Recent Stressful Life Events, Lifetime Traumatic Events, Missed Visits, and Antiretroviral Adherence Among Black Women With HIV in the Southeastern United States: A Cross-sectional Study : Journal of the Association of Nurses in AIDS Care

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Research Article

Recent Stressful Life Events, Lifetime Traumatic Events, Missed Visits, and Antiretroviral Adherence Among Black Women With HIV in the Southeastern United States: A Cross-sectional Study

Chapman Lambert, Crystal PhD, CRNP, FAAN*; Wright, Nicole C. PhD; Elopre, Latesha MD, MSPH; Fazeli, Pariya PhD; King, Kiko PhD; Raper, James L. PhD, CRNP, FAAN; Holstad, Marcia M. PhD, FNP-BC, FAAN; Azuero, Andres PhD; Turan, Janet M. PhD, MPH; Mugavero, Michael J. MD, MHSc

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Journal of the Association of Nurses in AIDS Care: November/December 2022 - Volume 33 - Issue 6 - p 593-604
doi: 10.1097/JNC.0000000000000355
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Abstract

Antiretroviral therapy (ART) greatly reduces HIV-related morbidity and mortality, thereby transforming HIV into a manageable chronic disease for people with HIV (PWH) with a life expectancy similar to people without HIV (Antiretroviral Therapy Cohort, 2017; Insight Start Study Group et al., 2015; Samji et al., 2013). Achieving and sustaining HIV viral suppression is the primary goal of HIV treatment and crucial to survival (Panel on Antiretroviral Guidelines for Adults and Adolescents, 2022). To achieve and sustain viral suppression, optimal adherence to ART is required. Despite the effectiveness of ART in suppressing HIV in the plasma and extending life expectancy, adherence to ART is suboptimal in the United States, especially among Black women (Centers for Disease Control and Prevention [CDC], 2019a; Geter et al., 2019).

In the United States, racial disparities are pronounced among women with HIV (WWH), with Black women being disproportionately burdened by the HIV epidemic, accounting for nearly 60% of all new diagnoses among women and 60% of WWH (CDC, 2020). On average, ART adherence is suboptimal for some WWH across racial and ethnic backgrounds, but ART adherence among Black WWH is often worse (Geter et al., 2019; Ike et al., 2015). For example, among a diverse sample of 426 women engaged in a multisite study, Black women were two times less likely to be adherent to ART compared with White women (Geter et al., 2019). In addition, achieving viral suppression was less common among Black women (Geter et al., 2018; Ike et al., 2015). In a 2018 analysis, Geter et al (2018) analyzed data from six sites across the United States (Northeast, Southeast, and Midwestern), and among the 795 women engaged in care, prescribed ART, and having had at least one viral load on record, Black women were nearly 2.5 times more likely than White women not to have achieved viral suppression. Although viral suppression among WWH in the United States improved from 2010 through 2015, Black women continue to struggle with viral suppression when compared with their White counterparts (Geter et al., 2018). The exact reason for the disparities is not clear. However, previous research suggests that factors such as social determinants of health (e.g., homelessness, poverty, and having less than a high school education), suboptimal ART adherence, and not being prescribed ART partially explain the race by sex disparity (Greter et al., 2018).

Adherence to scheduled HIV care visits, a requisite for being prescribed ART, is an important factor to consider in the ability to achieve viral suppression. Missed scheduled HIV care visit is a predictor of virologic failure and mortality (Mugavero, Lin, Allison, et al., 2009). Racial and gender disparities in scheduled missed HIV care visits are evident, with missed visits being more common among Black than White Americans (Howe et al., 2014; Mugavero, Lin, Allison, et al., 2009) and women being more likely to miss scheduled HIV care visits than men (Cohen et al., 2016; Meyer et al., 2014). However, little is known regarding the factors associated with missed visits and ART adherence among Black WWH. Therefore, it is crucial to identify the underlying factors that negatively influence missed scheduled visits, ART adherence, and ultimately viral suppression among Black WWH, with the goal of intervening on these determinants to improve HIV-related health outcomes and equity.

