Abstract
People living with HIV/AIDS (PLWH) are more likely to have a history of trading sex, but little research has examined whether trading sex is associated with lower health care utilization amongst PLWH. This study assesses this association with PLWH (N=583) recruited and surveyed from seven community sites in six US cities participating in a multi-site community-based HIV test and treat initiative. Participants were 90.6% Black or Latino, 30.4% homeless, and 9.0% (1 in 11) sold sex (past 90 days). Most reported receiving HIV clinical care (63.9%, past 6 months) and HIV case management (68.9%, past year), but 35.7% reported a missed health care appointment (past 3 months). In adjusted regression models, trading sex was associated with a missed health care appointment (OR=2.44) and receiving psychological assistance (OR=2.31), past 90 days, but not receipt of HIV care or supportive HIV services. Trading sex may compromise consistent health care utilization among PLWH.
RESUMEN
Las personas que viven con VIH/SIDA (SLWH) tienes más probabilidades de tener un historial de comercio sexual, poca investigación ha examinado si el comercio sexual está asociado con una menor utilización de atención médica entre las personas PLHW. Este estudio evalúa la asociación con PLWH (N=583) reclutados y encuestados en seis ciudades en los Estados Unidos. Los participantes fueron 90.6% Negros o Latinos, 30.4% sin hogar y 9.0% (1 en 11) vendió sexo (últimos 90 días). La mayoría informo que recibió atención médica (63.9%, últimos 6 meses) y manejo de caso VIH (68.9%, el pasado año), pero 35.7% perdió una cita médica (últimos 3 meses). En los modelos de regresión ajustada, el sexo comercial fue asociado con una cita médica perdida (OR=2.31), después de 90 días, pero sin atención o servicios de apoyo VIH. El comercio sexual puede comprometer el uso constante de atención medica en las PLWH.
INTRODUCTION
Globally, sex trade is seen as a key driver of HIV, and mathematical models indicate that elimination of gender-based violence combined with improved access to anti-retroviral therapy (ART) among those who trade sex would substantially and significantly reduce HIV rates nationally by country [1–2]. These analyses are based largely on data from sub-Saharan Africa and Canada, excluding the United States (US) due to the limited domestic data available on sex trade and HIV. Within the US, evidence documents the preponderance of sex trade- i.e., sex in exchange for money, drugs, or survival needs such as a place to stay- across a diversity of populations including STI clinic patients, women receiving family planning services, substance using populations, transgender women, and men who have sex with men [3–5]. These studies, as well as national data [6], document increased risk for HIV and related risk behaviors among those who trade sex, in particular when sex is traded for drugs [7]. Unfortunately, despite the extensive evidence on the intersection of sex trade and HIV, there remains a paucity of data on sex trade among people living with HIV (PLWH) and its associations with other health risks, post-diagnosis.
Regular HIV care utilization, combined with receipt of and adherence to ART can support the health and viral suppression of PLWH, and simultaneously reduce their risk for transmission of the virus to others [8]. Unfortunately, of the 1.2 million PLWH in the US, only 40% regularly utilize HIV care, though those that are engaged in care are more likely to be on ART and have achieved viral suppression. Barriers to HIV care utilization have been well documented in the scientific literature [9–12] and include substance use, social deprivation (poverty, food insecurity, homelessness), stigma related to HIV disclosure, lack of social support, fear of side effects, and the accessibility and quality of health services [9]. Many of these same factors, particularly substance use and social deprivation, are associated with sex trade involvement [13,14], but studies assessing the association between sex trade and HIV care utilization are largely lacking in the US [15].
Additionally, few studies have assessed whether sex trade affects the utilization of non-HIV services, i.e., substance use and mental health treatment, amongst PLWH. Research has documented that those involved with sex trade are less likely to seek health care, or to disclose their sex trade involvement in the context of care, due to sex trade-related stigma [16,17]. For example, outside of the US, studies show that among male and female persons engaged in sex trade, those who perceive greater sex trade-related stigma are more likely to delay or to avoid non-HIV specific services, as well as HIV counseling and testing services [18,19]. However, less is known about the association between sex trade and health care utilization among PLWH in the US.
This study examines the association between sex trade involvement, specifically selling sex (for money, drugs or a place to stay) and the receipt of HIV and non-HIV specific health care services among PLWH in the US. We hypothesize that sex trade involvement (selling sex) is associated with less utilization of HIV care, HIV case management, and other social and health services (substance use treatment, mental health services, general healthcare visits) among PLWH. Understanding the prevalence of sex trade involvement and its potential health impact among PLWH is important to guide broader health considerations for PLWH in the US, given the heightened physical and mental health issues faced by those in the sex trade, particularly by substance-using PLWH. Findings may also offer a more nuanced way of understanding who is actively involved in sex trade among PLWH in the US and the extent to which such involvement may affect their health care utilization.
METHODS
Data collection/recruitment
Persons living with HIV (N=583) were recruited for the current study and surveyed at baseline from October 2013 - August 2016 as part of a multi-site community-based HIV test and treat initiative. Participants were included in this study if they tested HIV positive as part of the study, or if they were already living with HIV but inconsistently utilized HIV care during the past year, or if they were already living with HIV but never utilized HIV care within the past six or 12 months. Research staff from seven community-based agency sites across six US cities recruited participants from populations disproportionately affected by HIV/AIDS: African American/Black and Latino MSM, transgender women, women of color, recently incarcerated persons, and persons who inject drugs. The regions included major metropolitan cities on the east and west coasts, a mid-Atlantic suburb, and rural southeastern areas.
Sites recruited participants via outreach, advertisements, or snowball sampling in various settings, and some sites recruited from within health care settings, substance use treatment, prison release programs, and HIV testing sites (e.g., bathhouses), while others additionally engaged in more focused street outreach to locate their target population. Trained staff obtained informed consent from participants and administered in-person baseline surveys. Survey data were gathered using mobile tablets, and when preferred, paper surveys. In the larger study’s evaluation design, participants were enrolled into an intervention or control condition and received three- and six- month follow-up surveys, in addition to their baseline survey. Current analyses were restricted to baseline data from this study.
Measures
Independent Variable:
Sex trade was defined as having ‘sex in exchange for money, drugs, food, or other goods’ in the past 90 days (Yes, No). While sex trade can include buying or selling sex, we focus on the selling sex aspect of the sex trade in this paper and we use the term sex trade interchangeably with selling sex. An item also assessed whether they gave someone money, drugs, or a place to stay in exchange for sex (buying sex) and those data are presented descriptively in this paper as a separate item.
