For participants who consented to having data abstracted from their electronic health record , we abstracted HIV viral load and CD4 counts. Data were abstracted only if the person had had a test within the past year, and the most recent test result was used. Viral load was dichotomized as detectable or undetectable . For the analysis, we focused on undetectable viral load as the outcome of interest. Patient-Provider relationship was measured using the Engagement with Health Care Provider scale , a 13-item instrument in which clients rate their interactions with their providers on a scale of 1 “always” to 4 “never”. Responses are summed to get a total score of 1-52, with lower scores indicated greater engagement. Appointment Adherence. Appointment adherence is the percentage of scheduled clinical appointments that were actually attended in the six months prior to the study visit. First, we generated descriptive statistics to summarize the baseline data. Second, we used bivariate linear and logistic regression analysis to examine relationships between trauma and various indicators of health. Third, we used bivariate linear and logistic regression analysis to examine factors that are associated with the two outcomes of interest: quality of life and undetectable viral load. In past focus group discussions with clinic patients, quality of life emerged as one of the most important outcomes of interest for patients themselves, and it is one that clinicians and other care team members want for patients as well. At the same time, viral suppression is a major focus of the HIV Care Continuum and remains a national priority in HIV/AIDS care and treatment. Thus, we elected to focus on trauma’s impact on one patient- centered outcome and one HIV Care Continuum outcome in this analysis. All analyses were conducted using Stata 14 . Participants in the study were 104 women living with HIV . Four participants identified as transgender or intersex; they were included in all analyses as the intervention being evaluated is clinic-wide and the four women represent an important portion of the clinic’s patient population.
The participants’ mean age was 52 years and almost 80% were women of color. Approximately half had a high school education or less,indoor growers only 20% were working for pay, and 61% reported food insecurity in the past year. Almost all participants were living in stable housing. The mean ACE score was 4.2, and more than half of participants reported four or more ACEs. In this study, lifetime trauma and recent trauma were also common , and many participants reported having experienced threats, abuse, and violence as a result of disclosing their HIV status to others . Participants who reported four or more ACEs were significantly more likely to report both lifetime and recent trauma. ACE scores and THS scores were highly correlated . Most study participants had been living with HIV for a substantial number of years, and the majority reported that they were currently on ART medications . Of the 96 participants who had available viral load data, 68 had an undetectable viral load . Of the 83 participants who reported being on HIV medications and who had available viral load data, 66 had an undetectable viral load. Two participants who reported not being on ART also had undetectable viral loads.One-third met the diagnostic criteria for PTSD ; almost one-half reported at least moderate levels of depression symptoms ; and more than one-quarter reported at least moderate levels of anxiety symptoms . Although the mean alcohol use disorder screening scores were low overall and 52.4% of participants reported no current alcohol use at all, 17% of participants reported binge drinking and 22.1% met the threshold for further alcohol use disorder screening, indicating high levels of use among those who do drink. Almost one-half of participants reported tobacco use in the past three months; 27.9% reported use of cocaine, amphetamines, sedatives, and/or illicit opioids in the past 3 months; and 17.3% reported at least moderate levels of drug abuse, reaching the threshold for further investigation or intensive assessment. Ratings of patient-provider relationship were very high with a mean of 1.2. We also investigated various forms of social health. Among study participants, the mean total Empowerment Scale score was 3.0 out of a total possible score of 4.0. Mean social support for all participants was 3.2. When asked how open or ‘out’ they were about their HIV status, 24 reported being completely out, while 24 reported being not at all out, and 7 participants had never told anyone of their HIV-positive status. However, participants overall reported only moderate levels of total HIV related stigma .
The mean quality of life score was 13.8, with 54.8% of participants scoring below 13, indicating poor quality of life.Next, we examined relationships between trauma and various indicators of health . Experiences of lifetime trauma, as measured by the THS, were significantly associated with ART medication use among participants; for each additional trauma experienced, participants had significantly reduced odds of being on ART medications . Similarly, participants with higher numbers of trauma experiences had significantly lower odds of reporting good 30-day HIV medication adherence . In contrast, there were no significant relationships between trauma and CD4 count, or whether the participant had an undetectable viral load . We then considered the relationship between trauma and behavioral health outcomes. Experiencing more traumatic events was significantly associated with higher PTSD symptom scores , higher depressive symptom scores , and higher anxiety symptom scores , as well as greater odds of reaching the diagnostic thresholds for all three . In addition, although higher counts of traumatic events were significantly associated with higher alcohol use scores , they were not significantly associated with the AUDIT screening threshold that would indicate an alcohol use disorder . Higher THS counts were also not associated with self-reported use of tobacco, cannabis, or sedatives in the past three months, but were significantly associated with recent use of cocaine , amphetamines , and illicit opioids . Higher counts on the THS were also associated with higher odds of self-reported overall “hard” drug use . Finally, more traumatic experiences was associated with higher drug abuse screening raw scores and with greater odds of having a positive drug abuse diagnosis .In examining well-being and social health outcomes, we found that trauma was associated with significantly greater HIV stigma . Trauma was also significantly negatively associated with quality of life and mental well being; those with more traumatic experiences had lower quality of life scores , as well as lower psychological well being scores .
