Involvement in Physical Fights among School Attending Adolescents: A Nationally Representative Sample from Kuwait

Background: Interpersonal violence in school settings is an important public health problem worldwide. This study investigated the individual and social correlates for being involved in a physical fight amongst a nationally representative sample of school-attending adolescents in Kuwait. Methods: We carried out bivariate and multivariate analyses to determine the strength and direction of associations with adolescent involvement in problematic fighting behavior within a 12-month recall period. Results: Within a total sample of 3637, n = 877 (25.2%) of school-attending adolescents reported being involved in two or more physical fights during the recall period. The multivariate analysis indicated that being male (OR = 2.71; CI = 1.88–3.90), a victim of bullying (OR = 2.77; CI = 2.14–3.58), truancy (OR = 2.52; CI = 1.91–3.32), planning a suicide (OR = 2.04; CI = 1.49–2.78) and food deprivation (OR = 1.91; CI = 1.37–2.65) were associated with an increased risk of involvement in physical fighting. Peer support in the form of having close friends (OR = 0.85; CI = 0.76–0.96) was found to be associated with a reduced involvement in fighting behavior. Conclusion: The results, when taken together, suggest that supportive school environments may represent important settings for violence mitigation and prevention strategies</p

Mechanisms linking gender-based violence to worse HIV treatment and care outcomes among women in the United States

Objective:To test whether substance use mediates the associations between gender-based violence (GBV) and suboptimal adherence to antiretroviral therapy (ART), and GBV and poor engagement in care, among women living with HIV (WLHIV) in the United States (US).Design:We analyzed longitudinal data collected among 1717 WLHIV in the Women's Interagency HIV Study (WIHS).Methods:From 2013 to 2017, WLHIV completed semi-annual assessments on GBV, substance use, and HIV treatment and care. Adjusted multilevel logistic regression models were built to estimate the impact of GBV on; suboptimal (<95%) adherence and at least one missed HIV care appointment without rescheduling in the past 6 months. Mediation analyses were performed to test whether heavy drinking and illicit drug use mediated the associations between GBV and the two HIV outcomes.Results:The mean age was 47 (standard deviation = 9), 5% reported experiencing GBV, 17% reported suboptimal adherence and 15% reported at least one missed appointment in the past 6 months. Women who experienced GBV had a significantly higher odds of suboptimal adherence [adjusted odds ratio (aOR) = 1.99; 95% confidence interval (CI) = 1.40-2.83] and missed appointments (aOR = 1.92, 95% CI = 1.32-2.33). Heavy drinking and illicit drug use mediated 36 and 73% of the association between GBV and suboptimal adherence and 29 and 65% of the association between GBV and missed appointments, respectively.Conclusions:Substance use is an underlying mechanism through which GBV affects outcomes along the HIV care continuum among WLHIV in the US. To optimize HIV treatment and care among women, interventions should address the combined epidemics of substance use, violence, and HIV

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

Comparing neighborhood and state contexts for women living with and without HIV: Understanding the southern HIV epidemic

In the South, people living with HIV experience worse health outcomes than in other geographic regions, likely due to regional political, structural, and socioeconomic factors. We describe the neighborhoods of women (n = 1,800) living with and without HIV in the Women’s Interagency HIV Study (WIHS), a cohort with Southern sites in Chapel Hill, NC; Atlanta, GA; Birmingham, AL; Jackson, MS; and Miami, FL; and non-Southern sites in Brooklyn, NY; Bronx, NY; Washington, DC; San Francisco, CA; and Chicago, IL. In 2014, participants’ addresses were geocoded and matched to several administrative data sources. There were a number of differences between the neighborhood contexts of Southern and non-Southern WIHS participants. Southern states had the lowest income eligibility thresholds for family Medicaid, and consequently higher proportions of uninsured individuals. Modeled proportions of income devoted to transportation were much higher in Southern neighborhoods (Location Affordability Index of 28–39% compared to 16–23% in non-Southern sites), and fewer participants lived in counties where hospitals reported providing HIV care (55% of GA, 63% of NC, and 76% of AL participants lived in a county with a hospital that provided HIV care, compared to >90% at all other sites). Finally, the states with the highest adult incarceration rates were all in the South (per 100,000 residents: AL 820, MS 788, GA 686, FL 644). Many Southern states opted not to expand Medicaid, invest little in transportation infrastructure, and have staggering rates of incarceration. Resolution of racial and geographic disparities in HIV health outcomes will require addressing these structural barriers

