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. Author manuscript; available in PMC: 2025 Feb 28.
Published in final edited form as: J Assoc Nurses AIDS Care. 2024 Feb 28;35(3):245–251. doi: 10.1097/JNC.0000000000000439

Associations of Intimate Partner Violence and Drug Use on Viral Suppression Among Women Living With HIV In South Florida: A Secondary Analysis

Caroline Deaterly 1,*, Veronica Richards 2, Michael Weaver 3, Karina Villalba 4, Deepthi Varma 5, Isaac Payton 6, Robert Cook 7
PMCID: PMC11216898  NIHMSID: NIHMS1939487  PMID: 38417080

Abstract

Sub-optimal viral suppression is associated with worse outcomes and increased HIV transmission among women with HIV (WWH). Based on syndemic theory, we hypothesized that women exposed to recent Intimate Partner Violence (IPV) and current drug use would be most likely to have sub-optimal HIV viral suppression. We analyzed baseline data from a longitudinal clinical trial (WHAT-IF? Will Having Alcohol Treatment Improve My Functioning?) that enrolled WWH from Miami, Florida who reported heavy drinking. Bivariate logistic regression was done, mean age was 48 years (n=194; SD:8.7), 40% had current drug use (other than alcohol), and 14% reported recent IPV. WWH who reported both IPV and drug use had the highest rate of sub-optimal viral suppression (45%), but these differences were not statistically significant. The high rates of sub-optimal viral suppression, drug use, and IPV suggest a need to include screening for IPV in clinical guidelines related to HIV care in women.

Keywords: HIV, Women, Substance-Related Disorder, Intimate Partner Violence, Viral Load, Secondary Data Analysis

Introduction

In the United States (U.S.) there are over a million persons living with HIV (HIV & AIDS, 2022), with over 200,000 of those persons being WWH (CDC, 2020). In 2021, the state of Florida had over 120,000 persons with HIV diagnoses, and over 30,000 of those persons were women, including over 6,000 women residing in Miami-Dade County (HIV Data Center, Florida Department of Health, 2021; FLHealthCHARTS Florida Department of Health, n.d.). Additionally, it is important to note that in 2017, Miami-Dade County had the highest rate of new HIV infections in the U.S. (CDC, 2023b). Currently, the Florida Department of Health (FDOH) has the goal of reducing new HIV infections by 90% by 2030 and sustained viral suppression in all Persons With HIV (PWH) (Florida Department of Health, n.d.). Nationally, the U.S. has a goal of reducing new HIV infections in all persons with HIV by 90% in 2030 (HIV & AIDS trends and U.S. Statistics Overview, n.d.).

Women with HIV (WWH) are more likely to have sub-optimal viral suppression compared to men (Philbin et al., 2020; Rice et al.,2018). Optimal viral suppression can be defined as <200 copies of HIV per milliliter of blood “(CDC, 2022b). Some factors that prevent WWH from maintaining their HIV health care and optimal viral suppression include intimate partner violence (IPV) and drug use (Anderson et al.,2018; Barai et al., 2017). IPV is described by the Centers for Disease Control and Prevention (CDC) as physical violence, sexual violence, stalking, and psychological aggression by a current or former intimate partner (CDC, 2022a). WWH are more likely to experience IPV than persons without HIV (Abdool & Baxter, 2016; Marshall et al., 2018).

Findings from a systematic review suggested that a high proportion of WWH experience IPV in their lifetime (Hatcher et al., 2015). This is concerning because, in WWH, IPV has been associated with sub-optimal viral suppression, increased drug use, risky sexual behaviors, and transmission of sexually transmitted infections (Anderson et al.,2018; Hatcher et al., 2015). Similarly, several previous analyses indicate that WWH who use drugs have lower odds of optimal viral suppression compared to those who do not (Barai et al., 2017; Gibbs et al., 2022; Hatcher et al., 2015 Ogbonnaya et al.,2021). Additionally, heavy drinking is also associated with sub-optimal viral suppression in WWH (Kelso-Chichetto et al.,2017).

