Investigating HIV care in the United States: race, gender and policy
Creators: name: Mahone, Anais
Publisher: name: No Publisher Supplied
Year: 2024

description: Background: Black Americans are disproportionately affected by HIV. Despite the availability of biomedical interventions that either prevent or manage HIV, disparities remain. Limited research has investigated antiretroviral (ART) adherence outcomes among Black Americans. Further, minimal research understands the role of social determinants of health (SDoH) and public policy in ART adherence and other HIV care outcomes. This three-paper dissertation contributed to HIV empirical literature by examining how race, gender and policy influenced HIV outcomes among U.S. populations. Methods: This dissertation included two empirical quantitative papers investigating the outcome variable, ART adherence, for people living with HIV (PWH). The last paper in this dissertation is a systematic review that investigated the inclusion of cisgender Black women in policy-driven HIV studies. For the quantitative papers, local Medical Monitoring Project surveillance data were examined. Paper 1 included a sample size of 716 adults with HIV living in a Midwestern state with Medicaid expansion. Data were collected between 2018-2021. Logistic regression models were used to estimate racial differences in ART adherence. Additional models estimated the effects of discrimination in healthcare settings and HIV-related stigma on the outcome of interest. Next, paper 2 used difference-in-differences models to estimate the effects of a social determinants of health (SDoH) - driven policy on ART adherence among PWH living in a southern state (n=1,207). Last, the systematic review examined literature considering cisgender Black women’s HIV outcomes in policy research. This paper followed the PRISMA review guidelines and is registered in the PROSPERO database.Results: In paper 1, results indicated that discrimination in health care settings decreased the ART adherence for PWH, although this was not true for HIV-related stigma. The effects of stigma were explained away when other covariates. Consistently in all models, Black PWH were significantly associated with lower odds of ART adherence compared to PWH in other racial/ethnic groups (p&lt;.05). Results in paper 2 found that PWH in the U.S. South had a 11% higher likelihood (p&lt;.05) of ART adherence in the post-policy years (2019-21), compared to years 2015-18. Analyses stratified by insurance status suggested that factors other than Medicaid policy may be driving this improvement. Further, food insecurity (p&lt;.05) and housing need (p&lt;.05) significantly lowered the likelihood of optimal ART adherence. Last, the systematic review found that few studies in the literature contextualized cisgender Black women’s needs within major U.S. health policies. Among the findings, emergent themes included biomedical intervention uptake and adherence, health insurance, poverty and programmatic barriers to care.Conclusion: This dissertation documents the impact of discrimination and policy on PWH, particularly for Black PWH. Despite innovative progress in HIV interventions, discrimination is a critical factor in ending the epidemic. Relatedly, although SDoH policies may improve barriers, results indicate that stakeholders should consider the specific needs of Black PWH to ensure meaningful outcomes for the population. The systematic review highlights the needs for further research, among large populations of cisgender Black women, notably in HIV prevention, to understand how federal and policy decision encourage, create, or exacerbate barriers to HIV care.