Effects of Health Insurance Interruption on Loss of Hypertension Control in Women with and Women Without HIV

Background: Among low-income women with and without HIV, it is a priority to reduce age-related comorbidities, including hypertension and its sequelae. Because consistent health insurance access has been identified as an important factor in controlling many chronic diseases, we estimated the effects of coverage interruption on loss of hypertension control in a cohort of women in the United States. Methods: We analyzed prospective, longitudinal data from the Women's Interagency HIV Study. HIV-infected and HIV-uninfected women were included between 2005 and 2014 when they reported health insurance at consecutive biannual visits and had controlled hypertension, and were followed for any insurance break and loss of hypertension control. We estimated hazard ratios (HRs) by Cox proportional hazards regression with inverse-probability-of-treatment-and censoring weights (marginal structural models), and plotted the cumulative incidence of hypertension control loss. Results: Among 890 HIV-infected women, the weighted HR for hypertension control loss comparing health insurance interruption to uninterrupted coverage was 1.37 (95% confidence interval [CI], 0.99-1.91). Inclusion of AIDS Drug Assistance Program (ADAP) participation with health insurance modestly increased the HR (1.47; 95% CI, 1.04-2.07). Analysis of 272 HIV-uninfected women yielded a similar HR (1.39; 95% CI, 0.88-2.21). Additionally, there were indications of uninterrupted coverage having a protective effect on hypertension when compared with the natural course in HIV-infected (HR, 0.82; 95% CI, 0.61-1.11) and HIV-uninfected (HR, 0.78; 95% CI, 0.52-1.19) women. Conclusions: This study provides evidence that health insurance continuity promotes hypertension control in key populations. Interventions that ensure coverage stability and ADAP access should be a policy priority

Longitudinal Associations Between Neighborhood Factors and HIV Care Outcomes in the WIHS

Identifying structural determinants affecting HIV outcomes is important for informing interventions across heterogeneous geographies. Longitudinal hierarchical generalized mixed-effects models were used to quantify the associations between changes in certain structural-level factors on HIV care engagement, medication adherence, and viral suppression. Among women living with HIV in the WIHS, ten-unit increases in census-tract level proportions of unemployment, poverty, and lack of car ownership were inversely associated with viral suppression and medication adherence, while educational attainment and owner-occupied housing were positively associated with both outcomes. Notably, increased residential stability (aOR 5.68, 95% CI 2.93, 9.04) was positively associated with HIV care engagement, as were unemployment (aOR: 1.59, 95% CI 1.57, 1.60), lack of car ownership (aOR 1.14, 95% CI 1.13, 1.15), and female-headed households (aOR 1.23, 95% CI 1.22, 1.23). This underscores the importance of understanding neighborhood context, including factors that may not always be considered influential, in achieving optimal HIV-related outcomes

Mental Health Mediates the Association Between Gender-Based Violence and HIV Treatment Engagement in US Women

Background: Gender-based violence (GBV) is associated with poorer engagement in HIV care and treatment. However, there is a dearth of research on the psychological (eg, mental health) and structural (eg, food insecurity) factors that mediate and moderate this association. GBV could lead to poor mental health, which in turn affects adherence, whereas food insecurity could worsen the effect of GBV on engagement in care. This study uses data from the Women's Interagency HIV Study to address these gaps. Methods: Women completed 6 assessments from 2013 to 2016 on GBV, mental health, food insecurity, adherence to antiretroviral therapy, and missed HIV care appointments in the past 6 months. Multilevel logistic regression models estimated associations between GBV and engagement in care and whether associations were mediated by depression, generalized anxiety disorder (GAD), and posttraumatic stress disorder (PTSD) and moderated by food insecurity. Results: GBV was associated with higher odds of suboptimal adherence (adjusted odds ratio: 1.88; 95% confidence interval: 1.24 to 2.87) and missed appointments (adjusted odds ratio: 1.76; 95% confidence interval: 1.16 to 2.67). The association between GBV and adherence was mediated by depressive symptoms, GAD, and PTSD, accounting for 29.7%, 15.0%, and 16.5%, respectively, of the total association. The association between GBV and missed appointments was mediated by depression and GAD, but not PTSD, with corresponding figures of 25.2% and 19.7%. Associations did not differ by food insecurity. Conclusions: GBV is associated with suboptimal engagement in care, which may be explained by mental health. Interventions should address women's mental health needs, regardless of food insecurity, when improving engagement in HIV care

