HIV-infected African American Women Research Articles

A Qualitative Description of HIV-Infected African American Women's Experiences of Psychological Distress and Their Coping Strategies

HIV-infected individuals are at risk for psychological distress, including depression, sadness, and suicidality. The purpose of this qualitative descriptive study was to examine 22 HIV-infected African American women's experiences of psychological distress and use of coping strategies. Data were collected through in-person one-on-one interviews until conceptual saturation was reached. Data were analyzed using inductive content analysis. Four themes were found: (a) psychoemotional suffering, (b) contextual factors negatively influence the everydayness of living with HIV infection, (c) HIV-related stigma perpetuates isolation and loneliness, and (d) creating a safe haven. Implications for nurses and other health care providers include (a) holistic assessment to include evaluation of emotional and mental state, and (b) coping strategies. Integration of spiritual practices into plan of care is also important. Development and evaluation of individualized coping interventions that address stigma and psychological distress through holistic modalities is warranted.

“God loves me no matter how I am”: a phenomenological analysis of the religious and spiritual experiences of HIV-infected African-American women with depression

ABSTRACTDepression is associated with increased HIV morbidity and mortality, particularly among African-American women (AAW) in the United States. The purpose of this qualitative study was to explore religious practices, spiritual beliefs, and experiences among AAW with co-occurring HIV infection and depression. A transcendental phenomenological study design was used to explore the experiences of AAW's religion and spirituality after an HIV diagnosis and living with depression. The four themes that were identified included: Religious Conflict and Return to Religious Practices; Religious Fortitude Broken and Feeling Judged; Spiritual Connection is More Powerful than Attending Church Services; and Spiritual Healing and Re-Connecting with Spirituality. These findings suggest that the distinction between internal and external manifestations of spirituality is important and that given the current religious climate, interventions that focus on supporting internal spiritual practice may be a more important and effective approach for AAW with co-occurring HIV infection and depression.

Frailty in Postmenopausal African American and Hispanic HIV-Infected Women.

Studies suggest frailty occurs earlier in HIV-infected individuals, but data in postmenopausal HIV-infected women are lacking. We assessed the prevalence of frailty and association with anthropometric measures in HIV-infected and uninfected postmenopausal women. Fried's frailty phenotype was measured in HIV-infected and uninfected Hispanic and African American postmenopausal women participating in a study of bone metabolism; fat and lean mass were measured by whole body dual energy x-ray absorptiometry (DXA). Multivariable logistic regression evaluated frailty risk factors. The study was conducted at Columbia University Medical Center between 2002 and 2007. The participants were 61 HIV-infected and 27 uninfected Hispanic and African American postmenopausal women. The study compared prevalence and predictors of frailty in HIV-infected and uninfected postmenopausal women. Prevalence of frailty tended to be higher among HIV-infected than uninfected controls (11.5% vs 0% p=0.07). Surprisingly, among HIV-infected women, total body fat, not lean mass, was associated with frailty in multivariate analysis. Higher prevalence of frailty in African American and Hispanic HIV-infected postmenopausal women (11.5%) was similar to the 11% prevalence reported in minority women who were 10 years older in the general population. Our data suggest that frailty occurs earlier in HIV-infected postmenopausal women, but larger longitudinal studies are necessary to confirm whether musculoskeletal aging is accelerated by HIV infection.

The Process of Writing a Constructivist Dissertation

The study depicts the procedure of writing a constructivist dissertation by reporting side by side the story of HIV-infected African American women’s reproductive health decision-making. The context of these women served as the framework from which the dissertation was written. The article describes how these women and their stakeholders experience HIV/AIDS and how they make their reproductive health decisions. These women’s perceptions and psychosocial factors are examined to understand what they view as important to them as women and as mothers. The article addresses how to teach doctoral students to complete doctoral research using the constructivist paradigm for research. Implications for social work education and practice are discussed.