Optimal viral suppression, defined as <200 copies of HIV per milliliter of blood, is crucial because it prevents the progression of HIV to AIDS and prevents the transmission of HIV (CDC, 2022b). It is important to address obstacles (e.g., IPV and drug use) preventing WWH from successfully maintaining optimal viral suppression. However, it is not as clear how the combination of both IPV and drug use together impacts viral suppression, particularly in WWH who also self-report heavy drinking.

The overlap of co-occurring conditions (i.e., IPV and drug use) is often known as a syndemic, which is a clustering of co-occurring conditions that may increase the burden of disease and create adverse health outcomes (Tsuyuki et al.,2017). Because of the overlap of IPV and drug use in WWH, we used syndemic theory to inform and guide this study. Syndemic theory also has the benefit of considering the impact and interaction between social conditions and diseases (Rudd et al.,2022). The co-occurrence of drug use, IPV, and HIV, known as the SAVA (Substance Abuse, Violence, and AIDS) syndemic, has adversely impacted HIV health outcomes in WWH (Illangasekare et al., 2013).

The aims of this study were to 1) describe the frequency of drug use other than alcohol use, IPV, and viral suppression among a sample of WWH in South Florida who self-report heavy drinking and 2) determine whether the combination of drug use other than alcohol use and IPV is associated with sub-optimal viral suppression among WWH who self-report heavy drinking. We hypothesize that WWH who report drug use other than alcohol use and IPV in combination will be most likely to have sub-optimal viral suppression.

Methods

A secondary analysis was conducted from the parent study WHAT-IF? (Will Having Alcohol Treatment Improve My Functioning?) which was a double-blinded randomized clinical trial of Naltrexone vs. Placebo among WWH in Miami, Florida (Cook et al., 2019). To qualify for the parent study, cis-gender (sex assigned at birth used) women with HIV had to report heavy drinking (>7 drinks/week or >3 drinks/occasion) per National Institute on Alcohol Abuse and Alcoholism guidelines (National Institute on Alcohol Abuse and Alcoholism guidelines, 2008) during the past 30 days. The parent study was longitudinal, and data were collected over four-time points (baseline, 2 months, 4 months, and 7 months). Participants completed baseline and follow-up questionnaires using an audio computer-assisted self-interview (ACASI) computer program. The parent study was approved by the Institution Review Board (IRB). This secondary analysis was approved by the Southern HIV and Alcohol Research Consortium (SHARC). All WWH for the parent study voluntarily consented and double-blinded randomization was done via a computer-generated randomization. A fixed sample size of 194 women enrolled in the study and completed the baseline survey. Syndemic theory was used to inform and guide this secondary analysis

Demographics

Demographic information was collected via self-report using a questionnaire at baseline. Questions included age, race/ethnicity, relationship status (re-coded as single or in a relationship), employment (re-coded as yes/no), and education level (categorized as <high school, high school diploma or equivalent, >high school). Race/ethnicity was categorized as Non-Hispanic, Black, African American, Hispanic, Non-Hispanic, White, and Non-Hispanic, Other.

Alcohol Use

The average number of alcoholic drinks per week in the past 30 days was reported and calculated using the timeline follow-back (TLFB) at baseline. The TLFB has been found in previous literature to be a reliable and valid measure of drinking (; Sobell & Sobell, 1992). Previous literature has shown a test-retest reliability for the alcohol TLFB ranging from .73 to 1.00 specifically for the 30-day TLFB, indicating this is a reliable tool for measuring alcohol use (Carey et al., 2004).

