Table 1.

Studies reporting on factors affecting viral suppression among women living with HIV in the United States.

Authors	Purpose/objectives	Design	Data source and study period	Sample size and characteristics	Intervention/procedure	Variables	Findings
Blank et. al. 23	Prospectively examined factors associated with viral suppression in women of color.	Cohort	Data from eight Health Resources and Services Administration (HRSA)-sponsored HIV programs across the U.S. Study period: not reported.	921 non-Caucasian or White adult women Average age: 42 years.	Applied predictive model to determine factors related to HIV care retention and viral suppression 12 months after baseline interviews.	HIV care retention: ⩾ 2 medical care visits ⩾ 90 days apart in 12 months. Viral suppression: most recent viral load in the last 12 months Viral load cut off: < 200 copies/mL.	Living with someone the past 3 months was associated with less suppression, current substance use, self-reported poor or fair health, and having more than 14 days of limited activity were associated with higher viral loads. However, being African American, medication adherence at baseline, not seeking care at baseline, and concerns about the impact of HIV management on family were associated with viral suppression. Undecided about care at baseline, having children below 18 years, thoughts that nothing can help HIV condition, housed in institutional facilities (such as substance use programs, psychiatry facilities) were associated with less retention. Also, having ⩾ 14 mentally unhealthy days per month and have lived in the United States for ⩾ 5 years were associated with higher retention.
Hanna et al. 24	To compare the effectiveness of single-tablet versus multiple-tablets and how they impact HIV- related outcomes (including adherence and quality of life).	Cohort	Women’s Interagency HIV Study (WIHS), 2006 to 2013	1727 adult women participating in WIHS across the United States Average age: 47 years.	Women self-reported the frequency of their prescribed medication use over the past 6 months. Quality of life was assessed using the Medical Outcomes Study-HIV score, AIDS events were assessed through self-reports and viral suppression at 6-month intervals measured through viral load test results.	ART adherence: ⩾ 95% of medication use. Viral suppression: having < 80 copies/mL. Incidence of AIDS: self-reported or through matches with cancer and tuberculosis registries and death. Viral load cut off: < 80 copies/mL	Single-tablet regimens were significantly associated with increased treatment adherence and viral suppression. But single-tablet regimens were not significantly associated with quality of life and AIDS-defining events.
Kelso et al. 25	To examine critical consciousness in relation to perceived racial and gender discrimination and HIV-related outcomes.	Cohort	CORE Center, Chicago site of the WIHS, 2009 to 2010	67 African American women from the WHIS Chicago who had semi-annual WIHS visits between October 1, 2009, and March 31, 2010 Average age: 46 years.	Participants participated in structured interviews. Self-reported data on HIV health history, HAART use adherence, perceived racial and gender discrimination, and critical consciousness were also collected.	HAART adherence: ⩾ 95% of medication use. CD4 count: < 350 cells/mm3 was considered poor HIV health. Viral load for detectable or undetectable. Viral load cut off: ⩾ 50 copies/mL	Higher critical consciousness was associated with a higher CD4 count. High perceived racial discrimination was associated with detectable viral loads. Women with high perceived racial discrimination and high critical consciousness were significantly less likely to have detectable viral load and were more likely to have CD4 above 350 cells/mm3 Perceived racial and perceived gender discrimination were positively correlated with critical consciousness but not significantly related to CD4 and viral loads.
Lazenby et al. 13	To determine the risk of contracting HIV among infants born in rural counties.	Cohort	South Carolina Department of Health and Environmental Control enhanced HIV/AIDS Reporting System (eHARS), 2004 to 2014	666 women in South Carolina who had babies between 2004 and 2014 Average age: not reported.	Evaluated HIV-related maternal data. Compared most recent viral load data before delivery to post-partum data (⩽12 weeks after delivery), then ART use before and during delivery.	Maternal outcomes: Viral load Neonatal outcomes: preterm birth (< 37 weeks), low birth weight (< 2500 grams), death (demise ⩽ 6 weeks postdelivery Viral load cut off: < 40 copies/mL	Maternal outcomes: Women in rural counties were less likely to be virally suppressed, but combination ART of ⩾ 3 regimens decreased viral loads. Intra- and post-partum maternal HIV diagnoses, parenteral drug use, and preterm birth were associated with perinatal HIV infection. Neonatal outcomes: 868 pregnancies and 885 babies. 1.5% of the babies died, 1.2% had HIV. Preterm birth and low birth weights between babies delivered in rural and urban were (21% versus 22%) and (28% versus 26%) respectively.