“Out of All of this Mess, I Got a Blessing”: Perceptions and Experiences of Reproduction and Motherhood in African American Women Living With HIV

HIV disproportionately impacts African American women of childbearing age residing in the southern United States. Antiretroviral therapy has increased the quantity and quality of life for people living with HIV and produced viable and safe reproduction possibilities for women living with HIV. However, little is known about reproductive decision-making processes for African American women living with HIV. The overall goal of our study was to qualitatively explore perspectives related to reproduction and motherhood in HIV-infected African American women of childbearing capacity. HIV-infected African American women of childbearing capacity in South Carolina (N=42) participated in in-depth interviews. Our respondents held positive views about pregnancy and motherhood, despite nonsupportive pregnancy messages from interpersonal influences, including health care providers. Study findings uncovered the need for programs and interventions to support women's reproductive autonomy and focus on reducing conception- and pregnancy-related transmission risks to infants and uninfected sexual partners.

Psychosocial Characteristics Associated with Both Antiretroviral Therapy Adherence and Risk Behaviors in Women Living with HIV.

The purpose of this study was to identify key psychosocial characteristics of HIV-infected women who exhibit different levels of both ART adherence and risk behaviors. We analyzed baseline data from 193 predominately African American HIV-infected women participating in a behavioral clinical trial. Women were categorized into high/low groups based on levels of adherence and risky behaviors. There was a significant interaction effect for internal motivation for adherence. Women at high risk for poor health and transmitting HIV (low adherence/high risk group) had the lowest levels of internal motivation and also reported more difficult life circumstances. Gender roles, caretaking and reliance on men for economic and other support may promote external versus internal motivation as well as riskier behaviors in this group. The highest levels of internal motivation were found in those with High Adherence/High Risk behaviors. This group was highly knowledgeable about HIV and had the lowest VL. Compared to others, this group seems to tolerate risky behaviors given their high level of adherence. Adherence and risk reduction behaviors are key to individual and public health. Motivation and risk compensation should be addressed when providing interventions to women living with HIV.

An Intersectional Perspective on Stigma as a Barrier to Effective HIV Self-management and Treatment for HIV-infected African American Women

Among those who are HIV-infected and striving to live well with HIV, African American women have poorer health outcomes and represent a higher portion of those women who die from HIV-related causes. These health inequalities have been associated with the presence of social determinants of health such as stigma. This analytical review asserts that stigmas precipitated by gender, race, and class in the context of HIV-related stigma constitute substantial barriers to active engagement in HIV self-management, care, and treatment for HIV-infected African American women. The utility of the intersectionality framework for analyzing how these various stigmas interact to create unique determents to effective treatment and active self-management of HIV among African American women and for serving as a foundation for intervention development is presented.

APOL1 Genotype and Glomerular and Tubular Kidney Injury in Women With HIV

APOL1 genotype is associated with advanced kidney disease in African Americans, but the pathogenic mechanisms are unclear. Here, associations of APOL1 genotype with urine biomarkers of glomerular and tubular injury and kidney function decline were evaluated. Observational study. 431 human immunodeficiency virus (HIV)-infected African American women enrolled in Women's Interagency HIV Study (WIHS). APOL1 genotype. Albumin-creatinine ratio (ACR), 4 tubular injury biomarkers (interleukin 18 [IL-18], kidney injury molecule 1 [KIM-1], neutrophil gelatinase-associated lipocalin [NGAL], and α1-microglobulin [A1M]), and kidney function estimated using the CKD-EPI cystatin C equation. Participants were genotyped for APOL1 single-nucleotide polymorphisms rs73885319 (G1 allele) and rs71785313 (G2 allele). Urine biomarkers were measured using stored samples from 1999-2000. Cystatin C was measured using serum collected at baseline and 4- and 8-year follow-ups. At baseline, ACRs were higher among 47 women with 2 APOL1 risk alleles versus 384 women with 0/1 risk allele (median, 24 vs 11mg/g; P<0.001). Compared with women with 0/1 risk allele, women with 2 risk alleles had 104% higher ACRs (95% CI, 29-223mg/g) and 2-fold greater risk of ACR>30 (95% CI, 1.17-3.44) mg/g after multivariable adjustment. APOL1 genotype showed little association with urine IL-18:Cr ratio, KIM-1:Cr ratio, and NGAL:Cr ratio (estimates of-5% [95% CI,-24% to 18%],-20% [95% CI,-36% to -1%], and 10% [95% CI,-26% to 64%], respectively) or detectable urine A1M (prevalence ratio, 1.13; 95% CI, 0.65-1.97) in adjusted analyses. Compared with women with 0/1 allele, women with 2 risk alleles had faster eGFR decline, by 1.2 (95% CI,0.2 to2.2) mL/min/1.73m(2) per year, and 1.7- and 3.4-fold greater rates of incident chronic kidney disease (95% CI, 1.1 to 2.5) and 10% annual eGFR decline (95% CI, 1.7 to 6.7), respectively, with minimal attenuation after adjustment for glomerular and tubular injury biomarker levels. Results may not be generalizable to men. Among HIV-infected African American women, APOL1-associated kidney injury appears to localize to the glomerulus, rather than the tubules.

