In this sample of HIV-positive adults with histories of CSA, nearly all reported being enrolled in medical care for HIV. While the majority of participants reported at least one outpatient visit in the previous 4 months (as per recommended guidelines), 20% reported no visits and 24% utilized emergency services. Among participants receiving ART, 22% were poorly adherent (<90%) to their medications during the past week. In sum, while nearly all participants had access to HIV treatment, a sizable minority was insufficiently adherent to recommended medical treatments and thus may not be benefiting optimally.
The rates of medical treatment utilization in our sample were lower than those observed in nationally representative samples of adults receiving HIV care in the United States,2,4
but they were comparable to other studies of socioeconomically disadvantaged persons.49,50
These findings add to the accumulating evidence that vulnerable persons, including those who have trauma histories, abuse alcohol and other drugs, and live in unstable conditions, may be at higher risk for suboptimal treatment utilization. CSA increases the likelihood of these and many other outcomes that may negatively impact health care, including sexual revictimization as children and adults, partner violence, unstable relationships, poor social support, substance abuse and dependence, suicidal and self-harm behaviors, and diminished self-care.13–21,23–28
Prior research has found that recent stressful events are associated with ART nonreceipt,36
and that number of lifetime traumas and current depression are associated with ART nonadherence22
in HIV-positive adults in general. Thus, trauma-related issues may play an important role in HIV treatment utilization.
In this sample of HIV-positive adults with CSA, we found that traumatic stress, binge drinking and illicit drug use, HIV symptoms, and poor social support were risk factors for one or more indicators of suboptimal treatment utilization. First, greater traumatic stress symptoms were associated with poorer adherence to ART; interestingly, psychiatric disorder, depressive symptoms, and perceived stress were not. Liu and colleagues32
also found that depression and anxiety were unrelated to medication adherence in HIV-positive women with histories of CSA. Second, as in previous studies of HIV patients in general,51,52
poor social support was associated with both not attending outpatient visits and not adhering to ART. Thus, in HIV-positive adults with CSA, symptoms of traumatic stress and interpersonal difficulties, specifically, may be more important predictors of treatment utilization than general psychiatric distress. Common symptoms of traumatic stress include flashbacks, hyperarousal, and intrusive images, which often lead to avoidance and escape behaviors.53
For some, medical care may serve as a trigger for prior life experiences that contributed to their HIV infection, resulting in missed medical appointments and medication doses. A sense of foreshortened future is also common,53
which may lead to hopelessness about the potential benefits of treatment. Many victims of interpersonal trauma have difficulty trusting others, including medical providers, which may further compromise treatment adherence.52
Finally, many traumatized individuals have difficulty recognizing harm and developing self-protective mechanisms, and non-adherence to medical treatment may be a manifestation of this.29
Thus, mental health treatment for trauma may be important for optimizing clinical outcomes in HIV-positive individuals. Indeed, in this study, mental health treatment was associated with increased utilization of medical care. Interventions aimed at improving treatment utilization might also focus on increasing supports, both formal and informal, particularly in communities of color.
Not surprisingly, individuals with more severe HIV symptoms were more likely to visit the emergency department, likely reflecting appropriate use of emergency services. After accounting for HIV symptoms, however, binge drinking and illicit drug use remained strongly associated with emergency department visits. Substance abuse may lead to injuries (e.g., due to falls or physical assaults) that require immediate medical attention, and it may also exacerbate physical illness. A study of HIV-positive veterans also found that alcohol abuse predicted emergency department visits.54
Binge drinking may also interfere with adherence to medication regimens, which may partially explain why hazardous alcohol consumption is associated with increased HIV and comorbid disease progression and mortality.55–57
In this sample, binge drinkers were more likely to be nonadherent to their medications, but this relationship was not significant in multivariable analyses accounting for other psychosocial variables. These results highlight the importance of assessing substance abuse among HIV-positive persons and providing treatment for alcohol and other drug use when indicated. Unfortunately, alcohol and other drug abuse is often underrecognized, with only a minority of patients discussing these issues with HIV medical providers.58
Finally, we found that African Americans were over three times less likely to have received outpatient medical care in the past 4 months. In the United States, African American women and men are 23 and 8 times more likely to be diagnosed with HIV/AIDS than are white women and men, respectively, and they have shorter survival times.59
Other studies have also observed suboptimal treatment utilization in minority groups.2,36,60,61
These findings reinforce the importance of eliminating health disparities by increasing services to provide early and equal access to health care for low-income persons living with HIV/AIDS.62
The results of this study must be interpreted in light of the following limitations. First, while the sample was diverse in terms of gender, race, and sexual orientation and was recruited from various community-based organizations, participants all sought group treatment for coping with HIV and CSA. Furthermore, the vast majority was enrolled in HIV care and had been living with HIV/AIDS for an average of 10 years. Thus, results may not generalize to HIV-positive individuals who live in communities with fewer HIV services, are not actively seeking or lack access to services, have been more recently infected, and/or live in other regions of the world. Second, this study relied on self-report data, which is subject to recall and social desirability biases. Prior studies of marginalized HIV-infected samples found that participants overestimated outpatient visits and medication adherence,63–65
so rates of treatment utilization in this study may have been even lower than reported.64,66,67
Future studies might consider multiple assessment methods, including medical record review and Medication Event Monitoring System, and lower adherence thresholds to account for improvements in ART regimens.12,64,65
Nevertheless, self- reported adherence to ART has been found to predict virologic failure,68
and it was predictive of immune functioning in this study. Finally, limited information on participants' medical history was available, so it was not possible to determine the purpose of medical visits or whether emergency department visits might have been prevented through more appropriate utilization of outpatient treatment.
In conclusion, the vast majority of participants in this diverse sample of HIV-positive adults with CSA had access to HIV medical care. Nevertheless, as in previous studies, a sizable minority did not adhere to recommended guidelines on outpatient visits and ART adherence. Trauma symptoms, binge drinking, illicit drug use, poor social support were associated with suboptimal treatment utilization. Interventions aimed at improving HIV clinical outcomes in this population may need to address these psychosocial problems. Prior research has found that HIV case management can improve treatment utilization, including more outpatient visits and fewer hospital days, with lower overall health care costs.64,66,67
Thus, many HIV-positive adults with CSA might benefit from case management or other interventions to help address psychosocial problems that interfere with optimal treatment utilization.