Ludema et al. 26	To estimate the effect of health insurance and income on viral suppression among WHIS participants.	Cohort	WIHS, 2006 to 2009	1481 HIV-positive infected women enrolled in WIHS and had viral load measurement at their 24th visit or after six months. Average age: 38 years	Participants were characterized based on access and type of insurance. Participation in AIDS Drug Assisted Program and income were self-reported by participants during each semi-annual WIHS visits and viral loads were measured during those visits.	Virologic failure: maintaining < 200 copies/mL after confirmed < 80 copies/mL, insurance status, insurance type, and income Viral load cut off: < 200 copies/mL	Having private insurance was associated with viral suppression. Women with no insurance but were participants of ADAP were more likely to be virally suppressed than Medicaid beneficiaries or uninsured women without ADAP.
McFall et al. 27	To describe racial/ethnic differences in virologic failure then, determine behavioral, psychosocial, socioeconomic, and healthcare-related correlates of virologic failure among HIV-positive women using HAART.	Cohort	WIHS, 2006 to 2011	887 women on HAART, virally suppressed six months before the study and were enrolled in WHIS between April 1, 2006, and March 31, 2011 Average age: not reported.	Data analysis of WIHS HIV-infected women on HAART between April 1, 2006, and March 31, 2011.	Virological failure: not having consistent viral load below 200 copies/mL Viral load cut off: < 200 copies/mL	Being Hispanic or White was significantly associated with a lower risk of virologic failure compared to being African American. Born in the United States, having a household income below $24,000, depressive symptoms, smoking, alcohol use, and no ADAP participation were significantly associated with virologic failure.
McKinney et al. 28	To evaluate HIV-adapted group prenatal care effects on viral suppression and post-partum retention in HIV- primary care.	Cohort	Primary data from a community-based health center in Houston, 2013 to 2019	194 English and Spanish-speaking HIV-positive women at a community-based health center in Houston, Texas, who had babies between September 1, 2013, and July 31, 2019. Average age: 29 years.	Women self-selected group or individual prenatal care. Both categories received clinical case management and social work services. Participants in group care participated in additional discussions on pregnancy and HIV-related topics. Groups comprised of 4 to 12 participants who had due dates within 8 weeks. Group sessions were 10 two-sessions led by an obstetrician, nurse practitioner, and/or social worker.	Viral suppression within 12 months post-partum and post-partum care retention. Viral load cut off: < 20 copies/mL	Women who participated in group prenatal care were more likely to be virally suppressed during delivery and within 12 months post-delivery. Parental group care was significantly associated with more prenatal care visits and having at least one primary care visit within 12 months post-partum.
Mills et al. 29	To estimate the effects of cumulative depression on HIV care appointments, ART adherence, and virologic failure.	Cohort	WIHS, 2013 to 2017	1491 HIV-infected women enrolled in WIHS between 2013 and 2017. Average age: 48 years	Participants completed questionnaires related to mental health and HIV during each semi-annual WIHS visits between 2013 and 2017. Afterward, baseline data were compared to final data.	Missed visits: HIV care visits missed in the last six months, ART adherence: 95% of medication use, Virologic failure: ⩾ 20 copies/mL Viral load cut off: < 200 copies/mL	Forty-six percent of the women had depressive symptoms. Percent of days depressed (PDD) or higher time spent depressed increased the risk of virologic failure. Also, PDD increased the risk of being < 95% adherent to ART and the likelihood of missing HIV care appointments. A twenty-five percent PDD increased the risk of nonadherence by 27%, missed appointments by 16%, and virologic failure by 8%.
Okonsky et al. 30	To examine reasons why women miss their medications and how results can improve patient-centered adherence research.	Cross-sectional	Data from questionnaires administered in Cleveland, Ohio, and San Francisco and Oakland, California from October 2010 through March 2011.	206 English speaking adult women with HIV diagnosis. Average age: 47 years	Participants completed 45–60 min questionnaire on demographic and HIV-related clinical information delivered at medical clinics and community support organizations.	Viral loads, CD4 count, ART adherence: < 100% medication use in the last 30 days. Viral load cut off: < 75 copies/mL	Forgetfulness was associated with not taking pills. Women on protease inhibitor-based regimens had more detectable viral loads, lower CD4 counts, and a higher risk of AIDS diagnosis than those not on protease inhibitor-based. Women on protease inhibitor-based regimen had an adherence level of 99 (79%) versus 107 (91%) among women in non-protease inhibitor-based regimen group.