Structural and sociocultural factors associated with cervical cancer screening among HIV-infected African American women in Alabama.

African American women have disproportionately high prevalence rates of HIV and cervical cancer. HIV-infected women are significantly less likely to obtain recommended cervical cancer screenings than HIV-uninfected women. The purpose of this study was to examine sociocultural and structural factors associated with cervical cancer screening among HIV-infected African American in Alabama. The PEN-3 Model and the Health Belief Model were used as theoretical frameworks. In-depth interviews were conducted with twenty HIV-infected African American women to identify perceptions, enablers, and nurturers, perceived susceptibility, perceived severity, and perceived benefits related to cervical cancer and screening. The most common positive perceptions, enablers, and nurturers that contributed to cervical cancer screening included internal motivation and awareness of the importance of HIV-infected women getting Pap tests due to their weakened immune system. Negative perceptions, enablers, and nurturers included lack of knowledge about cervical cancer and screening, and lack of perceived susceptibility to cervical cancer. The results of this study can be used to guide the development of culturally relevant cervical cancer and screening education interventions aimed at increasing cervical cancer screening adherence among HIV-infected African American women.

Infected Lives

This hermeneutic phenomenological study explored the lived experiences of young African American HIV-infected women. Eleven women between the ages of 21 and 35 participated. One pattern, Infected Lives, and three themes--Living Alone With HIV, Living With Unresolved Conflicts, and Living With Multiple Layers of Betrayal--emerged. The pattern and themes portray the very complex and challenging experiences faced by these young women living with HIV infection. They have experienced isolation, abandonment, betrayal, and discrimination in their interpersonal and social systems. They often dealt with conflicts of hope and anguish in the relationships with their children, and portraying strength, while feeling fragile. These complexities negatively influence the ability to fully engage in self-care activities. Implications for future research include further investigation about the experiences of psychological distress experienced post-diagnosis, development and evaluation of holistic nursing interventions, and evaluative research on mass media educational campaigns to reduce HIV-related stigma.

Novel Interventions for HIV Self-management in African American Women: A Systematic Review of mHealth Interventions

The purpose of this systematic review was to assess the quality of interventions using mobile health (mHealth) technology being developed for and trialed with HIV-infected African American (AA) women. We aimed to assess rigor and to ascertain if these interventions have been expanded to include the broad domain of self-management. After an extensive search using the PRISMA approach and reviewing 450 records (411 published studies and 39 ongoing trials at clinicaltrials.gov), we found little completed research that tested mHealth HIV self-management interventions for AA women. At clinicaltrials.gov, we found several mHealth HIV intervention studies designed for women in general, forecasting a promising future. However, most studies were exploratory in nature and focused on a single narrow outcome, such as medication adherence. Given that cultural adaptation is the key to successfully implementing any effective self-management intervention, culturally relevant, gender-specific mHealth interventions focusing on HIV-infected AA women are warranted for the future.

Taking it one day at a time: African American women aging with HIV and co-morbidities.

Self-managing HIV/AIDS presents challenges for anyone infected. These challenges may be further complicated for older HIV-infected African American women who acquired the disease at younger ages and now have co-morbidities. Little is known regarding how women's age identity, social responsibilities, co-morbidities, and romantic relationship status influence their HIV self-management. Five focus groups were conducted in Washington DC, with HIV-positive African American women aged 52-65. Topics included HIV and co-morbidity self-management, social support needs, medication adherence, and future plans for old age. A constant comparison approach was applied during data analysis. Co-morbidities, including diabetes and hypertension, were perceived to be more difficult to self-manage than HIV. This difficulty was not attributed to aging but to daily struggles such as lack of income and/or health insurance, an inflexible work schedule, and loneliness. Social responsibilities, including caring for family, positively impacted participants' ability to self-manage HIV by serving as motivation to stay healthy in order to continue to help family members. In contrast, inflexible work schedules negatively impacted women's ability to sustain medication adherence. Overall, this study demonstrates that HIV and co-morbidity self-management are inextricably linked. We can no longer afford to view engagement in HIV care as a single-disease issue and hope to attain optimal health and well-being in our HIV-affected populations. Optimal HIV self-management must be framed within a larger context that simultaneously addresses HIV and co-morbidities, while considering how social and cultural factors uniquely intersect to influence older African American women's self-management strategies.

