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Internal Working Models of Attachment Relationships and HIV Outcomes Among Women Living With HIV

Turan, Bulent, PhD*; Crockett, Kaylee B., PhD*; Kempf, Mirjam-Colette, PhD, MPH; Konkle-Parker, Deborah, PhD, FNP, FAAN; Wilson, Tracey E., PhD§; Tien, Phyllis C., MD║,¶; Wingood, Gina, ScD, MPH#; Neilands, Torsten B., PhD**; Johnson, Mallory O., PhD**; Weiser, Sheri D., MD, MPH††; Turan, Janet M., PhD‡‡

JAIDS Journal of Acquired Immune Deficiency Syndromes: January 1, 2019 - Volume 80 - Issue 1 - p e1–e8
doi: 10.1097/QAI.0000000000001872
Prevention Research

Background: Treatment adherence and viral suppression remain suboptimal in the United States. Attachment insecurity may be one understudied factor affecting adherence. According to attachment theory, people develop generalized internal working models of interpersonal relationships, which shape their perceptions of the availability of others at times of stress and how they handle stressors as an individual. Two dimensions of attachment insecurity are attachment-related avoidance (avoidance of intimacy with others and avoidance of negative emotions) and attachment-related anxiety (feeling unable to deal with stressors without others' help). For people living with chronic stressful health conditions that require life-long self-management, attachment-related avoidance and attachment-related anxiety may diminish the ability to cope with stressors as an individual leading to negative health outcomes.

Methods: We examined cross-sectional associations of the 2 attachment-related insecurity dimensions with antiretroviral treatment (ART) adherence, HIV visit adherence, CD4 cell counts, and viral suppression. Survey and clinical data from 453 women living with HIV in 4 US cities were analyzed controlling for age, education, income, time on ART, illicit drug use, and race.

Results: Attachment-related avoidance was the only unique predictor of suboptimal ART adherence, viral failure, and low CD4 count, and attachment-related anxiety was the only unique predictor of missed HIV care visits. These effects were over and above the effects of all covariates. ART adherence mediated the association of attachment-related avoidance with both viral failure and low CD4 counts.

Conclusions: Interventions may need to focus on the vulnerable subpopulation with high attachment insecurity and incorporate existing strategies that address insecure attachment models.

Departments of *Psychology;

Family, Community and & Health Systems, Health Behavior, Epidemiology and Medicine, University of Alabama at Birmingham, Birmingham, AL;

Department of Medicine/Infectious Diseases, University of Mississippi Medical Center, Jackson, MS;

§Department of Community Health Sciences, State University of New York Downstate Medical Center, School of Public Health, Brooklyn, NY;

Department of Medicine, University of California, San Francisco and Medical Service, San Francisco, CA;

Department of Veteran Affairs Medical Center, San Francisco, CA;

#Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, New York, NY;

**Department of Medicine, University of California, San Francisco, San Francisco, CA;

††Division of HIV, ID and Global Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA; and

‡‡Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham, Birmingham, AL

Correspondence to: Bulent Turan, PhD, Department of Psychology, University of Alabama at Birmingham, 415 Campbell Hall, Birmingham, AL 35294-1170 (e-mail:

Supported by Women's Interagency HIV Study (WIHS) substudy grants from the National Institute of Mental Health, R01MH104114 and R01MH095683. The contents of this publication are solely the responsibility of the authors and do not represent the official views of the National Institutes of Health (NIH). WIHS (Principal Investigators): UAB-MS WIHS (Mirjam-Colette Kempf and Deborah Konkle-Parker), U01-AI-103401; Atlanta WIHS (Ighovwerha Ofotokun and Gina Wingood), U01-AI-103408; Bronx WIHS (Kathryn Anastos and Anjali Sharma), U01-AI-035004; Brooklyn WIHS (Howard Minkoff and Deborah Gustafson), U01-AI-031834; Chicago WIHS (Mardge Cohen and Audrey French), U01-AI-034993; Metropolitan Washington WIHS (Seble Kassaye), U01-AI-034994; Miami WIHS (Margaret Fischl and Lisa Metsch), U01-AI-103397; UNC WIHS (Adaora Adimora), U01-AI-103390; Connie Wofsy Women's HIV Study, Northern California (Ruth Greenblatt, Bradley Aouizerat, and Phyllis Tien), U01-AI-034989; WIHS Data Management and Analysis Center (Stephen Gange and Elizabeth Golub), U01-AI-042590; Southern California WIHS (Joel Milam), U01-HD-032632 (WIHS I–WIHS IV). The WIHS is funded primarily by the National Institute of Allergy and Infectious Diseases (NIAID), with additional cofunding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), the National Cancer Institute (NCI), the National Institute on Drug Abuse (NIDA), and the National Institute on Mental Health (NIMH). Targeted supplemental funding for specific projects is also provided by the National Institute of Dental and Craniofacial Research (NIDCR), the National Institute on Alcohol Abuse and Alcoholism (NIAAA), the National Institute on Deafness and other Communication Disorders (NIDCD), and the NIH Office of Research on Women's Health. WIHS data collection is also supported by UL1-TR000004 (UCSF CTSA), UL1-TR000454 (Atlanta CTSA), and P30-AI-050410 (UNC CFAR). This research was also supported by the University of Alabama at Birmingham (UAB) Center for AIDS Research CFAR, an NIH funded program (P30 AI027767) that was made possible by the following institutes: NIAID, NCI, NICHD, NHLBI, NIDA, NIA, NIDDK, NIGMS, and OAR. Trainee support was provided by the Agency for Healthcare Research and Quality (grant number T32HS013852).

The authors have no funding or conflicts of interest to disclose.

Received June 05, 2018

Accepted September 12, 2018

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