Syndemic Pandemic: COVID-19, HIV, and Antiretroviral Therapy Adherence Among Black/African Americans in Atlanta 公开

Abstract

Introduction: The COVID-19 pandemic and its consequences pose a threat to optimal antiretroviral therapy (ART) adherence in underserved communities with HIV. The present sequential explanatory mixed methods study explored the impact of the pandemic on ART adherence among Black/African Americans (Black/AA) people with HIV (PWH) in Atlanta.

Methods: A total of 200 Black/AA PWH were recruited across three HIV clinics in Atlanta to complete a cross-sectional survey. Thirty-eight of these participants took part in either a focus group discussion or individual in-depth interview. Multivariable regression analysis was conducted on survey data prior to thematic analysis of the qualitative interview transcripts and triangulation of mixed methods data.

Results: Eighty percent of participants reported optimal (>95%) ART adherence across both Spring and Winter 2020. Multivariable logistic regression analysis revealed that optimal adherence to ART was significantly associated with housing stability, greater education attainment, and having a job that was not impacted by the COVID-19 pandemic. Qualitative findings complemented and enriched the quantitative results, providing insight into individual, social, and structural syndemic factors experienced among this sample. Participants cited overlap in discrimination and intersectional stigma experienced by people with COVID-19 and HIV.

Discussion: The impact of the COVID-19 pandemic on structural factors, such as housing stability, employment status, and access to transportation, pose a significant threat to optimal ART adherence among Black/AA PWH. These results have implications for researchers and policy makers. Future research that seeks to understand differential access to social and structural determinants of health in the Black/AA community should be prioritized. To this end, policy makers should advocate for social, structural, and economic justice for historically underserved communities.

Table of Contents

CHAPTER I: INTRODUCTION………………………………………………………………….1

INTRODUCTION………………………………………………………………………………….1

THEORETICAL FRAMEWORK…………………………………………………………………3

RESEARCH QUESTION…………………………………………………………………………8

SIGNIFICANCE STATEMENT………………………………………………..………………….9

DEFINITION OF KEY TERMS………………………………………………………………….10

CHAPTER II: REVIEW OF THE LITERATURE……………………………………………….12

INTRODUCTION……….…………………………………………………………..…………….12

SYNDEMIC THEORY…………………………………………………………………………….12

WHY ADHERENCE TO ANTIRETROVIRAL THERAPY (ART)?……………………………13

HIV PREVALENCE AMONG BLACK AND/OR AFRICAN AMERICANS….……………….14

FACTORS INFLUENCING ADHERENCE TO ART……………………………….………….15

Mental Health Comorbidities…………………………………………………………………….17

Social Support …………………………………………………………………………………….18

Housing, Employment, and Transportation…………………………………………………….19

Discrimination and Stigma…………………………………………………………………..…….20

COVID-19 AS A HEALTH DISRUPTOR…………………………………………………………21

SUMMARY OF THE CURRENT PROBLEM……………………………………………………22

CHAPTER III: METHODS……………………………………………………………………..….24

INTRODUCTION……………………………………………………………………………….….24

Study Purpose……………………………………………………………………….…………….24

Research Aims…………………………………………………………………………………….25

Human Subjects Approval…………………………………………….………………………….25

POPULATION AND SAMPLE …………………………………………...……………………….26

Synergy Quantitative Survey……………………………………………….…………………….26

Synergy Sampling Methodology………………………………………………………………….27

PHASE I: QUANTITATIVE…………………………………………………………….………….28

Data Collection………………………………………………………………………………….….28

Validity and Reliability…………………………………………………………..………………….29

Data Quality………………………………………………………………………..……………….29

Sample……………………………………………………………………………..……………….30

MEASURES……………………………………………………………….……………………….30

Adherence to Antiretroviral Therapy (ART)…………………………………………………….30

Personal Demographic Characteristics………………………………………………………….31

Additional Variables of Interest: Syndemic Factors……………………………………………33

DATA ANALYSIS METHODOLOGY…………………………………………………………….35

Preliminary Analyses…………………………………………………………………….……….35

Primary Analyses………………………………………………………………………...……….37

PHASE II: QUALITATIVE………………………………………………………………..……….38

Qualitative Interview Guides…………………………………………………………………….39

Data Collection………………………………………………………………………………..….39

Data Analysis……………………………………………………………………………….…….40

Data Triangulation………………………………………………………………….…………….42

ASSESSMENT OF RESEARCH AIMS……………………………………………………..…43

CHAPTER IV: RESULTS………………………………………………………………….…….45

INTRODUCTION…………………………………………………………………………...…….45

Study Purpose…………………………………………………………………………………….45

QUANTITATIVE FINDINGS………………………………………….………………………….46

Preliminary Analyses……………………………………………………………..……………….46

Primary Analyses by Study Aim………………………………………………………………….58

QUALITATIVE FINDINGS………………………………………………………………………….61

Barriers to Optimal ART Adherence…………………………………………………………..….62

Facilitators to Optimal ART Adherence……………………………………………………….….65

Syndemic Factors……………………………………………………………………………….….69

DATA TRIANGULATION……………………………………………………………..…………….74

SUMMARY OF FINDINGS………………………………………………………………….…….77

CHAPTER 5: DISCUSSION……………………………………………………………………...79

INTRODUCTION…………………………………………………………………………….…….79

SUMMARY OF STUDY…………………………………………………………..……………….79

DISCUSSION OF KEY RESULTS……………………………………………………………….80

Research Aim 1…………………………………………………………………………………….80

Research Aim 2…………………………………………………………………………………….82

Overall Findings…………………………………………………………………………………….84

STRENGTHS AND LIMITATIONS……………………………………………………………….86

Strengths……………………………………………………………………………………..…….86

Limitations………………………………………………………………………….……………….87

IMPLICATIONS AND RECOMMENDATIONS………………………………………….………89

Implications for Health Equity Research……………………………………………………..…89

Future Directions…………………………………………………………………………….…….90

CONCLUSION……………………………………………………………………….…………….92

REFERENCES……………………………………………………………….…………………….93

APPENDICES……………………………………………………………..……………………….100

APPENDIX A: SYNERGY QUANTITATIVE SURVEY………………………………….……….100

About this Master's Thesis

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School	Rollins School of Public Health
Department	Behavioral Sciences and Health Education
Degree	M.P.H.
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Public Health
关键词	HIV COVID-19 Antiretroviral Therapy
Committee Chair / Thesis Advisor	Eric Nehl, PhD, Emory University
Committee Members	Robert Bednarczyk, PhD, Emory University Claudia Ordóñez, MAIR, Emory University

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