Genetic Predictors of Cervical Dysplasia in African American HIV-Infected Women: ACTG DACS 268

Objective: To examine genome-wide associations in HIV-infected women with a history of cervical dysplasia compared with HIV-infected women with no history of abnormal Papanicolaou (Pap) tests. Design: Case-control study using data from women analyzed for the HIV Controllers Study and enrolled in HIV treatment-naïve studies in the AIDS Clinical Trials Group (ACTG). Methods: Genotyping utilized Illumina HumanHap 650 Y or 1MDuo platforms. After quality control and principal component analysis, ~610,000 significant single nucleotide polymorphisms (SNPs) were tested for association. Threshold for significance was P < 5 × 10–8 for genome-wide associations. Results: No significant genomic association was observed between women with low-grade dysplasia and controls. The genome-wide association study (GWAS) analysis between women with high-grade dysplasia or invasive cervical cancer and normal controls identified significant SNPs. In the analyses limited to African American women, 11 SNPs were significantly associated with the development of high-grade dysplasia or cancer after correcting for multiple comparisons. The model using significant SNPs alone had improved accuracy in predicting high-grade dysplasia in African American women compared to the use of clinical data (area under the receiver operating characteristic curve for genetic and clinical model = 0.9 and 0.747, respectively). Conclusions: These preliminary data serve as proof of concept that there may be a genetic predisposition to developing high-grade cervical dysplasia in African American HIV-infected women. Given the small sample size, the results need to be validated in a separate cohort.

Critical Consciousness, Racial and Gender Discrimination, and HIV Disease Markers in African American Women with HIV

Critical consciousness, the awareness of social oppression, is important to investigate as a buffer against HIV disease progression in HIV-infected African American women in the context of experiences with discrimination. Critical consciousness comprises several dimensions, including social group identification, discontent with distribution of social power, rejection of social system legitimacy, and a collective action orientation. The current study investigated self-reported critical consciousness as a moderator of perceived gender and racial discrimination on HIV viral load and CD4+ cell count in 67 African American HIV-infected women. Higher critical consciousness was found to be related to higher likelihood of having CD4+ counts over 350 and lower likelihood of detectable viral load when perceived racial discrimination was high, as revealed by multiple logistic regressions that controlled for highly active antiretroviral therapy (HAART) adherence. Multiple linear regressions showed that at higher levels of perceived gender and racial discrimination, women endorsing high critical consciousness had a larger positive difference between nadir CD4+ (lowest pre-HAART) and current CD4+ count than women endorsing low critical consciousness. These findings suggest that raising awareness of social oppression to promote joining with others to enact social change may be an important intervention strategy to improve HIV outcomes in African American HIV-infected women who report experiencing high levels of gender and racial discrimination.

The Concept of “Silencing the Self” in Low-Income, Aging, HIV-Infected African American Women: A 10-Year Community-Based Participatory Program of Research With Results

Despite a resilient spirit, the challenges that face low-income, aging Black women living with HIV infection are immense. This article describes a 10-year iterative history of using the Theory of Silencing the Self (TSTS) as an explanatory model that was found to be gender sensitive, culturally relevant, and helpful in guiding a community-based participatory research group of low-income, HIV-infected Black women living in Boston, Massachusetts. The group, called Sistah Powah, used the TSTS to design and implement a structured writing intervention in a women's drop-in center targeting low-income, aging Black women living with HIV infection as a way to give them and others a voice.