Outcome Variables
HIV and non-HIV service utilization was defined by self-reported use (Yes, No) of the following services: HIV care utilization (having a medical appointment in which they received their CD4 count) in the past six-months, HIV support services (seeing any professional for the primary purpose of getting help for an HIV issue or HIV case management need [e.g., related to shelter, food, coordination of services]) in the past 12-months, Psychological treatment (seeing any medical or mental health professional for the primary purpose of getting help for a psychological or emotional issue) in the past 12-months, Alcohol or drug treatment (seeing any professional for the primary purpose of substance use treatment) in the past 12 months was also measured, and Missed health care appointments (missed any scheduled appointment for any health services) in the past 3-months.
Covariates
Sociodemographic items included age, race, gender, sexual orientation (bisexual, lesbian/gay/queer, heterosexual), and gender identity (cisgender men, cisgender women, transgender women [male-to-female]). Because transgender individuals may self-identify as male or female, rather than transgender in the survey, a validity assessment using agency gender identity records was conducted. Participants not identified as having a lived transgender experience by either method were coded as cisgender man or cisgender woman, meaning they identified with the gender corresponding to their biological sex assignment at birth. Given extensive data on the intersection of violence and sex trade involvement [20–23], as well as substance use and violence among those trading sex [24–34], we also included the following variables in our analyses:
Sexual Violence was defined as, ‘having been forced or pressured for sex,’ or having someone ‘physically hurting the sexual parts of your body, including touching that made you feel uncomfortable.’ Participants indicated if they had ever (Yes, No) experienced sexual violence within the past year. Physical violence was measured by whether they were ever physically abused (slapped, beaten, kicked, choked, or threatened with a weapon) by someone in the past 90-days (Yes, No).
Drug and alcohol use were assessed using the TCU-DS2 and an adapted version of the AUDIT-10 (items 1–3, 9–10) [35], respectively [36]. Illicit drug use (Yes, No) in the past 30-days included any self-reported illicit drug use (excluding marijuana). Participants reported alcohol-related risk (Yes, No) if they had engaged in binge drinking (≥5 drinks in one setting). Alcohol-related risk was adapted from AUDIT (item 3) in the past 30 days or experienced alcohol-related harms (i.e., one’s drinking resulting in injury to self or others; AUDIT items 9–10) in the past 12 months.
Other covariates were:
History of incarceration (Yes, but not in the past 12 months; or Never), being medically insured (Yes, No), and running out of cash in the past year (daily, weekly, monthly, occasionally, never). Homelessness was coded as “Yes” if they reported being homeless or on the streets for one day or more in the past 90, and “No” if they recorded zero days for both. Time since first HIV diagnosis was dichotomized as “less than one year,” and “over one year” to differentiate between those who were newly diagnosed and not.
Data analysis
Descriptive statistics and bivariate regression models were run to characterize socio-demographics of the population and the associations between selling sex and the outcomes of interest. Multivariable mixed-effects logistic regression models (GLMM) with a random effect for study site were used to test for associations of sex trade involvement and HIV or non-HIV service utilization outcomes. Models adjusted for age, race, gender, history of incarceration and substance use, being insured, homelessness, running out of cash, time since first HIV diagnosis, and individuals nested within study sites. Even when not statistically significant at the bivariate level, these variables were kept in the final model based on empirically demonstrated, prior documented research that demonstrated associations with either HIV health care adherence or sex trade involvement (32, 37–41). We needed to consider a range of experiences (e.g. for those recently diagnosed, sex trade could have preceded their HIV diagnosis).
Hosmer-Lemeshow goodness of fit tests were run and checked for collinearity. All tests were two-tailed, statistical significance was evaluated at α=.05, and analyses were conducted using Stata, Version 14 SE (Stata Corp, College Station, TX).
RESULTS
Participants (N=583, median age 45 years, range: 18–78) were majority heterosexual (55.4%), gay/lesbian (29.0%), and bisexual (15.6%), although n=14 (2.4%) did not specify their sexual orientation. (See Table I). Over half were cisgender men (55.1%); 34.1% were cisgender women, and 10.8% identified as transgender women. Most participants were Black/African American (75.5%), and an additional 15.1% were Latino. More than a quarter reported being incarcerated over the past year (29.0%) and 40% were previously incarcerated. Nearly 1 in 5 (19.0%) used illicit drugs in the past 30 days and 16.3% were heavy drinkers in the past 30 days. The majority (82.3%) said they ran out of money over the past year, and 30.4% were homeless; 17% reported having no health insurance. Nine percent had traded (sold) sex and 3.5% had bought sex in the past 90 days. When adjusting for time since diagnosis, there were no significant differences in the proportion that sold sex (7.8% of those diagnosed <1 year vs. 9.2% of those diagnosed 1+ years) (nor 12.2% of those diagnosed 1–4 years vs. 8.7% of those diagnosed 5+ years).
Table I.
Socio-demographic and behavioral characteristics associated with trading sex among participants across seven US community-based sites, n=583
| Total Sample | Sold sex, past 90 days,** No. (%) |
p-value | ||
|---|---|---|---|---|
| n= 583 | Yes (n=52, 9.00) | No (n=526, 91.00) | ||
| Age** | 0.096 | |||
| (median, range) | 45 (18–78) | 43 (18–57) | 46 (18–78) | |
| Race | 0.909 | |||
| Black/African American | 440 (75.47) | 41 (78.85) | 394 (74.90) | |
| Latino | 88 (15.09) | 8 (15.38) | 80 (15.21) | |
| White | 28 (4.80) | 2 (3.85) | 26 (4.94) | |
| Other | 27 (4.63) | 1 (1.92) | 26 (4.94) | |
| Gender | <0.001* | |||
| Cisgender man | 321 (55.06) | 13 (25.00) | 305 (57.98) | |
| Cisgender woman | 199 (34.13) | 16 (30.77) | 182 (34.60) | |