Recent stressful and lifetime traumatic events are significant factors that negatively contribute to HIV-related health outcomes. Recent stressful events include hospitalization, car accidents, and major illness, as well as financial, relationship, employment, safety, and legal issues (Leserman et al., 2008). Lifetime traumatic events are events that happen before the age of 18 years, such as physical or sexual abuse (Leserman et al., 2008). Extant literature suggests that stressful and traumatic events negatively influence ART adherence (Leserman et al., 2008; Mugavero, Raper, et al., 2009; Reif et al., 2011). In a study among 105 PWH, predominately male and Black individuals, stressful life events were common among participants, and having more stressful life events was associated with suboptimal medication adherence (Leserman et al., 2008). Similarly, in a 2011 analysis, participants who reported experiencing three or more recent stressful events were as much as three times as likely to report suboptimal ART adherence, and women in the study were more likely to report recent stressful and traumatic life events compared with their male counterparts (Reif et al., 2011). Furthermore, among samples of predominately Black WWH residing in the Western United States, prior research suggests that exposure to recent traumatic events and lifetime traumatic events is associated with poor ART adherence and viremia (Cuca et al., 2019; Machtinger et al., 2012). Although it is evident that recent stressful life events and lifetime traumatic events influence health outcomes among PWH, less is known about their impact on ART and HIV care visit adherence among Black WWH in general and those in the Southeastern United States, where health outcomes are worse and racism and stigma are more prominent (Randolph et al., 2020; Reif et al., 2011). The Deep South represents the epicenter of the current U.S. HIV epidemic, and Black PWH, particularly women, experience the highest burden of HIV, as well as poorer health outcomes (CDC, 2019b,2021). Thus, the purpose of this study was to determine the prevalence of recent stressful (i.e., recent traumatic life events) and lifetime traumatic events and their association with missed HIV care visits and ART adherence among a sample of Black WWH in the Southeastern United States. In this study, recent stressful events are events that occurred in the 6 months preceding the study, and lifetime traumatic events include events that occurred before age 18 years. We hypothesize that greater numbers of stressful and traumatic events would be associated with poorer HIV adherence behaviors.

Methods

Study Design and Setting

We conducted a cross-sectional study on the association between recent stressful life events and lifetime traumatic events and HIV-related adherence outcomes among a sample of Black WWH. Participants were recruited from an academic comprehensive HIV care clinic in the Southeastern United States from December 2018 through July 2019. Women were eligible to participate if they met the following criteria: currently enrolled as patients at the HIV Clinic, self-identified as Black or African American (we will use the term Black throughout the paper), ≥18 years of age, attended at least one clinic appointment with a provider in the previous 12 months, able to speak and understand English, and self-identified as a cisgender woman. We recruited via flyers placed in examination rooms and the lobby of the clinic. In addition, we recruited by using a query of clinic data to identify potential participants. Eligible women, who previously provided consent to be contacted for future studies, were called to introduce the study. Those interested and meeting inclusion criteria were given a brief explanation of the study, and an appointment to complete the written consent process and the study instruments. Enrolled participants completed the survey regarding HIV-related stressors (described below) via tablet in a private room at the study site and consented for researchers to extract their HIV clinical data (i.e., CD4+ T-cell and missed scheduled HIV care visits) from the medical record. This study received approval from the University of Alabama at Birmingham IRB (IRB-300000221).

Recent Stressful Life Events

The study assessed recent stressful life events including events that are categorized as recent 1) moderately stressful life events, 2) severely stressful life events, and 3) traumatic life events, using a modified version of the Life Events Survey by Leserman et al. (2008). The Life Events Survey was modified by including events considered to be moderately to severely stressful based on previous studies, and the classification of stressful life events previously shown to be correlated with HIV-related clinical outcomes (Leserman et al., 2008; Mugavero, Raper, et al., 2009; Pence et al., 2010; Reif et al., 2011). The modified instrument consists of 47 possible events, including 26 categorized as moderately stressful and 21 categorized as severely stressful. Four of the severely stressful events are also categorized as traumatic events. Although the modified LES instrument consists of six possible financial stressors, the investigators only counted one financial stressor, despite a number of financial hardships being reported by the study participants. For this study, all financial stressors are combined into a single question, which provides examples of the six possible financial stressors. The questionnaire for this study inquired about a total of 44 recent stressful life events during the 6 months preceding survey administration, allowing participants to check any of the events they experienced. Moderate stressors (n = 24) include the following examples: major illness or injury not related to HIV, car accident, illness of close friends or grandparents, and job loss. Severe stressors (n = 18) include: illness or injury of a parent, sibling, or significant other; incarceration for greater than 1 week; and divorce. Traumatic events, a subset of severe stressors, include the following examples: sexual assault, physical assault, and death of a child or significant other. We added two additional stressors to assess HIV stigma and racial discrimination. Also, we created three summary measures of recent stressful life events: (a) the number of total recent stressful life events (moderate, severe, and traumatic), (b) the number of recent severely stressful life events, and (c) the number of recent traumatic life events, which is a subset of severe stressors (Mugavero, Raper, et al., 2009; Reif et al., 2011). Additionally, we created categorical variables summarizing the number of specific types of events such as health, sexual assault, financial, relationship, and legal, as done in previous studies (Leserman et al., 2008; Mugavero, Raper, et al., 2009; Pence et al., 2010; Reif et al., 2011). The Cronbach’s alpha for the survey is 0.85.