Longitudinal Relationship Between Food Insecurity, Engagement in Care, and ART Adherence Among US Women Living with HIV

Food insecurity disproportionately affects people with HIV and women in the United States (US). More evidence is needed to understand the interplay between levels of food insecurity and levels of antiretroviral therapy (ART) adherence over time, as well as how food insecurity relates to engagement in HIV care. We used random effects models with longitudinal data from the US Women’s Interagency HIV Study to estimate the (1) adjusted associations of current and 6-month lagged food security with ART adherence categories (n = 1646), and (2) adjusted associations of food security with engagement-in-care (n = 1733). Very low food security was associated with a higher relative risk of ART non-adherence at prior and current visits compared with food security, and this association increased across non-adherence categories. Very low food security was associated with lower odds of receiving HIV care and higher odds of a missed visit. Food insecurity among US women with HIV is associated with poorer engagement in care and degree of ART non-adherence over time

The Impact of Cumulative Depression Along the HIV Care Continuum in Women Living with HIV during the Era of Universal Antiretroviral Treatment

Background: Data are limited on cumulative impacts of depression on engagement in care and HIV outcomes in women living with HIV (WLWH) during the era of universal antiretroviral therapy (ART). Understanding the relationship of accumulated depression with HIV disease management may help identify benefits of interventions to reduce severity and duration of depressive episodes. Setting: A cohort of WLWH (N = 1491) from the Women's Interagency HIV Study at 9 sites across the US.Methods:This longitudinal observational cohort study (2013-2017) followed WLWH for a maximum of 9 semiannual visits. Depression was quantified as a time-updated measure of percent of days depressed (PDD) created from repeated assessments using the Center for Epidemiologic Studies Depression scale. Marginal structural Poisson regression models were used to estimate the effects of PDD on the risks of missing an HIV care appointment, <95% ART adherence, and virological failure (≥200 copies/mL). Results: The risk of missing an HIV care appointment [risk ratio (RR) = 1.16, 95% confidence interval = 0.93 to 1.45; risk difference (RD) = 0.01, -0.01 to 0.03], being <95% ART adherent (RR = 1.27, 1.06-1.52; RD = 0.04, -0.01 to 0.07), and virological failure (RR = 1.09, 1.01-1.18; RD = 0.01, -0.01 to 0.03) increased monotonically with increasing PDD (comparing those with 25 to those with 0 PDD). The total effect of PDD on virological failure was fully (%100) mediated by being <95% ART adherent. Conclusions: Time spent depressed increases the risk of virological failure through ART adherence, even in the era of universal ART regimes forgiving of imperfect adherence

Intensity of Social Support Matters: A Latent Class Analysis to Identify Levels of Social Support Associated with Optimal Health Outcomes Among Women Living with HIV

Social support is associated with improved HIV care and quality of life. We utilized latent class analysis to identify three classes of baseline emotional and tangible perceived social support, termed “Strong”, “Wavering” and “Weak”. “Weak” vs. “Strong” perceived social support was associated over time with an 8% decreased risk of optimal antiretroviral therapy (ART) adherence for emotional and 6% decreased risk for tangible perceived social support. Importantly, “Wavering” vs “Strong” social support also showed a decreased risk of ART adherence of 6% for emotional and 3% for tangible support. “Strong” vs. “Weak” perceived support had a similar association with undetectable viral load, but the association for “Strong” vs. “Wavering” support was not statistically significant. Intensity of social support is associated with HIV care outcomes, and strong social support may be needed for some individuals. It is important to quantify the level or intensity of social support that is needed to optimize HIV outcomes