The study findings suggest that main partners played a role in HAART non-adherence among a sample of US women. Study results indicated a strong linear association between partner status and adherence, with adherence among those with no main partner being higher than those with an HIV seronegative or unknown status partner, which in turn was higher than those with an HIV seropositive main partner. Adjusted analysis indicated adherence was 75% less likely among women with an HIV seropositive versus no or other status main partner, 78% less likely among those whose partner was perceived a main source of emotional support, and 83% less likely among those reporting high cognitive impairment.
The study findings contribute to theoretical understandings of mechanisms through which main partners may influence health. This study represents one of the few to link main partner factors with medical adherence behaviors (Molloy, et al., 2008
The finding on self-reported cognitive impairment indicates the need for greater attention to its assessment and to adherence intervention for those so impaired.
Relationship qualities and adherence
Study participants reported a high level of closeness, though two-fifths reported conflict, with their main partners. Interestingly, higher quality of the main partner relationship, as indicated by perceived emotional support from one's main partner, was associated with worse adherence. While it is possible that the findings were confounded by conflictive relationships or chaotic lifestyles, there was no evidence of that; no associations were found between partner serostatus and relationship conflict, partners’ drug use, or relationship closeness. Further research is needed to examine additional contextual factors of women, their partners, and their relationships that may help explain study findings. It is plausible that greater perceived emotional support from partners among non-adherent participants is an artifact of their poorer health status and greater normative expectation of emotional support from partners, especially those living with them.
The findings also underscore the need for greater understanding of ways in which interpersonal support transactions may affect HAART adherence (Wrubel, Stumbo, & Johnson, 2008
). Evidence suggests that social support of HIV medical adherence comprises a wide range of interpersonal behaviors (Wrubel et al., 2008
), and that the manner in which support is offered affects its impact on health outcomes. Support that is ambiguous, inadequate, offered in a controlling or harassing manner, or mismatched relative to need or expectation may invoke stress that counteracts its potential health benefits (Newsom, Rook, Nishishiba, Sorkin, & Mahan, 2005
Gender roles and unmet support needs
Gender roles and gender role conflicts may also help explain study findings. Women's caregiving roles, and competing priorities they engender, may impede their ability to management their illness or to obtain social support important to medical adherence. As a consequence, women may be more attentive to their partner's health needs than their own. Results of a national study suggest that caring for children is associated with women's delaying HIV medical care (Stein, et al., 2000
). African American women compared to men and other racial groups provide disproportionately high levels of informal caregiving, including for HIV/AIDS (Turner, et al., 1994
; Knowlton, 2003
). The present study findings are consistent with prior evidence suggesting informal HIV caregiving exacts considerable costs on caregivers’ physical health, and other resources, particularly for caregivers living with HIV/AIDS (Leblanc, London, & Aneshensel, 1997
; Kipp, Tindyebwa, Rubaale, Karamagi, & Bajenja, 2007
The study results suggest that direct assistance with HIV medication taking is not highly normative in the study population, and for women is offered primarily within main partner relationships. Only 36% of the sample reported receiving such assistance from partners, friends, or family in the prior year. However, over half (53%) of those with a main partner, and 68% among those with an HIV seropositive partner, reported medication taking assistance. It is plausible that HIV seropositive partners’ greater provision of adherence assistance is explained by their better understanding of the importance of or concern about adherence; yet the assistance appears to be ineffective in optimizing adherence.
The findings indicate women's unmet expectations of HIV support and caregiving from their main partners. Of those with a main partner, while 53% said they most preferred their partner provide them HIV-related support, only 35% reported their partner actually was the main person providing them HIV support. This difference was even greater among those with an HIV seropositive partner (68% and 32%, respectively). Also of note, only about half of women with a main partner perceived their partner as a source of emotional support. The findings are consistent with results of a prior national study of gender and racial differences in perceived availability of informal care among middle aged and older adults, and thus may reflect cultural norms. In that study, main partners were the most likely perceived informal caregivers for all groups except for African American women, who reported their daughters were (or were most likely to be) their caregivers (Roth, Haley, Wadley, Clay, & Howard, 2007
). The high expectation of partner support in the present study may be indicative of lack of availability of alternative sources of support or care in the study population.
Gender differences in partner factors associated with HAART adherence
Further research is needed to examine gender differences in support networks and functioning and its relation to HAART adherence (Lingler, Sherwood, Crighton, Song, & Happ, 2008
; Mitrani, Weiss-Laxer, Ow, Burns, et al., 2009
). In a study of HAART adherence among Baltimore men, having informal care was strongly positively associated with having a main partner and with HAART adherence (Knowlton et al., 2010
). The findings are consistent with results of an Italian study indicating the gender differences in relationship orientation were differentially associated with HAART adherence (Ubbiali, Donati, Chiorri, Bregani, et al., 2008
). These results add to the extensive literature indicating men's as compared to women's greater health benefits of having a main partner (Kiecolt-Glaser, 2001), and suggest that gender differences in partner support and caregiving effects on medical adherence may help explain these differential health benefits of partners.
Limitations of the study include the exclusive use of self-report data, which is associated with recall bias and socially desirable responding, and the cross-sectional study design which impedes an ability to infer causal directions of associations. The study is also limited by potential selection bias and a limited sample size. The sample was comprised of women in Baltimore who reported taking HAART. Women with challenges accessing and continuing HAART, which contribute to U.S. women's HIV health disparities, were under-represented in the sample.
Implications to intervention
Main partner relationships of HIV seropositive persons have gained attention regarding their role in HIV prevention (El-Bassel, Jemmott, Landis, Pequegnat, et al., 2010
). The study findings reveal the role of main partners in (African American) women's HAART adherence as well. The results suggest that partner-focused intervention, particularly targeting HIV seroconcordant main partners and those experiencing cognitive impairment, to facilitate effective HIV support may be important for improving women's HAART adherence (Lewis, McBride, Pollack, Puleo, et al., 2006
; Remien, Stirratt, Dolezal, Dognin, et al., 2005
). Promoting effective HIV support from male partners not traditionally involved in informal caregiving may have implications to U.S. gender disparities in HIV health outcomes.