Trauma was not, however, significantly associated with empowerment, social support, or disclosure.In this sample of women living with HIV, we found near-universal reports of lifetime trauma, including childhood and adult trauma, as well as a significant minority who reported incidents of abuse and threats in the past 30 days. These findings support the growing body of literature documenting high rates of trauma and PTSD among WLHIV , and uniquely add to it by documenting high mean ACE scores in a population of WLHIV for the first time. In examining quality of life as one of our two main outcomes of interest,trimming tray we found that over half of the women experienced poor quality of life despite the broad availability and use of antiretroviral therapy and despite most participants having an undetectable viral load. Those who had experienced more trauma had significantly poorer overall quality of life compared to those who had experienced less trauma. We also found that traumatic experiences were significantly associated with greater symptoms of depression, anxiety, and PTSD, worse HIV-related stigma, and poorer mental well being. In addition, trauma was associated with greater alcohol and drug use and higher drug abuse screening test scores. The link between adverse childhood experiences and later substance use and substance use disorders has been well described . The high level of substance use in this population is very concerning due to the known disproportionally high rates of death among WLHIV from substance use . In examining the impact of trauma on our second main outcome of interest, we did not find a significant relationship between trauma and having an undetectable viral load. However, trauma was significantly negatively associated with being on antiretroviral medications for HIV and with ART adherence, both of which are key outcomes on the HIV Care Continuum and are key contributors to the likelihood of achieving an undetectable viral load. These findings support prior research that has documented the impact of trauma sequelae such as PTSD and depression symptoms on HIV medication adherence . For individuals who have experienced significant trauma, the increased risk of PTSD symptoms such as avoidance behaviors, depression, and HIV-related stigma may make it more difficult to engage in self-care and to adhere to treatment regimens. Although we did not identify a significant relationship between trauma and an undetectable viral load, other studies have documented this relationship . In addition, the high rates of virologic suppression in our sample may have affected this study’s ability to detect the link between trauma and virologic suppression despite the identified association of trauma with the key predictors of it. This study had several limitations. First, because the data reported here are cross-sectional, causality cannot be determined. However, the associations between lifetime trauma and poor quality of life, PTSD, depression, anxiety, and substance use suggest a role for trauma in later health outcomes for WLHIV. Second, the sample size was relatively small. Within this clinic, however, the 104 patients who participated in the study accounted for approximately two thirds of all clinic patients who were eligible for the study at baseline. At the same time, the clinic population is fairly representative of the national population of women living with HIV, particularly in urban areas. Therefore, the study has some degree of generalizability to the larger population of WLHIV in the United States. Another limitation of the study was the measurement of trauma. Although we used three different measures that covered childhood, lifetime, and recent trauma, there are many other types of trauma that we did not measure. For example, although we recorded race, we did not include a specific measure of experiences and impact of racism in the study. Similarly, many patients in the clinic have been involved with the foster care and/or the prison systems, where trauma and violence are common, and we did not record this information or the impact that it may have had on their health outcomes. It is possible that individuals may have experienced other traumatic events that we did not measure. The overall study, however, has many strengths. These baseline data, as well as data from the parallel study with clinic staff , are being used to inform implementation of TIHC in the clinic. This includes educating staff about the impact of trauma on health, creating a safe and welcoming environment for patients, screening patients for the consequences of trauma, and using data to identify the most effective ways to respond to past and ongoing trauma . In addition, the results presented here are from the baseline stage of a larger longitudinal mixed-methods study that will allow us to evaluate the impact of trauma-informed health care on health outcomes for WLHIV. This larger study includes survey and EHR data collection at multiple times over a number of years, as well as qualitative data collection with both patients and staff to contextualize the findings of survey data. Although this baseline study was neither designed nor powered to elucidate the pathways to explain the relationship between trauma, poor quality of life, and other poor health outcomes, the results add to a growing recognition that the current national focus on virologic suppression is insufficient as a measure for health and well-being of WLHIV .The psychoactive effects of D 9 -tetrahydrocannabinol, the major pharmacological ingredient of Cannabis sativa, are produced through the activation of selective G protein-coupled membrane receptors . The abundant expression of cannabinoid receptors in brain and the behavioral consequences of their activation, ranging in humans from euphoria to memory deficits, underscore the potential importance of the endogenous signaling system by which these receptors are thought to be engaged . Yet, the biochemical nature, anatomical distribution, and physiological functions of such signaling systems remain elusive.