| Transgender woman | 63 (10.81) | 23 (44.23) | 39 (7.41) | |
| Sexual orientation** | 0.605 | |||
| Heterosexual | 315 (55.36) | 27 (54.00) | 285 (55.45) | |
| Gay/Lesbian | 165 (29.00) | 13 (26.00) | 151 (29.38) | |
| Bisexual | 89 (15.64) | 10 (20.00) | 78 (15.18) | |
| Incarceration | 0.031* | |||
| In past 12 months | 169 (28.99) | 14 (26.92) | 152 (28.90) | |
| Yes, but not in past 12 months | 233 (39.97) | 29 (55.77) | 203 (38.59) | |
| Never | 181 (31.05) | 9 (17.31) | 171 (32.51) | |
| Health Insurance*** | >0.999 | |||
| Yes | 484 (83.02) | 43 (82.69) | 436 (82.89) | |
| No | 99 (16.98) | 9 (17.31) | 90 (17.11) | |
| Illicit drug use, past 30 days, excluding marijuana | <0.001* | |||
| Yes | 111 (19.04) | 23 (44.23) | 88 (16.73) | |
| No | 472 (80.96) | 29 (55.77) | 438 (83.27) | |
| Heavy drinking, past 30 days | 0.558 | |||
| Yes | 95 (16.30) | 10 (19.23) | 85 (16.16) | |
| No | 488 (83.70) | 42 (80.77) | 441(83.84) | |
| Ran out of money, past 12 months | 0.127 | |||
| Daily | 104 (17.84) | 16 (30.77) | 87 (16.54) | |
| Weekly | 109 (18.70) | 8 (15.38) | 101 (19.20) | |
| Monthly | 130 (22.30) | 11 (21.15) | 118 (22.43) | |
| Occasionally | 137 (23.50) | 12 (23.08) | 124 (23.57) | |
| Never | 103 (17.67) | 5 (9.62) | 96 (18.25) | |
| Homelessness, past 90 days | <0.001* | |||
| Yes | 177 (30.36) | 28 (53.85) | 146 (27.81) | |
| No | 405 (69.47) | 24 (46.15) | 379 (72.19) | |
| Abused, physically (past 90 days) and/or sexually (past year)** | 0.187 | |||
| Yes | 32 (5.56) | 5 (10.00) | 27 (5.18) | |
| No | 544 (94.44) | 45 (90.00) | 494 (94.82) | |
| Time since first HIV diagnosis | 0.692 | |||
| 1 year or less | 77 (13.58) | 6 (10.58) | 71 (12.52) | |
| Less than a year | 490 (86.42) | 445 (89.42) | 45 (87.48) | |
| HIV clinical care, past 6 months (CD4 count) | >0.999 | |||
| Yes | 374 (64.15) | 33 (63.46) | 337 (64.07) | |
| No | 209 (35.85) | 19 (36.54) | 189 (35.93) | |
| HIV services (e.g. case management), past 12 months | >0.999 | |||
| Yes | 402 (68.95) | 36 (69.23) | 364 (69.20) | |
| No | 181 (31.05) | 16 (30.77) | 162 (30.80) | |
| Received psychological treatment, past 12 months | 0.009* | |||
| Yes | 202 (34.65) | 27 (51.92) | 173 (32.89) | |
| No | 381 (65.35) | 25 (48.08) | 353 (67.11) | |
|
Alcohol or drug treatment,
past 12 months |
0.009* | |||
| Yes | 109 (18.70) | 17 (32.69) | 90 (17.11) | |
| No | 474 (81.30) | 35 (67.31) | 436 (82.89) | |
| Missed any healthcare appointments, past 3 months | 0.068 | |||
| Yes | 208 (35.68) | 25 (48.08) | 182 (34.60) | |
| No | 375 (64.32) | 27 (51.92) | 344 (65.40) | |
Significant at p-value<0.05
Missing: sold sex (n=5); age (n=1); non-identified sexual orientation (n=14); physical/sexual abuse (n=7)
Study recruitment occurred during the implementation of the Affordable Care Act.
Regarding our primary outcomes, given the inclusion criteria (newly diagnosed, or inconsistent or non-utilizers of HIV services), over one-third of participants (35.9%) did not utilize HIV care in the past six months, though over two-thirds of participants (68.9%) utilized HIV support services in the past 12 months. Use of non-HIV services relatively was common, with one-third (34.7%) of participants utilizing mental health services in the past 12 months, and 18.7% utilizing substance abuse treatment in this same timeframe. Conversely, 35.7% of participants missed a healthcare appointment of any type in the past three months.
In bivariate analyses, no significant associations at the p< .05 level with trading sex were observed for utilizing HIV care or HIV support services, or for missing scheduled health care appointments. However, those who recently traded sex were significantly more likely to have utilized psychological help (p=.009) and substance abuse treatment (p=.009) in the past year, and a marginal association with missed health care appointments was observed (p=.068). Recent engagement in sex trade was significantly associated with transgender identity (p<.001), illicit drug use in the past 30 days (p<.001), recent incarceration (p=.031), and homelessness (p<.001).
For the final multivariable regression models (Table II), 558 participants were included; 25 observations were dropped due to missing data on sexual orientation (14 missing), sexual abuse (seven missing), selling sex (five missing), age (one missing), and homelessness (one missing). Participants reporting selling sex in the past 90 days were significantly more likely to report receipt of psychological assistance in the past 90 days (p=.019; OR=2.31, CI: 1.15, 4.67), opposite of what was hypothesized, and missing a health care appointment in the past 3 months (p=.007; OR=2.90, CI: 1.34, 6.28). No other significant associations between selling sex and our outcomes of interest were observed.
Table II.
Socio-demographic and behavioral characteristics associated with selling sex among participants across seven US community-based sites, n=558, adjusting for socio-demographic characteristics*
| HIV care utilization, past 6 months | HIV case management, past 12 months | Received psychological help, past 12 months | Alcohol or drug treatment, past 12 months | Missed any healthcare appointments, past 3 months | |
|---|---|---|---|---|---|
| (Odds Ratio, 95% Confidence Interval) | (OR, 95% CI) | (OR, 95% CI) | (OR, 95% CI) | (OR, 95% CI) | |
| Sold sex, past 90 days | |||||
| Yes | 1.10 (0.52, 2.34) | 0.62 (0.28, 1.37) | 2.31 (1.15, 4.67)** | 1.78 (0.79, 4.03) | 2.90 (1.34, 6.28)** |
| No | Ref. | Ref. | Ref. | Ref. | Ref. |
| Abused physically (past 90 days) and/or sexually (past year) | |||||
| Yes | 2.05 (0.84, 5.02) | 2.98 (1.03, 8.66)** | 1.63 (0.74, 3.59) | 1.45 (0.52, 3.99) | 2.35 (1.03, 5.34)** |
| No | Ref. | Ref. | Ref. | Ref. | Ref. |
| Age | 1.01 (0.99, 1.03) | 1.00 (0.98, 1.02) | 0.99 (0.98, 1.01) | 1.00 (0.98, 1.02) | 0.98 (0.96, 1.00)** |
| Race | |||||
| Black/African American | 1.26 (0.51, 3.12) | 1.64 (0.70, 3.85) | 1.36 (0.53, 3.46) | 1.04 (0.34, 3.21) | 0.42 (0.17, 1.05) |
| Latino | 2.42 (0.85, 6.88) | 1.23 (0.48, 3.19) | 2.17 (0.77, 6.16) | 1.02 (0.28, 3.69) | 0.52 (0.19, 1.44) |
| Other | 2.79 (0.72, 10.86) | 1.56 (0.44, 5.46) | 1.93 (0.56, 6.67) | 1.86 (0.40, 8.69) | 0.48 (0.13, 1.71) |
| White | Ref. | Ref. | Ref. | Ref. | Ref. |
| Gender | |||||
| Cisgender woman | 0.50 (0.28, 0.90) | 1.48 (0.94, 2.33) | 0.93 (0.57, 1.52) | 1.63 (0.85, 3.11) | 0.91 (0.49, 1.69) |
| Transgender woman | 1.34 (0.41, 4.39) | 4.18 (1.58, 11.06)** | 0.95 (0.43, 2.11) | 0.65 (0.20, 2.12) | 0.61 (0.17, 2.16) |