Lifetime Traumatic Events

Lifetime traumatic events were assessed using the 20-item Abuse and Trauma Questionnaire (Leserman et al., 2006; Meltzer-Brody et al., 2007), which assessed occurrence of both physical and sexual abuse, as well as other traumas experienced since childhood, with most questions asking about occurrences before age 18 years. Four-items inquired about Sexual abuse: (a) touching the participant's sex organs (i.e., breast, vagina, anus) with hands, mouth, or objects, (b) making the participant touch the perpetrator's genitals or anus, and (c) making the participants have vaginal or anal intercourse. The questionnaire assessed sexual abuse occurring before age 13 years and since age 13 years. Another 3 items inquired about physical abuse: (a) a life-threatening physical attack in which the participant thought they would be killed or seriously injured, (b) physical attack with a weapon such as a gun or knife that could cause serious injury, and (c) other physical abuse such as being beaten, hit, kicked, bitten, or burned. In addition, other forms of trauma (e.g., childhood poverty, parental incarceration, parental substance abuse, and loss of a child) were assessed by 13 items. Consistent with previous research with this instrument, a summary score for lifetime traumatic events (labeled traumatic life events) was created by allocating one point for each of the following traumas: childhood sexual abuse, adult sexual abuse, personal life-threatening attack, other physical abuse, parental alcohol or drug abuse or mental illness, foster care, reform school, or prison, death of a parent or sibling during the first 18 years of life, personal life-threatening illness not including HIV, child having a life-threatening illness or death (not including abortion), murder of a close friend or family member, and personal history of witnessing someone seriously injured or killed (Leserman et al., 2006; Meltzer-Brody et al., 2007). Item 13 of the other trauma items was excluded from the analysis because participants did not identify any other major trauma in their lifetime that was not already reported. Thus, our analysis is based on 19 items. We also created the following subcategories of lifetime traumatic events: childhood sexual abuse, adult sexual abuse, any sexual abuse, any physical abuse, and other trauma. In calculating the percentage of subjects exposed to at least one event, each participant received one point if they responded “yes” to one of the two items related to childhood sexual abuse, one point for answering “yes” to one of the 2 items related to adult sexual abuse, and “yes” to one of the 4 items related to sexual abuse (childhood or adult). Thus, all occurrences are unique and not counted more than once. The same approach was taken for calculating the occurrence of physical abuse, and only 1 point was allocated to each participant even if they answered “yes” to both physical abuse items.

HIV-Related Outcome Variables

HIV-related outcomes for the analysis included missed scheduled HIV care visits at the study clinic over 12 months and ART adherence. Missed scheduled HIV care visits were ascertained from the scheduling software system by clinic research staff. Specifically, missed HIV care visits represent the total number of “no show” visits during a 12-month period, excluding appointments that were canceled by the clinic or patient (Mugavero et al., 2014). The retrospective time frame of 12 months for missed HIV care visits is a commonly used measure in the field, but most important is that, in the current ART era, many participants with well controlled HIV do not attend the clinic more than once or twice a year; therefore, a 6-month window would not give an accurate or broad enough depiction of visit adherence (Zinski et al., 2015). Consistent with previous research, the variable was dichotomized into “no missed visits” or “missed visits” (≥1 missed visit), during a 12-month period (Pence et al., 2018). ART adherence was assessed with a single-item visual analog scale (Amico, 2006), and the results were dichotomized into two categories (≤90% adherence and >90%). Greater than 90% is considered an adequate level of adherence to achieve HIV viral suppression (Leach et al., 2021).