Trimble et al. 31	To examine ART adherence rates and viral loads among women living with HIV who had experienced IPV during the last 12 months.	Cross-sectional	Survey data collection among women receiving care at a large specialty clinic in southwestern Texas, 2010.	272 English or Spanish-speaking HIV-positive women who reported having intimate partner relationships, and had been on ART for at least 12 months. Average age: not reported	Participants completed interviews at the clinic. Two most recent viral load measurements at least 3 months apart were collected to measure adherence scores.	Adherence to ART, Viral loads were measured as detectable or undetectable Viral load cut off: Not reported	Fifty-two percent of the women reported physical or sexual IPV in the last 12 months. Experiencing IPV was significantly associated with detectable viral loads and low medication adherence scale scores.
Truong et al. 32	To evaluate virologic and immunological markers in HIV-positive women receiving different ART regimens and assess the correlation between elevated levels of immune activation and viral load.	Cohort	Patients’ medical records from the University of California, Los Angeles, and the Los Angeles Pediatric AIDS Consortium maternal-fetal HIV transmission study data and laboratory results, 1989 to 2003.	96 HIV-positive pregnant women prospectively enrolled between 1989 and 2003 in a maternal-fetal HIV transmission study in California. Average age: 27 years	Participants had laboratory test measurements of viral loads, CD4/CD8 T cells, and serum activation markers during their third trimester, at delivery, and eight weeks post-delivery.	Viral loads, CD4 counts, and β2-microglobulin. Viral loads cut off: ⩾ 400 copies/mL and 50 copies/ML	HIV-positive status was associated with increased viral loads, CD4 T cells, and β2-microglobulin post-partum regardless of ART. Immune activation increased viral loads during post-partum regardless of ART. Continued use of zidovudine and HAART post-partum were also associated with an increase in viral loads.
Turan et al. 33	To examine the association of attachment-related avoidance and attachment-related anxiety on ART adherence, viral suppression, CD4 count, and HIV visit adherence.	Cross-sectional	Data from Women’s Adherence and Visit Engagement (WAVE), a substudy nested in WIHS, 2016 to 2017	453 HIV-infected women enrolled in WIHS between 2016 and 2017 Average age: 49 years	Participants completed an interviewer-assisted psychosocial questionnaire during their WIHS visits in addition to WIHS data.	Attachment-related avoidance, and attachment-related anxiety measured with 18-item Experiences in Close relationships tool. ART adherence: ⩾ 95% medication use. Viral suppression: detectable or undetectable, CD4 count, and HIV Visit adherence. Viral load cut off: > 200 copies/mL	Attachment-related avoidance was a predictor for low ART adherence, viral failure, and low CD4 counts. Attachment-related anxiety was a predictor of missed HIV care visits. The association of attachment-related avoidance with viral failure and low CD4 count was mediated by ART adherence.
Wilson et al. 34	To describe the association between women’s healthcare empowerment and ART adherence and HIV primary care retention.	Longitudinal	WIHS, 2014 to 2016	973 WHIS HIV-infected women enrolled between April 2014 to March 2016 Average age: 49 years	Participants completed the Health Care Empowerment Inventory during their WIHS study visits at six months intervals for four consecutive times from April 2014 to March 2016. Participants self-reported ART adherence during each visit.	Viral load, care retention, ART adherence: > 95% medication use. Illicit substance use, and heavy drinking were assessed through self-reported quantity and frequencies. Burden of depression symptoms. Viral load cut off: < 200 copies/mL	Being older, having a higher income, and no heavy drinking were associated with viral suppression. Substance use and depression symptoms were not significantly associated with viral suppression but were related to adherence at six month. Healthcare empowerment and viral suppression were mediated by adherence and retention in HIV care.
Yee et al. 35	To determine if IPV experience during pregnancy was associated with factors that increased the risk of vertical transmission of HIV.	Cohort	Northwestern Memorial Hospital, Texas patients’ record. 2007 to 2014	197 HIV-positive pregnant women with a history of IPV who received perinatal care at Northwestern Memorial Hospital in Texas between 2007 and 2014. Average age: 29	Review and analyses of participants’ medical records and self-reported demographic information.	Medication adherence and viral load. Viral load cut off: not reported	IPV during pregnancy was associated with poor ART adherence. The time to achieve initial viral suppression among women who experienced IPV during pregnancy was 10 weeks versus 5 weeks among those who did not experience IPV during pregnancy. IPV during pregnancy was associated with high viral loads. Time to achieve stable viral suppression among women who experienced IPV during pregnancy was 16 weeks versus 8.5 weeks among women who did not experience IPV during pregnancy.