| Cisgender man | Ref. | Ref. | Ref. | Ref. | Ref. |
| Incarceration | |||||
| In past 12 months | 1.25 (0.66, 2.38) | 1.77 (1.03, 3.03)** | 1.70 (0.90, 3.22) | 4.30 (1.82, 10.17)** | 1.10 (0.55, 2.19) |
| Yes, but not in past 12 mos. | 1.04 (0.64, 1.69) | 1.20 (0.74, 1.93) | 1.61 (1.00, 2.60)** | 2.94 (1.39, 6.24)** | 1.74 (1.04, 2.92)** |
| Never | Ref. | Ref. | Ref. | Ref. | Ref. |
| Health Insurance | |||||
| Yes | 2.76 (1.64, 4.66)** | 1.95 (1.18, 3.22)** | 1.43 (0.83, 2.48) | 1.14 (0.55, 2.34) | 1.69 (0.95, 3.03) |
| No | Ref. | Ref. | Ref. | Ref. | Ref. |
| Illicit drug use, past 30 days*** | |||||
| Yes | 0.90 (0.49, 1.65) | 0.82 (0.49, 1.38) | 0.83 (0.45, 1.53) | 2.06 (1.05, 4.02)** | 0.93 (0.48, 1.80) |
| No | Ref. | Ref. | Ref. | Ref. | Ref. |
| Ran out of money, past 12 months | |||||
| Yes | 1.21 (0.72, 2.03) | 1.29 (0.78, 2.13) | 1.74 (1.02, 2.96)** | 1.13 (0.57, 2.25) | 1.86 (1.06, 3.25)** |
| No | Ref. | Ref. | Ref. | Ref. | Ref. |
| Heavy drinking, past 30 days | |||||
| Yes | 0.83 (0.49, 1.41) | 1.08 (0.63, 1.84) | 0.86 (0.52, 1.44) | 1.08 (0.56, 2.09) | 1.36 (0.79, 2.34) |
| No | Ref. | Ref. | Ref. | Ref. | Ref. |
| Homelessness | |||||
| Yes | 0.77 (0.49, 1.21) | 1.18 (0.75, 1.87) | 0.84 (0.54, 1.29) | 1.45 (0.87, 2.43) | 1.27 (0.80, 2.01) |
| No | Ref. | Ref. | Ref. | Ref. | Ref. |
| Time since first HIV diagnosis | |||||
| 1 year or less | 0.60 (0.33, 1.11) | 0.44 (0.25, 0.79)** | 0.32 (0.15, 0.65)** | 0.51 (0.19, 1.39) | 0.43 (0.22, 0.84)** |
| More than a year | Ref. | Ref. | Ref. | Ref. | Ref. |
Individuals are nested within study sites
Odds ratios significant at p-value<0.05
Excluding marijuana
In terms of covariates significantly associated with our HIV care outcomes of interest, participants reporting health insurance had higher odds of utilizing HIV medical care in the past 6 months (p<.001; OR=2.76, CI: 1.64, 4.66), whereas cisgender women compared to cisgender men had lower odds of having an HIV care appointment (p=.020; OR=0.50, CI: 0.28, 0.90). Participants reporting health insurance (p=.009; OR=1.95, CI: 1.18, 3.22), past year physical and/or sexual abuse (p=.045; OR=2.98, CI: 1.03, 8.66), incarceration in the past 12 months (p=.038; OR=1.77, CI: 1.03, 3.03), and transgender women (compared to cisgender men) (p=.004; OR= 4.18, CI: 1.58, 11.06) reported higher odds of receiving HIV support services (e.g. case management).
In terms of covariates associated with utilizing psychological or substance use treatment, participants who ran out of money during the past year had higher odds of receiving psychological care (p=.042; OR=1.74, CI: 1.02, 2.96), where participants diagnosed with HIV less than a year ago were less likely to have received psychological care (p=.002; OR=0.32, CI: 0.15, 0.65). Participants reporting illicit drug use in the past 30 days were more likely to report utilization of substance use treatment (p=.036; OR=2.06, CI: 1.05, 4.02) than those who did not use illicit drugs in the past 30 days, as were participants reporting a history of incarceration (p=.001; OR=4.30, CI: 1.82, 10.17 for those incarcerated in the past 12 months; and p=.005; OR= 2.94, CI: 1.39, 6.24 for those incarcerated previously), relative to those with no incarceration history.
In terms of covariates associated with a missed health care appointment of any kind in the past three months, participants reporting physical and/or sexual abuse in the past year (p=.041; OR=2.35, CI: 1.03, 5.34), those incarcerated prior to the past 12 months relative to no incarceration history (p=.035; OR=1.74, CI: 1.04, 2.92), and those having ran out of money in the past year (p=.031; OR=1.86, CI:1.06, 3.25) had increased odds of missing a clinical appointment. Participants reporting recent (less than a year) HIV diagnosis had lower odds of having missed a clinical appointment (p=.013; OR=0.43, CI: 0.22, 0.84).
Missing a health care appointment of any kind and having an HIV care appointment in the last six months were not necessarily mutually exclusive categories because healthcare appointment could also be an HIV appointment. Overall, 64.2% had an HIV care appointment in the past 6 months, and 35.8% did not. Of those with an HIV care appointment in the past 6 months, 62.3% said they never missed a healthcare appointment in the past 3 months. However, 37.7% of those with a HIV care appointment in the past 6 months reported missing a healthcare appointment in the past 3 months. Of those who did not have an HIV care appointment in the past 6 months (35.8%), 32.1% said they missed a healthcare appointment in the last 3 months (therefore a non-HIV medical care appointment), and 67.9% said they did not miss their healthcare appointments. Therefore, whether or not they had an HIV care appointment, 32–38% missed a healthcare appointment, and 35.8% had no HIV care appointment in the past 6 months.
The adjusted models also show that participants who had been diagnosed <1 year were significantly less likely than those who had been diagnosed more than a year to receive HIV case management (p=.006; OR=0.44, CI: 0.25, 0.79) and to receive psychological help (p=.002; OR=0.32, CI: 0.15, 0.65).
DISCUSSION
Among persons living with HIV across six cities in this US study, one in eleven people was found to have traded sex in the past 90 days. The overlap between sex trade and homelessness reinforces indications that many PLWH are suffering from economic deprivation and may be turning to sex trade for survival. Findings further demonstrate that social marginalization- transgender identity, recent incarceration, and illicit drug use- is linked with sex trade involvement among PLWH, and that engaging in the sex trade can increase the likelihood of missing health care appointments. Sex trade involvement, especially when living with HIV, remains greatly stigmatized [42, 43]. Those trading sex were also more likely to use illicit drugs, but were not more likely to utilize substance use treatment, suggesting a greater need to address drug use in this population. Globally, such associations of sex trade and substance use have been seen among PLWH [3,4], but until now, this has not been well documented among persons living with HIV in the US. The results of this paper provide insights into the potential effects sex trade may have on engagement in HIV care and non-HIV related health services, particularly among racial and sexual minority PLWH in the US [44,45].