Other Variables of Interest

Demographic variables of interest included age, income, education level, marital status, and health insurance type. Age was used as a continuous variable. The most recent CD4 T-lymphocyte count, within a 6-month timeframe plus 2 months if no CD4 was available within the 6-month timeframe, was extracted from the medical record as a continuous number. Annual household income included three categories (<$10,000, $10,000–$14,999, and ≥$15,000), and education level included two categories (less than high school and high school or greater). Marital status included three categories (unmarried, married, and divorced) and the unmarried category included individuals who are not married, but live with their partner. Health insurance type included three categories (public, private, and uninsured).

Sample Size

Based on the limiting sample size considerations in the modeling textbook of Harrell (2015), that is, the number of degrees of freedom considered in logistic model building should not exceed the m/10 range, where m is the number of samples of the smaller category in the outcome. Our sample size (n = 200) allowed for reliable conclusions from our logistic models, as long as the models for ART adherence included no more than nine coefficients, and the models for HIV medical visit adherence included no more than 7 coefficients. The models were fitted with these considerations in mind.

Statistical Analysis

The characteristics of the study sample were described using frequencies and percentages for categorical data and mean values and SDs and/or medians with minimum and maximum values for continuous data. Mean values and SDs of incident stressful life events and incident traumatic life events were calculated. T-tests and chi-square tests were used to assess differences in stressful life events and traumatic life events by ART adherence and missed scheduled HIV care visits. Logistic regression was used to evaluate the bivariate and multivariate analyses, with adjustment for significant confounder associations between all recent stressful and traumatic life event and lifetime traumatic event variables and ART adherence and missed scheduled visits. The following confounder variables were selected a priori: age, education, insurance type, time since HIV diagnosis, and CD4 T-lymphocyte count. Statistical significance was considered p ≤ .05. All data analyses were conducted using SPSS version 25.

Results

Sample Characteristics

A total of 221 women were approached about study participation, of which 200 enrolled. Ten did not meet eligibility criteria and 11 declined. Of the 200 women who enrolled, their mean (SD) age was 50.6 (10.5) years, mean (SD) time since HIV diagnosis was 15.2 (8.0) years. The majority of participants had an optimal clinical HIV marker and ART adherence, with the majority having a recent CD4 T-lymphocyte count of 500 or greater cells per cubic millimeter of blood (73.5%) and ART adherence ≥90% (55.5%; Table 1).

Table 1. - Demographic and HIV Characteristics of Study Sample
Variables Overall
Age (years, range 27–77) 50.6 ± 10.5
Number of living children (range 0–11) 2.5 ± 1.6
Education level
 High school or lesser 47 (23.5%)
 High school 92 (46.0%)
 Some college/college grad 61 (30.5%)
Income, N = 199
 <$10,000 108 (54.3%)
 $10,000–$14,999 47 (23.6%)
 ≥$15,000 44 (22.1%)
Marital status
 Unmarried 130 (65.0%)
 Married 38 (19.0%)
 Divorced 32 (16.0%)
Insurance type
 Public 92 (46.0%)
 Private 79 (39.5%)
 Uninsured 29 (14.5%)
Time since HIV diagnosis (years; range 0–38) 15.2 ± 8.0
Number of total recent stressful life events (median = 5.0) 6.0 ± 5.5
Number or lifetime traumatic events (median = 3.0) 3.7 ± 3.3
CD4+ T-Lymphocyte count (n = 199; range 15–2068) 770.8 ± 426.3
ART adherence
 ≥90% 111 (55.5%)
 <90% 89 (44.5%)
Missed scheduled medical visits in the past 12 months
 0 135 (67.5%)
 ≥1 65 (32.5%)
Note. The sample size is 200 unless specified.
Note: ART, antiretroviral therapy.

Exposure to Recent Stressful Life Events and Lifetime Traumatic Events

Recent Stressful Life Events

Recent stressful life events were common among the study participants (Table 2). In the 6-month period before data collection, 91% of participants reported at least one event, with a mean (SD) of 6.0 (5.5) events out of 44 possible events. A total of 67 and 22.6% reported at least one recent severely stressful life event and at least one recent traumatic life event in the previous 6 months, respectively.