Tenofovir plasma concentrations in post-menopausal versus pre-menopausal HIV-infected women

Sir, Menopause is associated with age-related physiological changes—such as a decline in renal and hepatic function, altered genital secretions and/or impaired production of sexual hormones—that can potentially affect the disposition of several drugs. The role of menopause on the pharmacokinetics of antiretrovirals, however, has not been investigated so far. Given the potential impact of tenofovir on long-term kidney and bone complications, which are known co-morbidities affecting post-menopausal women, we decided to perform a retrospective analysis of data from post-menopausal and premenopausal HIV-infected women receiving 300 mg of tenofovir/day as part of their maintenance antiretroviral therapy regimen for at least 3 months who underwent therapeutic drug monitoring of tenofovir plasma trough concentrations as routine outpatient follow-up. Menopause was established by menstrual and medical history (12 months of lack of menstrual cycle for women aged 50 years or more, with hormonal confirmation for women younger than 50 years). Creatinine clearance was calculated by using the formula of Cockcroft–Gault as follows: glomerular filtration rate1⁄4 (1402age)×body weight/ serum creatinine×72. As the patients were female, the formula was multiplied by a constant of 0.85. As per our clinical practice, tenofovir plasma trough concentrations were collected immediately before the following morning’s tenofovir dose (a time window of +5 min was considered as acceptable). For patients given tenofovir once daily in the evening, plasma trough (24 h) concentrations were estimated from the concentrations collected at 12 h after drug intake and taking into account the terminal portion of the pharmacokinetic drug profile. Tenofovir concentrations were assessed by a validated liquid chromatography–tandem mass spectrometry (‘LC-MS/MS’) method. A total of 50 HIV-infected women were identified from our database: 22 were post-menopausal women, while the remaining 28 were pre-menopausal women. A wide distribution of plasma tenofovir trough concentrations was observed when considering the data from the overall study population (n1⁄450, tenofovir concentrations ranged from 10 to 452 ng/mL). We first compared tenofovir plasma trough concentrations, together with demographic and haemato-chemical characteristics, in the post-menopausal women (n1⁄422) versus the pre-menopausal women (n1⁄428). As shown in Table 1, no major differences were observed between the two groups of patients in terms of concomitant antiretroviral therapy, kidney and liver function, as well as for other demographic characteristics with the (expected) exceptions of age and time on tenofovir therapy. It is worth mentioning that tenofovir plasma concentrations measured in post-menopausal women exactly matched those assessed in pre-menopausal women (119+64 versus 121+98 ng/mL, P1⁄40.924). In order to further investigate the potential effect of menopause on tenofovir exposure, we also performed multiple regression analysis in the overall population (n1⁄450) using tenofovir plasma trough concentrations as the dependent variable and menopause, serum transaminase, serum creatinine, age, body weight, concomitant antiretroviral therapy and days on tenofovir therapy as independent covariates. Using this approach we found that the only factors independently associated with tenofovir plasma concentrations were serum creatinine (r1⁄40.411, P1⁄40.043) and body weight (r1⁄420.432, P1⁄40.021), whereas no effect of menopause was documented (r1⁄420.049, P1⁄40.852). This trend was also confirmed when using creatinine clearance (r1⁄420.384, P1⁄40.022) and body mass index (r1⁄420.305, P1⁄40.037) instead of serum creatinine and body weight, respectively. Taken together, our results argue against a significant effect of menopause on tenofovir exposure. These findings are at odds with those presented by Patterson et al., who reported significantly higher (up to 160%) tenofovir plasma and genital tract concentrations in 6 post-menopausal versus 12 pre-menopausal African American HIV-infected women. The discrepant results of Research letters

Genetic Predictors of Cervical Dysplasia in African American HIV-Infected Women: ACTG DACS 268

Objective: To examine genome-wide associations in HIV-infected women with a history of cervical dysplasia compared with HIV-infected women with no history of abnormal Papanicolaou (Pap) tests. Design: Case-control study using data from women analyzed for the HIV Controllers Study and enrolled in HIV treatment-naïve studies in the AIDS Clinical Trials Group (ACTG). Methods: Genotyping utilized Illumina HumanHap 650 Y or 1MDuo platforms. After quality control and principal component analysis, ~610,000 significant single nucleotide polymorphisms (SNPs) were tested for association. Threshold for significance was P < 5 × 10–8 for genome-wide associations. Results: No significant genomic association was observed between women with low-grade dysplasia and controls. The genome-wide association study (GWAS) analysis between women with high-grade dysplasia or invasive cervical cancer and normal controls identified significant SNPs. In the analyses limited to African American women, 11 SNPs were significantly associated with the development of high-grade dysplasia or cancer after correcting for multiple comparisons. The model using significant SNPs alone had improved accuracy in predicting high-grade dysplasia in African American women compared to the use of clinical data (area under the receiver operating characteristic curve for genetic and clinical model = 0.9 and 0.747, respectively). Conclusions: These preliminary data serve as proof of concept that there may be a genetic predisposition to developing high-grade cervical dysplasia in African American HIV-infected women. Given the small sample size, the results need to be validated in a separate cohort.