Importantly, utilization of HIV care was less likely to occur for cisgender women compared to cisgender men, a finding consistent in the literature [46–48]. Women living with HIV experience greater barriers to care, largely due to fears of disclosing their HIV status [49], as well as experiencing structural barriers [50], depression, and trauma [51, 52]. More research is needed on strategies to get women into care in the US [53, 54] and on antiretroviral medication.
Additionally, we sought to understand whether sex trade involvement and other factors presented a barrier to health care appointments. Although no associations existed between trading sex and recent HIV care utilization in this study, trading sex was associated with missing health care appointments in general. Those who were physically and/or sexually abused in the past year, who had an incarceration history, and who reported running out of money were also more likely to miss health care appointments. These findings may be a result of barriers to care resulting from vulnerable conditions faced by PLWH and have implications for quality of life issues for those having difficulty following up on their health care appointments [3–5]. In addition, missed medical visits among PLWH have been identified as a factor associated with poorer virologic suppression and increased risk for mortality [55, 56]. While we did not observe sex trade involvement affecting recent use of HIV care, the observed association with missed health care appointments raises further questions about the potential long-term health impacts of economic deprivation, sex trade, and HIV treatment success.
Notably, participants with health insurance were three times more likely to have an HIV care visit in the past six months and nearly two times more likely to have accessed HIV support services. Few studies have documented the effect health insurance has on the utilization of health care in the US for PLWH, but some have documented problems with the quality or lack of health insurance for PLWH in other parts of the world [57, 58]. In other studies, having health insurance has been shown to increase the likelihood of people returning for their HIV test results [59]. Also, having no access to Medicaid prior to the US Patient Protection and Affordable Care Act (PPACA) [60] left many PLWH without health care coverage. These findings reinforce the need for health insurance coverage for PLWH in terms of affecting quality of life [61] as well as the need for non-stigmatizing, quality health insurance [62]. Without the PPACA, many more would likely have been without insurance in this study, not including those excluded from PPACA because of their undocumented or immigration status (documented but within 5 years of entering the country). With 20 million previously uninsured Americans now covered under PPACA [63], and PPACA as a significant source of coverage for PLWH [64], a dismantling of the PPACA would result in sharp decreases in the insured, especially among people of color, women, and those with pre-existing conditions [63].
Surprisingly, those who sold sex also had greater odds of receiving recent psychological treatment, which was in the opposite direction of the hypothesis. Perhaps the finding may be explained by the fact PLWH who trade sex often face greater trauma or mental health diagnoses than those who don’t trade sex [65–67]. Studies show a high prevalence of mental health disorders among harder-to-reach persons living with HIV, and that poorer mental health was associated with sexual violence and stigma experiences [68], experiences also heightened by involvement in the sex trade. Additionally, those who ran out of money during the past year in the current study were less likely to utilize psychological services, indicating that destabilization may be more influential than stigma in the population as explained by the participants’ increased likelihood of missed healthcare appointments.
The findings of this study highlight the prevalence of trading sex in the context of illicit drug use and the need to improve their access to substance use services. Substance use was higher for those selling sex, confirming other research on PLWH who have traded sex for money and drugs [69]. In the current study, those accessing substance use services were more likely to occur for participants with any incarceration history and for those who reported engaging in illicit drug use in the past 30 days, rather than for those who sold sex. These findings highlight the need for more attention to those who trade sex and use drugs. In the absence of treatment, research has shown that alcohol and substance use has a negative effect on ART adherence and subsequent viral suppression, emphasizing likely consequences of not utilizing substance use treatment among PLWH engaged in sex trade [70].
Transgender women (compared to cisgender men), and participants who were incarcerated in the past 12 months (compared to those with no incarceration history), and those who were abused, were more likely to access HIV support services. Transgender women in this study experienced high levels of violence, as found in the literature [71], and both being a transgender individual and/or experiencing violence have typically posed barriers to care. An explanation for this study’s contradictory findings is that transgender women in San Francisco [72] and those recently released from incarceration in New York City [73] in our study may have better access to case management because of the specialized services and policies for transgender persons and prisoners in those cities. The US Patient Protection and Affordable Care Act of 2010 [57], and coverage of hormone treatments for transgender persons in certain geographic areas, may have also increased these populations’ utilization of HIV support services. Likewise, those who have been abused or incarcerated in the past year may have been more likely to access HIV support services in the current study due to their higher likelihood of coming into contact with HIV case management services, either in jail or after a police report. Nevertheless, these results emphasize the need to further study the impact that specific state and local provisions of care have on transgender, incarcerated, and abused populations.
Also, time since diagnosis appeared to make a difference in this study. Participants who had been diagnosed with HIV for less than a year were less likely to miss healthcare appointments in general, but they were also less likely to receive HIV support services and psychological help. However, more than one in five of those first HIV diagnosed for a year or less did not have an HIV care appointment in the past 12 months, which is worth noting because the first year is usually a critical time to have an appointment. These results have implications for who are linked and retained in HIV treatment, and for patterns of health seeking behavior among the newly diagnosed. Studies show higher antiretroviral (ARV) drug resistance in newly diagnosed individuals among African American MSM and transgender individuals compared to other populations [74]. Likewise, our findings could be from participant denial, stigma, or lack of awareness about HIV services, or merely a result of newly diagnosed individuals having less time to access services, which needs further exploration [75].
Unfortunately, those who tested positive for HIV for the first time was not systematically collected at the study sites. However, generally speaking, sites reported very low cases of HIV identified through their testing efforts (0–3 per year). Therefore, it is not possible to check whether those who just tested positive for the first time were included among those not engaged in treatment for the past 6 months. However, by the very low rates of new diagnoses at the study sites, we can assume most were not very newly diagnosed.
Other limitations of this study include the cross-sectional nature of the baseline data, and generalizability may be limited to contexts of the sites in this US study. Timeframes also varied across variables, as did the community-based sites and populations of interest. However, variations across sites were controlled for with a nested design and included population differences as covariates when possible. Missing general healthcare appointments as a finding should be interpreted with caution because those who had access to medical insurance were more likely to report having missed healthcare appointments than those who were without any appointments due to being uninsured. Furthermore, missing health care appointments does not necessarily translate into not receiving HIV or non-HIV-related services. Also, the study occurred during the roll out of PPACA, with some sites located in states that accepted Medicaid expansion dollars. Therefore, it was difficult to determine whether or not participants had access to health insurance at the time they were surveyed.