Table 2. - Frequency of Exposure to Stressful Life Event and Lifetime Trauma
Recent Stressful and Traumatic Life Event in the Past 6 Months (n = 199) Exposure to At least One Event, % (N)
Total recent stressful events 91.0 (181)
Recent severely stressful events 67.3 (134)
Recent traumatic event 22.6 (45)
Categories of stressful events
 Sexual assault 9.5 (19)
 Physical assault 7.0 (14)
 Health: major illness; injury, accident 43.7 (87)
 Death of family member or close friend 60.8 (121)
 Major illness of family/close friend 40.2 (80)
 Financial 35.7 (71)
 Relationship 46.7 (93)
 Employment 29.1 (58)
 Legal 10.1 (20)
 Safety-related 21.1 (42)
 Life transition 22.1 (44)
 HIV stigma 22.1 (44)
 Racial discrimination 29.6 (59)
Lifetime Traumatic Events (n = 200) % Yes to At least One Event
Lifetime traumatic events 82.0 (164)
Childhood sexual abuse 34.0 (68)
Adult sexual abuse 28.0 (56)
Any sexual abuse 40.0 (80)
Any physical abuse 23.0 (46)
Other trauma 80.0 (160)
Note. Total recent stressful life events include recent severely stressful life events and traumatic life events. Lifetime traumatic events include sexual abuse, physical abuse, and other types of traumas.

We further explored specific recent stressful life events by categories and found that death of a family member or close friend was the most frequently reported stressful life event (60.8%). Relationship stress, including recent divorce, increased arguments, and estrangement, was the next most commonly reported event (46.7%), followed by health-related stress, including major illness, injury, or accident not related to HIV (43.7%; Table 2). Recent physical and sexual assaults were uncommon, with less than 10% of participants reporting an event in the previous 6 months.

Lifetime Traumatic Events

Traumatic life events were common as well, with 82% of participants reporting at least one lifetime traumatic event, with a mean (SD) of 3.6 (3.3) out of a possible 19 lifetime traumatic events. One third of participants (34%) reported experiencing childhood sexual abuse and 28% reported sexual abuse as an adult. Forty percent of participants reported either childhood sexual abuse or adult sexual abuse (Table 2); if a participant reported both childhood and adult sexual abuse, only one event was counted.

Associations of Recent Stressful Life Events and Lifetime Traumatic Events and Adherence

The association between ART adherence and recent stressful life events and lifetime traumatic events is displayed in Table 3. There was no significant difference in the number of total recent stressful life events, recent severely stressful, recent traumatic events, lifetime traumatic events, or other types of lifetime traumas by ART adherence category in the bivariate analysis. Thus, no multivariate analysis was performed.

Table 3. - Unadjusted Association Between Stressful Life Events and Lifetime Trauma and ART Adherence
Optimal Adherence ≥90% Suboptimal Adherence <90% p-Value OR (95% CI)
Recent stressful & traumatic life event, M (SD)
 All recent stressful events 5.4 (4.8) 6.9 (6.2) .06 0.95 (0.90–1.00)
 Recent severely stressful events 1.9 (2.3) 2.2 (2.7) .44 0.96 (0.85–1.07)
 Recent traumatic event 0.26 (.58) 0.38 (.72) .23 0.22 (0.49–1.18)
Lifetime trauma
 Traumatic life events, M (SD) 3.5 (3.0) 3.9 (3.7) .36 0.96 (0.88–1.05)
 Childhood sexual abuse, N (%) .82 0.94 (0.52–1.68)
  Yes 37 (33.3) 31 (34.8)
  No 74 (66.7) 58 (65.2)
 Adult sexual abuse, N (%) .11 0.60 (0.32–1.12)
  Yes 26 (23.4) 30 (33.7)
  No 85 (76.6) 59 (66.3)
 Physical abuse, N (%) .39 0.75 (0.39–1.45)
  Yes 23 (20.7) 23 (25.8)
  No 88 (79.3) 66 (74.2)
 Other lifetime traumas, M (SD) 2.7 (2.3) 3.0 (2.7) .53 0.96 (0.86–1.08)
ART = antiretroviral therapy; CI = confidence interval; OR = odds ratio.
*Adjusted for age, time since diagnosis, CD4+ T-lymphocyte count, education level, and insurance type.
Note. Total recent stressful life events include recent severely stressful life events and traumatic life events. Lifetime traumatic events include sexual abuse, physical abuse, and other types of traumas.

