Date of Degree
Doctor of Philosophy (Ph.D.)
Health Policy and Management
HIV care, nativity, ADAP, Medicaid health policy
Background: As of 2020, human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) remains a serious public health problem in the United States (U.S.). There are more than 1.1 million people living with HIV/AIDS (PLHIV) in the U.S. in 2020. While HIV predominately affects men in the U.S., women are less likely to achieve viral suppression than men. Among the women living with HIV, women of color (WOC) have borne a disproportionate burden of the HIV epidemic in the U.S. for decades. A wealth of evidence has demonstrated the importance of viral suppression as a tool for controlling the HIV epidemic in the U.S. However, surprisingly few studies have examined HIV viral suppression among WOC in the U.S. and considered factors across the Social-Ecological Model (SEM) as predictors, barriers, or enablers of viral suppression. This mixed methods study aimed to fill this gap through analysis of de-identified data from the Health Resources and Services Administration (HRSA) funded Special Projects of National Significance (SPNS) study called the “Women of Color Initiative” (2009-2013), as well as an examination of HIV policies in California, Florida, New York, and Texas (four states included in the HRSA SPNS WOC study). Specific research aims included:
Aim 1: Investigate the association of nativity status with viral suppression among HIV+ WOC before and after controlling for selected site/state characteristics; and whether this association varies with education and housing status.
Aim 2: Investigate the association of state of residence and Aids Drug Assistance Program (ADAP) income eligibility thresholds with viral suppression among HIV+ WOC before and after controlling for selected individual characteristics.
Aim 3: Conduct a policy analysis in the states with the largest numbers of PLHIV in the U.S.: California, New York, Texas, and Florida to explain how state policies may act as barriers and/or enablers to WOC achieving viral suppression.
Methods: In Aim 1 generalized estimating equation (GEE) models were used to fit a logistic regression and quantify the association between nativity status and viral suppression in WOC before and after controlling for selected covariates. We also tested interactions of education and housing with nativity status to determine the effect modification of these variables.
In Aim 2, we ran two separate models and tested the hypotheses that state of residence and ADAP income eligibility were associated with HIV viral suppression. State of residence and ADAP income eligibility thresholds were both state-level variables; therefore, they were collinear and could not be included in the same model. A logistic regression model was run for each of the exposure variables to quantify the association of state of residence and ADAP income eligibility thresholds with viral suppression in WOC before and after controlling for the selected covariates. As a sensitivity analysis, log binomial models were run because the majority of the WOC in the sample achieved viral suppression and, therefore, prevalence ratios would yield more accurate association estimates than odds ratios. For Aim 1 and 2, correlations were run to test for multicollinearity, and assessed using a variance inflation factor threshold of less than 10. All analyses were conducted using SPSS V24.
For Aim 3 of this dissertation, the methodology for reviewing the state policy environment involved a review of data from several sources which included 1) Medicaid policies, 2) ADAP policies, and 3) state-specific HIV plans and data from 2012 and 2017/2018 or the most recent data available. The time periods 2012 and 2017/2018 correspond with the period for the data used in Aims 1 and 2 of the dissertation (Health Resources and Services Administration-funded WOC Initiative 2009–2013) and the period of the most recent data available, respectively. Medicaid and ADAP policies were reviewed because they are the two largest providers of health coverage to PLHIV in the country.
Results: In Aim 1 we found foreign-born HIV+ WOC were more likely to achieve viral suppression than their U.S.-born counterparts, regardless of education or housing status. In Aim 2 we found that state of residence and state-level policies impact HIV viral suppression among HIV+ WOC in the U.S. Adjusting for age, race/ethnicity, education, employment, housing, health insurance, current ART, any current risk behavior, and transportation, logistic regression models show that among our study population the HIV+ WOC in New York and Texas were less likely to achieve HIV viral suppression than the HIV+ WOC in California. Regarding ADAP income eligibility, we found that the findings were nearly identical to the ones for state of residence. WOC in New York where ADAP income eligibility threshold was 435% federal poverty level (FPL) were less likely to achieve viral suppression than the WOC in California where ADAP income eligibility threshold was 447% FPL, and WOC in Texas where ADAP income eligibility threshold was 200% FPL were less likely to achieve viral suppression than the WOC in California after adjusting covariates.
In Aim 3 we found that the rates of HIV viral suppression among PLHIV increased in all California, Florida, New York and Texas between 2012 and 2017/2018. However, none of these states were on track to meet their HIV targets for 2020/2021 in 2018, and there were disparities in the eligibility criteria for HIV/AIDS related resources across these states. We found that policies such as: Medicaid expansion, more generous ADAP income eligibility thresholds, higher Medicaid payments per enrollee with HIV/AIDS, and higher ADAP expenditures per client served in California and New York created an enabling environment for PLHIV to achieve viral suppression. Conversely, we found PLHIV in Texas and Florida face several barriers to HIV care such as; restrictive Medicaid and ADAP eligibility requirements, lower Medicaid payments per enrollee with HIV/AIDS, and lower ADAP expenditures per client.
Conclusion: Overall, the findings from this mixed-methods dissertation suggest that there is a complicated relationship among the individual, community, societal, and political factors which impact HIV viral suppression among WOC in the U.S. To this researcher’s knowledge, this was the first investigation of the association between nativity and HIV viral suppression among WOC in the U.S. Given the significance of our findings, and the inconclusive state of the literature to date further research is warranted. Future HIV research should continue to explore the factors that facilitate viral suppression among foreign-born WOC in the U.S. because the resulting findings could inform policies and programs that benefit all PLHIV.
Our findings that state of residence and state-level policies impact HIV viral suppression among HIV+ WOC in the U.S. were expected given the robust literature which validates the SEM and the idea that behaviors both shape and are shaped by multiple levels of influence (individual, interpersonal, organizational, community, and societal). However, considering the importance of viral suppression as an HIV prevention tool, the disparities in HIV viral suppression across states must be addressed. Healthcare providers, state and local health departments, community-based organizations, and PLHIV should advocate for more equitable state-level HIV policies which ensure access to ART and facilitate viral suppression regardless of state or income level.
The HIV epidemic is complex, and therefore an effective response requires an understanding of the diversity and dynamic nature of individuals, communities, and our socio-political environment. Failing to recognize the heterogeneity of HIV+ WOC or the diversity of state-level resources available to PLHIV in the U.S. and their impact on HIV viral suppression is like painting with a broad brush when we have finer tools at our disposal. We need to encourage the use of multi-level modelling and mixed methods studies if we want to better understand why the U.S. is failing to meet its HIV treatment targets and why there are disparities in HIV/AIDS diagnoses, morbidity, and mortality by gender, race/ethnicity and state. We possess the tools needed to end the HIV epidemic in the U.S.; now is the time to garner political will and advocate for a new federal policy which provides ART for all.
Nace, Amanda J., "HIV VIRAL SUPPRESSION AMONG HIV POSITIVE WOMEN OF COLOR IN THE UNITED STATES" (2020). CUNY Academic Works.
Available for download on Saturday, September 10, 2022