We conducted 24 in-depth interviews with participants from the intervention community and 12 key informant interviews with HIV care providers, police, venue managers, community advisory board members and research staff. Content analysis was employed, and salient themes were extracted. Findings reveal that the community empowerment process was facilitated by the meaningful engagement of sex workers in programme development, encouraging sex worker ownership over the programme, providing opportunities for solidarity and capacity building, and forming partnerships with key stakeholders. Through this process, sex workers mobilised their collective agency to access their health and human rights including HIV prevention, care and treatment.

Precarity and health: Theorizing the intersection of multiple material-need insecurities, stigma, and illness among women in the United States.

Material-need insecurities (including insecurities in basic resources such as income, food, housing, and healthcare) are widespread in the United States (US) and may be important predictors of poor health outcomes. How material-need insecurities besides food insecurity are experienced, however, remains under-researched, including how multiple material-need insecurities might intersect and converge on the individual. Here we used qualitative methods to investigate experiences with multiple material-need insecurities among 38 food-insecure women aged over 50 years living with or at risk for HIV in the US. Our aims were: (1) to understand the co-experience of material-need insecurities beyond food insecurity; (2) to elucidate how multiple material-need insecurities might intersect; and (3) to discover how this intersection might be detrimental to health. During November 2017-July 2018, we conducted semi-structured interviews at three sites across the US (Northern California, Georgia, North Carolina) and analyzed the data using an inductive-deductive approach. We identified a common and complex picture of multiple material-need insecurities, stigma, and illness among participants across all three sites. There were five primary themes: (1) insecure income arising from a combination of precarious wage labor and federal disability benefits; (2) resultant experiences of uncertainty, compromised quality, insufficiency, and having to use socially unacceptable coping strategies across finances, food, housing, and healthcare; (3) participants' disempowerment arising from their engagement with social safety net institutions; (4) closely related experiences of intersectional stigma and discrimination; and (5) negative implications for health across a wide range of illnesses. By employing the sociological concept of precarity-a term denoting the contemporary convergence of insecure wage labor and retraction of the welfare state-we combine these themes into a unifying framework of precarity and health. This framework may prove useful for testing how the widespread intersection of multiple material-need insecurities interacts with stigma and discrimination to negatively impact physical and mental health.

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.

Poverty stigma is associated with suboptimal HIV care and treatment outcomes among women living with HIV in the United States.

OBJECTIVE: To examine whether experienced poverty stigma is associated with worse HIV care and treatment outcomes. DESIGN: We analyzed cross-sectional data from 433 women living with HIV enrolled in the Women's Adherence and Visit Engagement substudy of the Women's Interagency HIV Study. METHODS: Exposure was experienced poverty stigma, measured using the Perceived Stigma of Poverty Scale. Outcomes were viral suppression, CD4 cell count at least 350 cells/µl, and attending all HIV care visits in the past 6 months. Multivariable logistic regression models adjusted for income, age, race/ethnicity, education, substance use, months taking antiretroviral therapy (ART), number of antiretroviral pills in ART regimen, unstable housing, relationship status, and exchanging sex for money, drugs, or shelter. We also explored whether self-reported at least 95% ART adherence mediated the relationship between poverty stigma and viral suppression and CD4 cell count at least 350 cells/µl. RESULTS: Experienced poverty stigma was associated with lower adjusted odds of viral suppression [adjusted odds ratio (aOR) 0.76; 95% confidence interval (CI) 0.61-0.96], CD4 cell count at least 350 cells/µl (aOR 0.69; 95% CI 0.52-0.91), and attending all HIV care visits (aOR 0.73; 95% CI: 0.54-0.98). Exploratory mediation analysis suggests that at least 95% ART adherence significantly mediates the relationship between experienced poverty stigma and viral suppression and CD4 cell count at least 350 cells/µl. CONCLUSION: Longitudinal research should assess these relationships over time. Findings support interventions and policies that seek to reduce poverty stigma among people living with HIV.