Associations of Recent Stressful Life Events and Lifetime Traumatic Events and Missed HIV Care Visits

The bivariate analysis showed that total recent stressful, severely stressful, and traumatic life events as well as lifetime traumatic events, and other lifetime traumas were all significantly associated with missed HIV care visits (Table 4). Those who missed HIV care visits had a significantly larger mean number of all recent stressful life events (7.9 vs. 5.1, p = .001), recent severely stressful life events (2.8 vs. 1.7; p = .01), and recent traumatic life events (0.5 vs. 0.2, p = .02), as well as lifetime traumatic events (4.7 vs. 3.2; p = .002) and other lifetime traumas (3.7 vs. 2.4; p = .001). Using separate logistic regression models for each stress variable, we found that higher exposure to recent total stressful life events, recent severely stressful life events, and recent traumatic life events was significantly associated with higher odds of missed scheduled medical visits (odds ratio [OR] 1.10, 95% confidence Interval [CI] 1.04–1.16; OR 1.19, 95% CI 1.06–1.35; OR 1.74, 95% CI 1.11–2.73, respectively), with an exposure–response relationship with escalating event severity. Likewise, higher exposure to lifetime traumatic events was significantly associated with 15% higher odds of missed scheduled visits (OR 1.15, 95% CI 1.05–1.26), and higher exposure to other traumas (e.g., food insecurity, parental alcohol or drug abuse, or mental illness) was significantly associated with 22% higher odds of missed scheduled visits (OR 1.22, 95% CI 1.08–1.39; Table 4).

Table 4. - Unadjusted and Adjusted Association Between Stressful Life Events and Lifetime Trauma and Scheduled Medical Visit Adherence
No Missed Visits Missed Visits p-Value b Unadjusted OR (95% CI) Adjusted OR a (95% CI)
Recent stressful & traumatic life event, M (SD)
 All recent stressful events 5.1 (4.3) 7.9 (7.1) .001 1.10 (1.04–1.16) 1.08 (1.01–1.16) a
 Recent severely stressful events 1.7 (2.0) 2.8 (3.0) .01 1.19 (1.06–1.35)
 Recent traumatic event 0.2 (0.6) 0.5 (0.8) .02 1.74 (1.11–2.73)
Lifetime traumatic events
 Traumatic life events, M (SD) 3.2 (3.1) 4.7 (3.6) .002 1.15 (1.05–1.26) 1.10 (0.99–1.23) a
 Childhood sexual abuse, N (%) .12 1.63 (0.88–3.01)
  Yes 41 27
  No 94 38
 Adult sexual abuse, N (%) .11 1.69 (0.89–3.22)
  Yes 33 23
  No 102 42
 Physical abuse, N (%) .27 1.47 (0.74–2.90)
  Yes 28 47
  No 107 18
 Other lifetime traumas, M (SD) 2.4 (2.2) 3.7 (2.7) .001 1.22 (1.08–1.39)
CI = confidence interval; OR = odds ratio.
aAdjusted for age, time since diagnosis, CD4+ T-lymphocyte count, education level, and insurance type.
bp < 0.05.
Note. Total recent stressful life events include recent severely stressful life events and traumatic life events. Lifetime traumatic events include sexual abuse, physical abuse, and other types of traumas.

The multivariate analysis only included total recent stressful life events and lifetime traumatic events as predictors of interest. After controlling for age, education, insurance type, time since HIV diagnosis, and CD4 T-lymphocyte count, reporting exposure to total recent trauma was independently significantly associated with missed visits, such that Black WWH with more recent stressful events had 8% higher odds of missed visits (OR 1.08, 95% CI 1.01–1.15).

Discussion

We found that recent stressful life events (in the past six months) were highly prevalent among Black WWH, as were lifetime traumatic events such as a history of sexual abuse. In addition, recent stressful and traumatic life events were individually and independently associated with missed scheduled medical visits. With greater numbers of recent stressful, recent severely stressful, or recent traumatic life events, significantly higher odds of missed visits were observed, with a dose–response relationship and higher odds of missed visits with increased stressor severity. Lifetime traumatic events were also significantly individually associated with missed HIV care visits, but not independently associated in a multivariate model, highlighting their role, but emphasizing the impact of more recent stressful life events on missed HIV care visits. Of note, our associations between recent stressful life events and missed HIV care visits are particularly robust because this was an objective measure using clinic attendance data, in contrast to a self-report missed HIV care visit measure, which can be limited by recall bias.