Drug Use Other Than Alcohol Use

The baseline questionnaire asked about the frequency of use for nine different classes of drugs – heroin, methadone, narcotic pain medications (not prescribed), anxiety medications/benzodiazepines (not prescribed), cocaine, amphetamines, marijuana, and hallucinogens. Participants who endorsed using one or more of any of these drugs in the past 30 days (not including alcohol or tobacco) were categorized as current drug users.

Intimate Partner Violence

IPV was measured at baseline using the 3-item Partner Violence Screen (PVS), a tool that has been used to screen for IPV in the past 12 months (Feldhaus et al., 1997). The specific questions are: 1) Have you been hit, kicked, punched, or otherwise hurt by someone in the past 12 months? 2) Do you feel safe in your current relationship? and 3) Is there a partner from a previous relationship who is making you feel unsafe now? If a participant answered yes to questions 1 or 3 (or both), and/or no to question 2, they were coded as having experienced recent IPV in the past 12 months. (Feldhaus et al., 1997). The Cronbach α for this current study was 0.44, however, this may be a result of limited variability in the questions for IPV in this study. Additionally, a previous systematic review has shown the PVS scale to have a sensitivity between 35%–71%, and a specificity between 80%–94% (Rabin et al., 2009).

Viral Suppression

Blood samples were collected at baseline and sent to a commercial laboratory for HIV viral load testing. Participants were categorized as having sub-optimal viral load if their HIV viral load was >200 copies/ml (CDC, 2022b).

Combination variables

Four groups were created from a combination of the IPV and drug use variables: 1) Drug Use and IPV (reporting yes to both IPV and drug use), 2) drug use alone (reporting yes to drug use and no to IPV), 3) IPV alone (reporting no to drug use and yes to IPV), and 4) neither drugs nor IPV (reporting no to both drug use and IPV).

Analytical Approach

The data were analyzed using SAS version 9.4 (SAS Institute, Cary, NC). Descriptive statistics on socio-demographic variables (age, race/ethnicity, education, relationship status), IPV, and drug use were produced. A bivariate logistic regression model examined associations between the combination variable exposure (four levels; Drug use and IPV; IPV alone; Drug use alone; Neither drugs nor IPV) and sub-optimal viral suppression. A p-value of <.05 and a confidence interval of 95% were utilized. The adequacy of model fit, presence of outliers, and tenability of assumptions were examined using the Hosmer-Lemeshow goodness of fit test (Hosmer & Lemeshow,1980) and plots of residuals and influence measures. As this was a secondary analysis, detectable effect sizes given the available 194 subjects were estimated using PASS 2023 (PASS, 2023). For the logistic regression model, an effect size (odds ratio) of 0.43 (between a small and medium) effect size is detectable at 80% power.

Results

Baseline Descriptive Statistics

Participants’ mean age at baseline was 48 years (n=194, SD=8.7) (see Table 1–1). The majority (83%) identified as Black/African American, 11% as Hispanic, 4% as White, and 2% as “other”. Most (90%) self-reported being unemployed, 43% had less than a high school education, and 16% reported being in a relationship. At baseline, women consumed an average of 66 drinks per week (SD=77.7), and 40% reported drug use other than alcohol use in the past 30 days (defined as any use of heroin, methadone, narcotic pain medications, anxiety medications/benzodiazepines, cocaine, amphetamines, marijuana, and hallucinogens included while alcohol and tobacco excluded). Additionally, 14% of women in this sample reported experiencing IPV in the past 12 months, and 36% were sub-optimally virally suppressed (see Table 1–1). For frequencies of individual IPV items (questions 1–3) see Table 1–1.

Table 1-1.

