Date of Award

Spring 1-1-2025

Document Type

Dissertation

Degree Name

Doctor of Philosophy (PhD)

Department

Public Health

First Advisor

Monin, Joan

Abstract

Background: Approximately 54% of the nearly 1.1 million people living with diagnosed HIV in the United States are aged 50 and older. From 2015 to 2019, diagnoses among women ages 55 years and older increased by 7% while diagnoses among other age groups decreased. In 2019, women made up 19% of all HIV diagnoses. Despite advances in HIV science and education, there is still a dearth of research focused on the growing population of older women with HIV. Durvasula’s Contextualized Model for HIV/AIDS Care and Prevention for Older Women highlights that older women with HIV face different barriers to care, prevention, and comorbidities compared to older men or younger populations. These barriers occur in differing contexts of racism, sexism, ageism, and HIV stigma. As the population of women aging with HIV continues to increase in the coming years, it is imperative to examine psychosocial factors impeding HIV education, prevention efforts and care engagement in both clinical and community-based settings for women with and without HIV. This dissertation engages both qualitative and quantitative methods to examine the following: 1) the influences of gender-based stigma on HIV prevention and care engagement; 2) the association between HIV stigma and cognitive functioning; and 3) the role of care networks in mitigating the effects of stigma and improving HIV care engagement. Methods: Study 1 employed a scoping review to map and synthesize the existing evidence pertaining to how experiences of gender-based stigma impacts HIV prevention and care among older women, following Arksey and O’Malley and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR). MEDLINE/PubMed, Web of Science, PsycINFO, CINAHL and Scopus were searched for empirical literature published between January 1981 and July 2023 (the date of search commencement). Study 2 was a secondary analysis of longitudinal data from the Women’s Interagency HIV Study (WIHS, now MACS/WIHS Combined Cohort Study/MWCCS). Multivariable linear regression models were used to assess the relationship between internalized HIV stigma and seven cognitive domains (executive function, processing speed, attention/working memory, verbal learning, verbal memory, verbal fluency, and fine motor function) in a sample of 760 older women with HIV. Study 3 was a qualitative exploration of how caregiving and care receiving networks impacted HIV management. Semi-structured, one-on-one, in-depth interviews were conducted with 23 participants in the United States who were older women with HIV, followed by content and thematic analyses of interview transcripts. Results: For study 1, the systematic search yielded 25 articles describing 22 unique studies. There were five main themes highlighting how gender-based stigma exists at individual, interpersonal, and societal levels to adversely impact HIV prevention and treatment among older women: 1) Relationship power, safe sex practices, and intimate partner violence, 2) stigma, discrimination, and harmful stereotypes, 3) quality of care, 4) caregiving roles and responsibilities, and 5) psychological and physiological manifestations. Study 2 found that higher internalized HIV stigma was associated with poorer global cognitive function (B= -0.68, p<0.05), verbal learning (B= -1.42, p<0.05), and verbal memory (B= -1.40 p<0.05) at time 2. Lastly, qualitative interviews from study 3 illustrated that 1) Participants received the most care (i.e., instrumental/emotional support to help manage HIV) from their adult children and HIV support group peers. Participants provided the most care to their grandchildren and own parents; 2) Despite occasional periods of stress balancing caregiving responsibilities while managing HIV, participants have pride and joy in being caregivers to loved ones; 3) Caregiving and receiving networks not only help disease management, but also promote self-love and acceptance; 4) Despite receiving care, participants are highly proactive in their own HIV management; 5) Many had concerns about being able to keep up with their HIV care needs due to uncertainty about who will be in their care networks in the future and comorbidity. Conclusions: This dissertation employed a mixed methods approach to examine psychosocial correlates of HIV prevention, care, and well-being among older women with HIV. Results from the scoping review (Study 1) illustrated that gender-based stigma exists at multiple levels (individual, interpersonal, and societal) to adversely impact HIV prevention and treatment among older women. Despite limited quantitative evidence, rich qualitative findings indicated that gender-based stigma is pervasive and manifests in similar ways among the lives of older women across geographic locations. Outstanding questions remain on best methods for measuring and conceptualizing gender-based stigma in HIV/AIDS research and ways to translate these findings to best research and clinical practices to improve quality of life and well-being for older women. Results from the quantitative longitudinal analysis highlighted (Study 2) an additional aspect of stigma, internalized HIV stigma, that could negatively impact cognitive health. The significant negative relationship between internalized HIV stigma and cognitive function suggests that assessing and monitoring HIV stigma may benefit cognitive function for older women aging with HIV by identifying those at greater risk for cognitive decline who could be targeted for stigma reduction interventions. Lastly, the qualitative interviews and thematic analysis (Study 3) expanded on findings from studies 1 and 2 by emphasizing the role of caregiving and care receiving networks in promoting self-care and combatting intersectional stigmas associated with HIV, ageism, and sexism. Findings highlighted that being a caregiver and care recipient were sources of meaning and strength to help older women manage HIV. Public health programs should consider engaging both older women with HIV and their care networks in healthcare discussions and educational efforts. Taken together, results from this mixed methods dissertation underscore that older women face unique barriers to HIV prevention and management due to the compounded effects of HIV stigma, gender-based stigma, and ageism. While beyond the scope of this dissertation, additional macro-level influences stemming from racism, poverty, etc., also negatively impact the sexual health and well-being of older women. Continuing public health and clinical efforts must be made to increase representation of older women in HIV research and programs.

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