Our findings are consistent with extant literature reporting high exposure to recent stressful life events and lifetime traumatic events among PWH (Cuca et al., 2019; Machtinger et al., 2012; Mugavero, Raper, et al., 2009; Pence et al., 2010; Reif et al., 2011). For example, among a sample of 600 PWH who completed the modified Life Events Survey used in this project assessing recent stressful and traumatic events, about 90% of participants reported a recent stressful event, 60% reported a recent severely stressful event, and about 10% reported a recent traumatic event (Reif et al., 2011). In addition, the reported prevalence of lifetime traumatic events among WWH in the literature ranges from 72% to as high as 97% (Cuca et al., 2019; Machtinger et al., 2012), which is consistent with our findings. The participants in our study were similar to participants of previous studies, in that they all identified as women. However, the women in our study were cisgender women residing in the Southeastern United States, whereas the women in previous studies were cisgender and transgender women living on the west coast of the United States. In addition, all women in our study identified as Black, whereas the racial demographic of other studies was about half Black. Thus, this study adds to the current literature by highlighting the high prevalence of recent stressful and traumatic life events and lifetime traumatic events among Black WWH in the Southern United States, the domestic epicenter of the HIV epidemic overall, and among Black women.

The findings of our study suggest that recent stressful life events and lifetime traumatic events are associated with missed scheduled HIV care visits, which support the findings of Campbell, Raffanti, and Nash (2019). Campbell et al. (2019) found that PWH who experience more lifetime traumatic events are 3 to 8 times more likely to miss scheduled HIV care visits. Although our study did not examine the relationship between racial discrimination and HIV outcomes, 26% of the women in our study reported racial discrimination as a stressful life event. Of note, experiencing discrimination due to race, gender, or sexual orientation can cause distress and trauma symptoms (Williams et al., 2018). Among the 1,578 diverse cisgender female participants in the Women's Interagency HIV Study (WIHS), which focused on lifetime discrimination and its relationship to missed scheduled medical visits, women reporting exposure to discrimination were more likely to miss scheduled medical visits in the 6 months before data collection when compared with those who did not report exposure to discrimination (Cressman et al., 2020). We cannot compare the characteristics of our participants to the participants in the study by Campbell et al. (2019); however, we can state that both studies included samples of individuals with HIV who reside in the Southeastern United States. Our study sample was similar to the WIHS sample, in that the sample included cisgender WWH. Our study sample included only women who identified as Black and we recruited from one clinic in the Southeastern United States, whereas WIHS participants are located across the United States and include a predominately Black sample. Furthermore, we collected missed visit data from the electronic medical record, and in the WIHS study, missed HIV care visit data were self-reported. Collecting self-reported data is acceptable; however, individuals frequently overreport HIV outcomes such as medical visit history (Cunningham et al., 2007). Research on recent stressful life events and lifetime traumatic events and missed scheduled medical visits is limited; thus, our findings add to the literature.

Clinical Implications

There is a call for universal and routine screening for traumatic events (Machtinger et al., 2018). Currently universal recommendations have not been established for initial and ongoing screening or implementation of an evidence-based screening instrument (Gentry & Paterson, 2021), but a group of experts have been advocating for universal and routine screening as a trauma-informed approach for women (Machtinger et al., 2018). Machtinger et al. (2018) suggests primary care settings screen for: recent traumas (i.e., intimate partner violence), lifetime trauma, and the mental and physical consequences of trauma. Our findings support the need for screening patients not only for lifetime traumatic events but for recent stressful and traumatic events as well. The prevalence of recent stressful life events among our participants was high and the events were associated with missed HIV care visits, which is similar to findings in other studies among PWH (Machtinger et al., 2012; Mugavero, Raper, et al., 2009; Reif et al., 2011). Therefore, screening patients has potential to identify those at risk for missed HIV care visits, providing an opportunity to intervene early and as often as needed. In addition, further research is needed to identify the frequency of screening.