Sociostructural Correlates of AIDS Progression for African American Women Living with Diagnoses of HIV Infection in the District of Columbia

Background: Among women living with HIV infection in the District of Columbia (DC), African American women are disproportionately affected, comprising > 90% of reported cases. Sociostructural exploration of local HIV epidemics among African American women has been understudied. We explored sociostructural correlates of health for HIVinfected African American women in DC to inform local HIV prevention and intervention efforts. Methods: HIV surveillance data from the District of Columbia Department of Health for African American women living with HIV were reviewed. We analyzed data for sociostructural correlates for progressing to acquired immune deficiency syndrome (AIDS) (CD4 counts < 200 cells/ml) among African American women. Data were analyzed using SAS 9.2 and mapped by census tracts using ArcGIS. Results: Of 4,619 women living with HIV, 4,204 (91%) were African American; 3,050 (72.5%) had census tract information available and were included. Median age at diagnosis was 36.6 years. Among these 3,050 African American women, 1,814 (59.4%) had ever progressed to AIDS, 1,109 (36.4%) had CD4 counts < 200 cells/μl (AIDS) at most recent clinical visit, and 208 of 1,109 (18.8%) had progressed to AIDS within 12 months of their HIV diagnosis (late testers). Women who progressed to AIDS had a higher probability of being diagnosed at private facilities compared with public facilities (PR=1.1, 95% CI=1.1-1.3) and of being exposed through injection drug use (IDU) compared to being exposed through heterosexual contact (PR=1.3, 95% CI=1.2-1.5). In multivariate and geomapping analyses, poverty, education levels and census tracts were not associated with an AIDS diagnosis. Conclusion: Progression to AIDS is prevalent among HIV-infected African American women in DC. Increased, early routine HIV screening and intensified treatment efforts with African American women living with HIV infection in DC, regardless of socioeconomic status, are warranted, to improve outcomes and decrease disparities.

The Impact of a Health Promotion Educational Program on Cardiovascular Risk Factors for HIV Infected Women on Antiretroviral Therapy

This study investigates the efficacy of a health promotion educational program on improving cardiovascular risk factors of weight, Body Mass Index, and waist to hip ratio in 76 predominately African American HIV-infected women. The health promotion educational program was the control group (that focused on improving self-efficacy for nutrition, exercise, stress reduction and women’s health behaviors) of a NIH-funded study. The majority of participants was overweight, obese, or at high risk based on waist hip ratio at the beginning of the study. There were no statistically significant improvements in body mass index or waist hip ratio from pre intervention to up to 9 months post intervention. There were significant changes in waist hip ratio and body mass index in both directions (improvement and worsened) for a small group of participants. The health promotion program did not affect significant changes in cardiovascular risk and should be revised, lengthened, and refocused on nutrition, diet, exercise, and long term goal commitments to reduce the high risk for cardiovascular disease in this group.

HIV-Disclosure, Social Support, and Depression Among HIV-Infected African American Women Living in the Rural Southeastern United States

This cross-sectional study examined the relationships between social support, HIV disclosure, and depression among 340 rural African American women with HIV disease living in the southeastern United States. Three aspects of social support (perceived availability of support, sources of available support, and satisfaction with available support) were measured along with HIV disclosure and depression. Perceived availability of support (p < .0001), sources of support (p = .03), satisfaction with support (p = .003), and HIV disclosure (total and to children; p = .05 and .04, respectively) were significantly and inversely correlated with depression. Perceived availability of support and satisfaction with support mediated the relationship between HIV disclosure and depression. If confirmed in longitudinal studies, these findings have implications for designing and implementing interventions supporting African American women with HIV disease in disclosing their HIV status appropriately, particularly to their children. In long run, appropriate self-disclosure may help decrease depression and improve quality of life among HIV infected African American women living in limited resource settings.