Baseline Characteristics of 194 Women Living with HIV Who Have Heavy Alcohol Consumption

Variables n %
Mean Age 48 8.8
Race/Ethnicity
 Non-Hispanic, Black/AA 161 83
 Hispanic 22 11
 Non-Hispanic, White 8 4
 Non-Hispanic, Other 3 2
Education
<High School 84 43
High School diploma or Equivalent 66 34
>High School 44 23
Relationship Status
Single 163 84
In a Relationship 31 16
Mean drinks per week (SD) 66 77.7
Viral Suppression (<200/ml)
Yes 124 64
No 70 36
Employment Status
Yes 20 10
No 174 90
1. Have you been hit, kicked, punched, or otherwise hurt by someone in the past 12 months?
Yes 37 19
No 157 81
2. Do you feel safe in your current relationship?
Yes 163 84
No 31 16
3. Is there a partner from a previous relationship who is making you feel unsafe now?
Yes 18 9
No 176 91
Combination Variables
Drug Use and IPV 31 16
IPV Alone 27 14
Drug Use Alone 78 40
Neither Drug Use nor IPV 58 30
Open in a new tab

IPV: Intimate Partner Violence, SD: standard deviation. AA: African America

The proportion of WWH with sub-optimal viral suppression who were exposed to IPV, drug use, and their combination is reported in Table 1–2. Sub-optimal viral suppression was highest in women with both IPV and drug use, followed by those with drug use alone, although the differences were not statistically significant (see Table 1–3).

Table 1-2.

IPV, Drug Use, and their Combination Among Sub-Optimally Virally Suppressed WLWH (n=70)

Combination Variables Sub-Optimal Viral Suppression n (%)
Drug Use and IPV 14 (45)
IPV Alone 31 (40)
Drug Use Alone 7 (26)
Neither Drug Use nor IPV 18 (31)
Open in a new tab

Table 1-3.

The Odds of Sub-Optimal Viral Suppression in WLWH According to Their IPV and Drug Use History: Bivariate Logistic Regression Model (n=194)

Variable S.E. Chi-square p-value Odds Ratio (95% Cl)
Drug Use and IPV 0.50 1.73 0.20 1.83 0.74-4.50
Drug Use Alone 0.40 1.10 0.30 1.50 0.71-3.00
IPV Alone 0.52 0.23 0.63 0.78 0.30-2.20
Neither Drug Use nor IPV . . . . .
Open in a new tab

SE: Standard Error. Neither Drug Use nor IPV category is the referent for this model.

Logistic Regression

Results from the bivariate logistic regression are presented in Table 1–3. Overall, the model was consistent with the data (Hosmer-Lemeshow χ2=0.00, DF=3, p = 1.00). There was no statistically significant difference in odds of sub-optimal viral suppression between the four combination variable levels: both drug use and IPV (OR=1.83 Cl (0.74,4.50)), drugs only (OR=1.50 Cl (0.71,3.00)), and IPV only (OR=0.78 Cl (0.30,2.20), compared to women with neither risk factor.

Discussion

Consistent with these previous studies, the current sample of women reported high rates of IPV and drug use, and approximately one-third (36%) of the WWH in the sample were not virally suppressed, which is consistent with previous literature and shows that a high portion of WWH in the U.S. are not virally suppressed (CDC, 2023a). Although the rates of sub-optimal viral suppression were highest in women with drug use (either alone or combined with IPV), the overall differences in sub-optimal viral suppression were not statistically significant. This is contradictory to some other studies indicating that IPV and drug use are associated with reduced viral suppression in WWH (Anderson et al.,2018; Hatcher et al., 2015). These results may be explained by the smaller sample size of this study. These results may also be explained by improvements in clinical care created in the United States by HIV work, especially for example the positive impact of the Undetectable = Untransmittable (U=U) campaign. These results may be explained by the fact that participants for the parent study were recruited from clinical and community-based settings where they had access to care and resources. The participants in this sample from the parent study also self-reported heavy drinking and joined the parent study with the intent of reducing their heavy drinking with their participation which may have impacted the study outcomes and possibly made no statistical significance between IPV, drug use, and their combination on sub-optimal viral suppression. Additionally, the survey for the parent study asked about healthcare-seeking behaviors which may have impacted the results on self-reported survey data for IPV and drug use. Overall, the potentially increased access to care and resources, the individual health goals of the participants, and the survey questions asking about healthcare-seeking behavior in the parent study may have impacted the results from this current study, which merits further investigation in future research.