CONCLUSIONS
One in eleven PLWH in our study reported selling sex in the past 90 days, and selling sex was associated with social deprivation (homelessness) and social marginalization (transgender identity, recent incarceration, and recent illicit drug use), suggesting that these individuals are turning to sex as a means of survival. Further, trading sex was associated with missed medical appointments, possibly due to less stability and greater stigma, again related to social deprivation and marginalization. More social and economic supports for PLWH may help reduce reliance on sex trade, and increase consistency in health care use, particularly for socially marginalized groups such as transgender women, those exiting prison, and those actively using drugs. Additional findings in this study highlight the lack of health insurance and money as key drivers of non-utilization of services. Again, these findings highlight the importance of economic supports and health care for PLWH. Overall, these findings highlight that while access to medical care is important, housing stability and economic opportunity combined with health care coverage are key to ensuring the health and safety of PLWH in the US.
Acknowledgements
The authors would like to thank the community-based agencies, staff, and participants of the larger HIV Test and Treat initiative, as well as the Kaiser Permanente Community-Based HIV Test and Treat Study Team (Alexandra X. Caraballo, John Edmiston, Pamela M. Schwartz, Melissa Ramos), without whom this study would not be possible. We are also indebted to the countless hours of administrative and analytic support provided by Sankari Ayyaluru, Emma Jackson, Sanne P. Møller and Osika Tripathi, respectively. The writing/analysis of this manuscript was also supported by NIDA K01036439 (Urada) & NIDA K01039767 (Smith).
Footnotes
Compliance with Ethical Standards
Conflict of interest: The authors declare that they have no conflict of interest.
Ethical Approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Sites obtained site-specific institutional review board approval, and the Institutional Review Board of the University of California San Diego provided approval for the overall cross-site evaluation study protocol (ref: 130077/2013).
Informed Consent: Informed consent was obtained from all individual participants included in the study.
REFERENCES
- 1.Shannon K, Strathdee SA, Goldenberg SM, et al. Global epidemiology of HIV among female sex workers: influence of structural determinants. Lancet 2015. January; 385(9962):55–71. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Steen R, Wheeler T, Gorgens M, Mziray E, Dallabetta G. Feasible, Efficient and Necessary, without Exception - Working with sex workers interrupts HIV/STI transmission and brings treatment to many in need. PLoS One 2015. October; 10(10): e0121145. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Decker MR, Beyrer C, Sherman SG. Ending the invisibility of sex workers in the US HIV/AIDS surveillance and prevention strategy AIDS 2014. September; 28(15): 2325–2327. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Loutfy M, Johnson M, Walmsley S, et al. The association between HIV disclosure status and perceived barriers to care faced by women living with HIV in Latin America, China, Central/Eastern Europe, and Western Europe/Canada. AIDS Patient Care STDS 2016. September; 30(9):435–44. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Dunne EM, Dyer TP, Khan MR, Cavanaugh CE, Melnikov A, Latimer WW. HIV prevalence and risk behaviors among African American women who trade sex for drugs versus economic resources. AIDS Behav 2014. July;18(7):1288–92. [DOI] [PubMed] [Google Scholar]
- 6.Gerassi LB, Jonson-Reid M, Plax K, Kaushik G. Trading sex for money or compensation: prevalence and associated characteristics from a sexually transmitted infection (STI) clinic sample. J Aggress Maltreat Trauma 2016; 25(9):909–920. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Centers for Disease Control and Prevention (CDC). HIV infection among heterosexuals at increased risk--United States, 2010. MMWR Morb Mortal Wkly Rep 2013. March; 62(10):183–8. [PMC free article] [PubMed] [Google Scholar]
- 8.Gardner EM, McLees MP, Steiner JF, del Rio C, Burman WJ. The spectrum of engagement in HIV care and its relevance to test-and-treat strategies for prevention of HIV infection. Clin Infect Dis 2011; 52(6): 793–800. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Arnold EA, Weeks J, Benjamin M, et al. Identifying social and economic barriers to regular care and treatment for Black men who have sex with men and women (BMSMW) and who are living with HIV: A qualitative study from the Bruthas cohort. BMC Health Serv Res 2017. January;17(1):90. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Mendoza C, Barrington C, Donastorg Y, et al. Violence from a sexual partner is significantly associated with poor HIV care and treatment outcomes among female sex workers in the Dominican Republic. J Acquir Immune Defic Syndr 2017. March; 74(3): 273–278. [DOI] [PubMed] [Google Scholar]
- 11.Barrington C, Acevedo R, Donastorg Y, Perez M, Kerrigan D. ‘HIV and work don’t go together’: Employment as a social determinant of HIV outcomes among men who have sex with men and transgender women in the Dominican Republic. Glob Public Health 2016. March; 1–16. [DOI] [PubMed]
- 12.Lion RR, Watt MH, Wechsberg WM, Meade CS. Gender and sex trading among active methamphetamine users in Cape Town, South Africa. Subst Use Misuse 2017. May; 52(6):773–784. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Kim S, Johnson TP, Goswami S, Puisis M. Risk factors for homelessness and sex trade among incarcerated women: A structural equation model. J Int Womens Stud 2011; 12(1):128–148. [PMC free article] [PubMed] [Google Scholar]
- 14.Urada LA, Strathdee SA, Morisky DE, et al. Sex work and its associations with alcohol and methamphetamine use among female bar and spa workers in the Philippines. Asia-Pacific Journal of Public Health 2013; 26(2):138–146. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Risher K, Mayer K, Beyrer C. The HIV treatment cascade in men who have sex with men, people who inject drugs and sex workers. Curr Opin HIV AIDS 2015. November; 10(6): 420–429. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Hall BJ, Sou KL, Beanland R, et al. Barriers and facilitators to interventions improving retention in hiv care: a qualitative evidence meta-synthesis. AIDS Behav 2017. June; 21(6):1755–1767. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Govindasamy D, Ford N, Kranzer K. Risk factors, barriers and facilitators for linkage to antiretroviral therapy care: a systematic review. AIDS 2012. October; 26(16):2059–67. [DOI] [PubMed] [Google Scholar]
- 18.Burnette ML, Lucas E, Ilgen M, Frayne SM, Mayo J, Weitlauf JC. Prevalence and health correlates of prostitution among patients entering treatment for substance use disorders. Arch Gen Psychiatry 2008. March; 65(3):337–44. doi: 10.1001/archpsyc.65.3.337. [DOI] [PubMed] [Google Scholar]