Although our study did not assess the relationship between trauma and psychological distress, previous research suggests a significant association between trauma and psychological distress and identifies psychological stress, specifically depression, as a mediator between trauma and health outcomes (Brown et al., 2021; Dale & Safren, 2018). Given the role of trauma and psychological distress in HIV outcomes, clinicians can make an effort to equip PWH with strategies that potentially mitigate negative consequences and bolster psychological resilience, using trauma-informed approaches such as cognitive behavioral interventions and mindfulness-based interventions including stress management, relaxation therapy, yoga, and meditation (Dutton et al., 2013; Fazeli et al., 2021; Han et al., 2021). A trauma-informed approach realizes that trauma is prevalent, understands how trauma affects health and systems, and responds using evidence-based strategies (Substance Abuse and Mental Health Services Administration, 2014). Thus, evidence-based strategies such as cognitive behavioral interventions and mindfulness-based interventions have been effective in addressing psychological distress and stress, as well as improving self-efficacy, medication adherence, and access to social networks (Han et al., 2021; Scott-Sheldon et al., 2019). However, given the limited research on the effectiveness of such cognitive behavioral interventions and mindfulness-based interventions among Black WWH who have experienced recent and lifetime stressful events, such strategies need to be tailored for the target population and pilot-tested to determine the feasibility and acceptability of the intervention and its components.

This study is not without limitations. First, we had a modest sample size, which could have limited statistical power in the ability to find associations between stressors and the HIV outcomes of interest. Second, the ART adherence outcome was a self-reported measure, which is acceptable and frequently used, but often results in overreporting (Cunningham et al., 2007). Future studies should consider multilevel approaches to assessing ART adherence, including self-report, pharmacy refill, and electronic adherence devices (Stirratt et al., 2018). This is a cross-sectional study and therefore we cannot make any causal determinations. In addition, we cannot determine the temporal relationship between stressful and traumatic events and HIV outcomes. Finally, the study was conducted at an academic ambulatory HIV clinic that provides comprehensive core medical and social services, as well as mental health services, which may make these findings less applicable to HIV care settings in resource-limited areas.

Conclusion

In summary, our findings provide some insight into the association between lifetime and recent stressful and traumatic life events and missed HIV clinic visits and ART adherence. Data from this study can be used to inform future gender-specific and culturally appropriate interventions aimed at addressing recent stressful life events and lifetime traumatic events among Black WWH, as a means to optimize outcomes toward achieving health equity among this disproportionately affected group in the United States, and particularly in the South.

Authors' Contributions

All authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All authors reviewed and approved the final version of this manuscript. Conceptualization and Methodology: C. Chapman Lambert, N. C. Wright, L. Elopre, P. Fazeli, M. J. Mugavero, J. M. Turan, J. L.Raper, M. M. Holstad, A. Azuero; Funding acquisition: C. Chapman Lambert. Formal analysis: N. C. Wright; Investigation: K. King, C. Chapman Lambert; Writing–original draft: C. Chapman Lambert, N. Wright, L. Elopre, M. M. Holstad, P. Fazeli, J. L. Raper, A. Azuero, J.M. Turan, M. J. Mugavero; Writing/Revising: C. Chapman Lambert, N. Wright, P. Fazeli, K. King, J. L. Raper, A. Azuero, J. M. Turan, M. J. Mugavero; Supervision: C. Chapman Lambert, J. L. Raper, J. M. Turan, M. J. Mugavero.

Disclosures

The authors have not actual or perceived vested interests that relate to this article that could be seen as a conflicts of interest.

Funding

Research reported in this publication was supported by the National Center for Complementary and Integrative Health (NCCIH) of the National Institutes of Health under award number KL2TR1419 (PI: Ken Saag with Crystal Chapman Lambert serving as PI of subaward).

The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Key Considerations

  • Recent and lifetime stressful events are common among people with HIV, and stressful events may negatively influence HIV care outcomes such as medication and scheduled medical visit adherence.
  • Among Black women with HIV, recent stressful events were reported by the majority of participants.
  • Our results suggest that recent and lifetime stressful events may interfere with scheduled medical visit adherence.
  • Understanding the role of recent and lifetime stressful events may assist clinicians in identifying Black women at risk for suboptimal medical visit adherence.

Acknowledgments

The authors are grateful to all the study participants and the stakeholders who helped us to better understand the role of recent stressful life events and recent and lifetime stressful life events in adherence and retention in care. Without their contributions, the study would not have been complete, and the authors would not have the data to advance the science.

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    Keywords:

    adverse childhood events; HIV; lifetime trauma; recent stressful life events; retention in care; women with HIV

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