Implications for Clinical Practice

Although our findings did not show statistically significant correlations between IPV, drug use, and their combination on sub-optimal viral suppression, IPV and drug use were widespread in this sample and previous evidence does show that IPV is associated with reduced viral load suppression and increased drug use (Anderson et al.,2018; Hatcher et al., 2015). Thus, there are clinical implications for nurses and other clinicians involved in clinical care for WWH that can be seen from the results of this study. It could be beneficial to add into clinical guidelines recommendations to increase screening (done in a sensitive and unbiased manner), education (on IPV prevention), and resources (i.e., shelter resources and exit strategy resources) for IPV in WWH to improve and maintain long-term viral suppression in WWH and reduce drug use.

These recommendations can be implemented by clinicians throughout the U.S., specifically in Florida, and in Miami-Dade County, which has the highest rate of new HIV infections in the U.S. (CDC, 2023b). Increasing screening and education on IPV for WWH has the potential to help achieve this goal. Additionally, nurses and clinicians providing care to WLHW can provide resources and education on programs such as Undetectable = Untransmittable (U=U), which is a campaign aimed at educating and raising awareness on the importance of maintaining viral suppression and being untransmittable.

Strengths and Limitations

A strength of this study included the ethnic and racial diversity of the sample. However, the sample did have an overrepresentation of Black/African American participants with a smaller comparable sample of other races within the overall sample of 194 participants. Data were limited to a small sample of WWH in Miami, Florida, which reduces the generalizability of findings and may explain why statistical significance was not supported. However, conducting this study in Miami, Florida is also a strength of the study given the prevalence of HIV in this area. It should also be noted that as stated above this sample of WWH self-reported heavy drinking and voluntarily joined the parent study to reduce their drinking. These individual health goals may have impacted the outcomes of this current study.

Conclusion

Results from this study indicated that associations between sub-optimal viral suppression, IPV, drug use, and their combination were not supported in bivariate logistic regression analysis. However, there was a widespread self-report of IPV in the past 12 months (14%) and past 30-day drug use (40%). The main takeaway from these results are clinical implications which include clinical guidelines for HIV care in women and recommendations to increase screening and education related to IPV in WWH to reduce drug use and improve and maintain long-term viral suppression in WWH.

Key Considerations.

  • There was not an association between sub-optimal viral suppression IPV, drug use, and the combination of both IPV and drug use in this study.

  • Self-report of IPV and substance use is prevalent in WWH.

  • Clinical guidelines for WWH should provide recommendations to increase screening and education for IPV.

Acknowledgments

We would like to thank all the participants and study staff who committed time to make the What If Study possible. This study is supported by the following grants U01AA020797 (R. Cook), T32 DA017629, and U24AA022002

The data that supported this study findings is available upon request from the Southern HIV and Alcohol Research Consortium

Footnotes

Disclosures

The authors report no real or perceived vested interests related to this article that could be construed as a conflict of interest

Contributor Information

Caroline Deaterly, University of Florida College of Nursing and a pre-doctoral student with the Southern HIV and Alcohol Research Consortium, Gainesville, FL, USA..

Veronica Richards, Pennsylvania State University, University Park, PA, USA..

Michael Weaver, University of Florida College of Nursing, Gainesville, FL, USA..

Karina Villalba, University of Central Florida College of Medicine, Orlando, FL, USA..

Deepthi Varma, University of Florida Department of Epidemiology, Gainesville, FL, USA..

Isaac Payton, University of Florida College of Nursing and a pre-doctoral student with the Southern HIV and Alcohol Research Consortium, Gainesville, FL, USA..

Robert Cook, University of Florida Department of Epidemiology, Gainesville, FL, USA.

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