- 19.Ganju D, Saggurti N. Stigma, violence and HIV vulnerability among transgender persons in sex work in Maharashtra, India. Cult Health Sex 2017. January; 30:1–15. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Goldenberg SM, Krüsi A, Zhang E, Chettiar J, Shannon K. Structural determinants of health among immigrants in the indoor sex industry: experiences of workers and managers/owners in Metropolitan Vancouver. PLoS One 2017. January; 12(1):e0170642. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Raj A, Clarke JG, Silverman JG, et al. Violence against women associated with arrests for sex trade but not drug charges. Int J Law Psychiatry 2006; 29:204–211. [DOI] [PubMed] [Google Scholar]
- 22.Silverman JG, Raj A, Cheng DM, et al. Sex trafficking and initiation-related violence, alcohol use, and HIV risk among HIV-infected female sex workers in Mumbai, India. J Infect Dis 2011; 204(suppl 5): S1229–S1234. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Silverman JG. Adolescent female sex workers: Invisibility, violence and HIV. Arch Dis Child 2011; 96:478–481. [DOI] [PubMed] [Google Scholar]
- 24.Decker MR, McCauley HL, Phuengsamran D, Janyam S, Silverman JG. Sex trafficking, sexual risk, sexually transmitted infection and reproductive health among female sex workers in Thailand. J Epidemiol Community Health 2011; 65:334–339. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Shannon K, Strathdee S, Shoveller J, Zhang R, Montaner J, Tyndall M. Crystal methamphetamine use among female street-based sex workers: moving beyond individual-focused interventions. Drug Alcohol Depend 2011; 113: 76–81 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Semple SJ, Strathdee SA, Zians J, Patterson TL. Correlates of trading sex for methamphetamine in a sample of HIV-negative heterosexual methamphetamine users. J Psychoactive Drugs 2011; 43:79–88. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Kang D, Liao M, Jiang Z, et al. Commercial sex venues, syphilis and methamphetamine use among female sex workers. AIDS Care 2011; 23(suppl 1):26–36. [DOI] [PubMed] [Google Scholar]
- 28.Couture MC, Evans JL, Sothy NS, et al. Correlates of amphetamine-type stimulant use and associations with HIV-related risks among young women. Drug Alcohol Depend 2012. January; 120(1–3):119–26. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Urada LA, Morisky DE, Hernandez LI, Strathdee SA. Social and structural factors associated with consistent condom use among female entertainment workers trading sex in the Philippines. AIDS Behav February;17(2):523–35. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Strathdee SA, Lozada R, Martinez G, et al. Social and structural factors associated with HIV infection among female sex workers who inject drugs in the Mexico-US border region. PLoS One 2011;6(4):e19048. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31.Urada LA, Morisky DE, Pimentel-Simbulan N, Silverman JG, Strathdee SA. Condom negotiations among female sex workers in the Philippines: Environmental influences. PLoS One 2012;7(3):e33282. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.Urada LA, Raj A, Cheng DM, et al. History of intimate partner violence is associated with sex work but not STI among HIV-positive female drinkers in Russia. International Journal of STD/AIDS 2013; 24(4), 287–292. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Gilbert L, El-Bassel N, Chang M, Wu E, Roy L. Substance use and partner violence among urban women seeking emergency care. Psychol Addict Behav 2012;26:226–235. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34.Gilbert L, Raj A, Hien D, Stockman J, Terlikbayeva A, Wyatt G. Targeting the SAVA (substance abuse, violence, and AIDS) syndemic among women and girls: A global review of epidemiology and integrated interventions. J Acquir Immune Defic Syndr 2015. June;69 Suppl 2:S118–27. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35.Babor TF, Higgins-Biddle JC, Saunders JB, et al. AUDIT: the alcohol use disorders identification test guidelines for use in primary care: World Health Organization; Geneva: Switzerland: 2001. [Google Scholar]
- 36.Knight K, Simpson DD, Hiller ML. Screening and referral for substance-abuse treatment in the criminal justice system. In: Leukefeld CG, Tims F, Farabee D, eds. Treatment of drug offenders: Policies and issues New York: Springer; 2002. [Google Scholar]
- 37.Heestermans T Browne JL, Aitken SC, Vervoort SC, Klipstein-Grobusch K. Determinants of adherence to antiretroviral therapy among HIV-positive adults in sub-Saharan Africa: a systematic review. BMJ Glob Health 2016. December 30;1(4):e000125. doi: 10.1136/bmjgh-2016-000125.eCollection2016. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 38.Abgrall S, Del Amo J. Effect of sociodemographic factors on survival of people living with HIV. Curr Opin HIV AIDS 2016. September;11(5):501–506. [DOI] [PubMed] [Google Scholar]
- 39.Buttram ME, Kurtz SP. A mixed methods study of health and social disparities among substance-using African American/Black men who have sex with men. J Racial Ethn Health Disparities 2015. March;2(1):1–10. doi: 10.1007/s40615-014-0042-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 40.Howe CJ, Cole SR, Napravnik S, et al. The role of at-risk alcohol/drug use and treatment in appointment attendance and virologic suppression among HIV(+) African Americans. AIDS Res Hum Retroviruses 2014. March;30(3):233–40. doi: 10.1089/AID.2013.0163. Epub 2014 Jan 20. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 41.Raj A, Reed E, Santana MC, et al. The associations of binge alcohol use with HIV/STI risk and diagnosis among heterosexual African American men. Drug Alcohol Depend 2009. April 1;101(1–2):101–6. doi: 10.1016/j.drugalcdep.2008.11.008. Epub 2008 Dec 30. [DOI] [PubMed] [Google Scholar]
- 42.Strathdee SA, West BS, Reed E, Moazen B, Azim T, Dolan K. Substance use and HIV among female sex workers and female prisoners: Risk environments and implications for prevention, treatment, and policies. J Acquir Immune Defic Syndr 2015. June;69 Suppl 2:S110–7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 43.Kalemi G, Gkioka S, Tsapatsari P, et al. Stigma and self-esteem: A case of HIV-positive sex-workers. Psychiatriki 2017. Jan-Mar;28(1):67–74. [DOI] [PubMed] [Google Scholar]
- 44.Hoots BE, Finlayson TJ, Wejnert C, Paz-Bailey G. National HIV Behavioral Surveillance (NHBS) Study Group. Updated data on linkage to human immunodeficiency virus care and antiretroviral treatment among men who have sex with Men-20 Cities, United States. J Infect Dis 2017. March 29; [Epub ahead of print]. [DOI] [PMC free article] [PubMed]
- 45.Gorbach PM, Javanbakht M, Bornfleth L, Bolan RK, Lewis Blum M. Drug resistant HIV: Behaviors and characteristics among Los Angeles men who have sex with men with new HIV diagnosis. PLoS One 2017. March;12(3):e0173892. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 46.Clark KA, Keene DE, Pachankis JE, Fattal O, Rizk N, Khoshnood K. A qualitative analysis of multi-level barriers to HIV testing among women in Lebanon. Cult Health Sex 2017. February; 13:1–15. [DOI] [PubMed] [Google Scholar]
