Publication Date

2019-10-30

Availability

Open access

Embargo Period

2019-10-30

Degree Type

Dissertation

Degree Name

Doctor of Philosophy (PHD)

Department

Nursing (Nursing)

Date of Defense

2019-09-06

First Committee Member

Rosina Cianelli

Second Committee Member

Natalia Villegas Rodriguez

Third Committee Member

Karina Gattamorta

Fourth Committee Member

Giovanna De Oliveira

Fifth Committee Member

Lunthita Duthely

Abstract

Engagement in postpartum Human immunodeficiency virus (HIV) treatment is critical to decreasing maternal morbidity and mortality, and poor infant health outcomes. HIV-related maternal morbidity is one of the leading causes of death among women of reproductive age, with as many as 8,500 HIV-infected women giving birth annually in the US. The risk of HIV-related maternal morbidity is greater for Black women who are disproportionately affected by the disease with an infection rate of 59% compared to 20% for Whites, and 21% for other minorities. Black women also have the highest rates of unintended pregnancies, HIV-related mortality, and being lost to follow-up (LTFU) for postpartum HIV treatment. Studies demonstrate that social determinants of health (SDH) can influence the likelihood of engagement in HIV treatment for women living with HIV (WLWH). SDH are the conditions in which people are born, grow, live, work, and age. Poor social and economic situations negatively impact health throughout life, particularly for people living with HIV, and minorities are most likely to live in such conditions. To date, there has been a lack of research on the social determinants of engagement in HIV treatment among postpartum WLWH, particularly Black women who are significantly and disproportionately affected by HIV. Therefore, the aim of this study was to investigate the social determinants of engagement in HIV treatment among postpartum Black WLWH, at the intrapersonal and interpersonal levels of the McLeroy social ecological model (SEM). The SEM is best suited to analyze the integrative-interactive synergy that exists between a person and her environment, and how such interactions influence health behaviors. The model postulates that patterned behavior is an outcome of interrelatedness among an individual’s intrapersonal attributes, interpersonal relationships, institutional factors, community factors, and societal factors. Postpartum engagement (PPE) was operationally defined as keeping at least 70% of scheduled postpartum visits in the first three months postpartum and having at least 500 Cluster of differentiation 4 glycoprotein (CD4) copies/mL and a viral load (VL) less than 200 copies/mL. Ongoing primary care engagement (PCE) was operationally defined as keeping as least 50% of scheduled postpartum visits in the first postpartum year and having at least 500 CD4 copies/mL and a VL less than 200 copies/mL. This study was a retrospective, secondary data analysis of 143 Black postpartum WLWH who received immediate postpartum care at the University of Miami Prenatal Immunologic (PRIM) clinic and then transitioned into ongoing primary care at the Women’s Integrated Services for Health (WISH) clinic from May 2009 to May 2017. Data were retrieved manually and electronically from patients’ medical charts. Inclusion criteria for study participants were postpartum women age 18 years and older who self-identified as Black and had started prenatal care (PNC) at least one month prior to delivery of a live infant at PRIM before transitioning to WISH. The researcher explored SEM variables at the intrapersonal and interpersonal levels. The variables investigated at the individual level were age, income, employment, education, health insurance, and maternal health status (HIV-related, obstetric, gynecologic, and psychosocial health status). HIV-related health status included the mode of HIV transmission, timing of HIV-diagnosis, and HIV biomarkers (VL count and CD4 count at baseline and delivery). The obstetric health status included the term at birth, type of delivery, and adequacy of PNC, including the gestational month at PNC entry and duration. The gynecologic health status included the women’s other medical comorbidities, while the psychosocial health status was measured by depressive symptoms and substance use. The variables investigated at the interpersonal level were relationship status, intimate partner violence/abuse, caregiver burden, HIV disclosure, and social support. Data were analyzed using the IBM Statistical Package for the Social Sciences (SPSS). The analyses were conducted to examine the SDH that significantly affected two outcomes, independent of each other: postpartum HIV treatment engagement at three months (immediate postpartum engagement; PPE) and at 12 months (ongoing primary care engagement; PCE). The data analysis included descriptive statistics, chi-square, t-tests, and logistic regression. Of the 143 women included in the study, the PPE rate was 32.9% and the PCE rate was 24.5%. Among women who attained PPE, more than half were unemployed (51.1%), had a high school diploma or more (71.7%), and had health insurance (78.1%). Among women who attained PCE, more than half were unemployed (68.6%), had a high school diploma or more (74.2%), and had health insurance (74.3%). The PPE logistic regression analysis indicated that women had greater odds of engagement when their HIV VL was less than 200 copies/mL at baseline, they had delivered vaginally, and they had disclosed their HIV status to a family member, partner, or significant other. In contrast, women who were abused were less likely to engage in treatment. For PCE, women had greater odds of engagement when their HIV VL was less than 200 copies/mL and they had had term births. Conversely, women who had private health insurance were less likely to engage in treatment. Therefore, these findings indicated that the SDH significantly affecting PPE were maternal health status (HIV-related and obstetric health status), HIV disclosure. The SDH significantly affecting PCE were health insurance and maternal health status (HIV-related and obstetric health status). This study is the first to provide evidence about HIV treatment disengagement among Black postpartum WLWH in Miami, FL—the city with the nation’s highest HIV rate. Because these results show that SDH may be contributing to this disparity, the researcher offers recommendations for future nursing research, teaching, practice, and policy. The results from this study also can be used to develop a measure to assess HIV treatment engagement for Black postpartum WLWH. Such a measure could help identify at-risk women, which would allow healthcare providers to intervene promptly. Building on this study’s findings, future researchers could use a sample of other minority groups to allow the results to be extrapolated to other minority women populations. In light of this study, nursing school curricula should be adjusted to offer course content on the disparities in HIV treatment engagement for pregnant and postpartum women, and the SDH that are linked to such outcomes. Practicing nurses should be empathetic and sensitive to their patients’ physical and cultural needs. Women whose treatment could be hindered by their socioeconomic status should be referred to a social worker and educated about available Federal healthcare insurance plans (e.g., the Ryan White HIV/AIDS program). This study’s results also highlight the effect that HIV disclosure and abuse can have on engagement. Offering a nurse-facilitated disclosure intervention, such as the one discussed in this study, could help empower nurses to intervene when they see signs of abuse among their patients.

Keywords

Socia determinants of health; Women Living With HIV (WLWH); Black; African-American; HIV Treatment Engagement, Pregnant; Peripartum; Postpartum; Primary Care; Socioecologic Model

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