- 47.Puskas CM, Kaida A, Miller CL, et al. The gender gap: a longitudinal examination of men’s and women’s art adherence in British Columbia, 2000–2014. AIDS 2017. January 21 [Epub ahead of print]. [DOI] [PubMed]
- 48.Ho SS, Holloway A. The impact of HIV-related stigma on the lives of HIV-positive women: an integrated literature review. J Clin Nurs 2016. January; 25(1–2):8–19. [DOI] [PubMed] [Google Scholar]
- 49. Onu C, Ongeri L, Bukusi E, et al. Interpersonal psychotherapy for depression and posttraumatic stress disorder among HIV-positive women in Kisumu, Kenya: study protocol for a randomized controlled trial. Trials 2016. February;17:64 Erratum in: Trials. 2016;17(1):151. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 50.Sales JM, Swartzendruber A, Phillips AL. Trauma-informed HIV prevention and treatment. Curr HIV/AIDS Rep 2016. December;13(6):374–382. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 51.Kinsler JJ, Wong MD, Sayles JN, Davis C, Cunningham WE. The effect of perceived stigma from a health care provider on access to care among a low-income HIV-positive population AIDS patient care and STDs 2007. August; 21(8): 584–592. [DOI] [PubMed] [Google Scholar]
- 52.Nyblade L, Stangl A, Weiss E, Ashburn K. Combating HIV stigma in health care settings: what works? Journal of the International AIDS Society 2009; 12:15. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 53.McMahon SA, Kennedy CE, Winch PJ, Kombe M, Killewo J, Kilewo C. Stigma, facility constraints, and personal disbelief: Why women disengage from HIV care during and after pregnancy in Morogoro Region, Tanzania. AIDS Behav 2017. January; 21(1): 317–329. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 54.Adam GP, Di M, Cu-Uvin S, Halladay C, Smith BT, Trikalinos TA. Strategies for improving the lives of women aged 40 and above living with HIV/AIDS [Internet] Rockville (MD): Agency for Healthcare Research and Quality (US); 2016. November Report No.:16(17)-EHC040-EF. [PubMed] [Google Scholar]
- 55.Mugavero MJ, Lin HY, Willig JH, et al. Missed visits and mortality among patients establishing initial outpatient HIV treatment. Clin Infect Dis 2009. January; 48(2): 248–56. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 56.Mugavero MJ, Lin HY, Allison JJ, et al. Racial disparities in HIV virologic failure: do missed visits matter? J Acquir Immune Defic Syndr 2009. January; 50(1):100–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 57.Johs NA, Wu K, Tassiopoulos K, et al. Disability among middle-aged and older persons with HIV infection. Clin Infect Dis 2017. March; [Epub ahead of print]. [DOI] [PMC free article] [PubMed]
- 58.Heimer R, Usacheva N, Barbour R, Niccolai LM, Uusküla A, Levina OS. Engagement in HIV care and its correlates among people who inject drugs in St. Petersburg, Russian Federation and Kohtla-Järve, Estonia. Addiction 2017. August; 112(8):1421–1431. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 59.Ngangue P, Bedard E, Zomahoun HT, et al. Returning for HIV Test results: A systematic review of barriers and facilitators. Int Sch Res Notices 2016. December; 2016:6304820. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 60.Patient Protection and Affordable Care Act, 42 U.S.C. § 18001 et seq (2010). Available at: https://www.ihs.gov/ihcia/includes/themes/newihstheme/display_objects/documents/home/PL111_148_PPACA.pdf
- 61.Nguyen QL, Nguyen LH, Tran BX. Co-financing for viral load monitoring during the course of antiretroviral therapy among patients with HIV/AIDS in Vietnam: A contingent valuation survey. PLoS One 2017. February;12(2):e0172050. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 62.Burnette ML, Lucas E, Ilgen M, Frayne SM, Mayo J, Weitlauf JC. Prevalence and health correlates of prostitution among patients entering treatment for substance use disorders. Arch Gen Psychiatry 2008; 65(3):337–44. [DOI] [PubMed] [Google Scholar]
- 63.Uberoi N, Finegold K, Gee E (March 3, 2016). Health Insurance Coverage and the Affordable Care Act, 2010–2016 U.S. Department of Health and Human Services Office of the Assistant Secretary for Planning and Evaluation. Available at: https://aspe.hhs.gov/system/files/pdf/187551/ACA2010-2016.pdf [Google Scholar]
- 64.Kaiser Family Foundation. Current Status of State Medicaid Expansion Decisions. Available at: http://kff.org/health-reform/slide/current-status-of-the-medicaid-expansion-decision/
- 65.Maman S, Mbwambo JK, Hogan NM, et al. HIV-positive women report more lifetime partner violence: findings from a voluntary counseling and testing clinic in Dar es Salaam, Tanzania. Am J Public Health 2002. August;92(8):1331–7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 66.Lane T, Osmand T, Marr A, et al. The Mpumalanga Men’s Study (MPMS): Results of a baseline biological and behavioral HIV surveillance survey in two MSM communities in South Africa. PLoS One 2014. November; 9(11):e111063. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 67.Erickson M, Goldenberg SM, Akello M, et al. Incarceration and exposure to internally displaced persons camps associated with reproductive rights abuses among sex workers in northern Uganda. J Fam Plann Reprod Health Care 2017. July;43(3):201–209. [DOI] [PubMed] [Google Scholar]
- 68.Salters KA, Irick M, Anema A, et al. Harder-to-reach people living with HIV experiencing high prevalence of all-type mental health disorder diagnosis. AIDS Care 2016. September; 9:1–9. [DOI] [PubMed] [Google Scholar]
- 69.Mbonye M, Rutakumwa R, Weiss H, Seeley J. Alcohol consumption and high risk sexual behaviour among female sex workers in Uganda. Afr J AIDS Res 2014;13(2):145–51. [DOI] [PubMed] [Google Scholar]
- 70.Nolan S, Walley AY, Herren TC, et al. HIV-infected individuals who use alcohol and other drugs, and virologic suppression. AIDS Care 2017. September; 29(9):1129–1136. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 71.Lerner JE, Robles G. Perceived Barriers and Facilitators to Health Care Utilization in the United States for Transgender People: A Review of Recent Literature. J Health Care Poor Underserved 2017; 28(1):127–152. [DOI] [PubMed] [Google Scholar]
- 72.San Francisco Department of Public Health. Transgender Health Services. https://www.sfdph.org/dph/comupg/oprograms/THS/communityresources.asp.
- 73.City of New York. Inmate Jail Release Services. http://www1.nyc.gov/nyc-resources/service/1157/inmate-jail-release-services.
- 74.Gorbach PM, Javanbakht M, Bornfleth L, Bolan RK, Lewis Blum M. Drug resistant HIV: Behaviors and characteristics among Los Angeles men who have sex with men with new HIV diagnosis. PLoS One 2017. March; 12(3):e0173892. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 75.Naar-King S, Bradford J, Coleman S, Green-Jones M, Cabral H, Tobias C. Retention in care of persons newly diagnosed with HIV: outcomes of the Outreach Initiative. AIDS Patient Care STDS 2007;21 Suppl 1:S40–8. [DOI] [PubMed] [Google Scholar]