Associations between the legal context of HIV, perceived social capital, and HIV antiretroviral adherence in North America

Abstract

BackgroundHuman rights approaches to manage HIV and efforts to decriminalize HIV exposure/transmission globally offer hope to persons living with HIV (PLWH). However, among vulnerable populations of PLWH, substantial human rights and structural challenges (disadvantage and injustice that results from everyday practices of a well-intentioned liberal society) must be addressed. These challenges span all ecosocial context levels and in North America (Canada and the United States) can include prosecution for HIV nondisclosure and HIV exposure/transmission. Our aims were to: 1) Determine if there were associations between the social structural factor of criminalization of HIV exposure/transmission, the individual factor of perceived social capital (resources to support one’s life chances and overcome life’s challenges), and HIV antiretroviral therapy (ART) adherence among PLWH and 2) describe the nature of associations between the social structural factor of criminalization of HIV exposure/transmission, the individual factor of perceived social capital, and HIV ART adherence among PLWH.MethodsWe used ecosocial theory and social epidemiology to guide our study. HIV related criminal law data were obtained from published literature. Perceived social capital and HIV ART adherence data were collected from adult PLWH. Correlation and logistic regression were used to identify and characterize observed associations.ResultsAmong a sample of adult PLWH (n = 1873), significant positive associations were observed between perceived social capital, HIV disclosure required by law, and self-reported HIV ART adherence. We observed that PLWH who have higher levels of perceived social capital and who live in areas where HIV disclosure is required by law reported better average adherence. In contrast, PLWH who live in areas where HIV transmission/exposure is a crime reported lower 30-day medication adherence. Among our North American participants, being of older age, of White or Hispanic ancestry, and having higher perceived social capital, were significant predictors of better HIV ART adherence.ConclusionsTreatment approaches offer clear advantages in controlling HIV and reducing HIV transmission at the population level. These advantages, however, will have limited benefit for adherence to treatments without also addressing the social and structural challenges that allow HIV to continue to spread among society’s most vulnerable populations.

Criminalization of HIV Exposure: A Review of Empirical Studies in the United States

“…Thirteen studies explored potential influences of HIV exposure laws on the behavior of PLH and those who are HIV-negative or serostatus unknown (26, 31-34, 40-43, 46-49). For PLH, potential influences examined included increased (or decreased) sexual risk behavior, increased (or decreased) seropositive status disclosure, and decreased antiretroviral therapy adherence (31, 33, 40-43, 46-49).…”

“…For PLH, potential influences examined included increased (or decreased) sexual risk behavior, increased (or decreased) seropositive status disclosure, and decreased antiretroviral therapy adherence (31, 33, 40-43, 46-49). For persons who reported being HIV-negative or not knowing their HIV status, potential influences examined included increased sexual risk behavior, and decreased HIV testing (26, 31, 32, 34, 47).…”

“…Phillips and colleagues (49) reported that among 1,873 HIV-positive participants, those that had higher perceived social capital (i.e., more resources to support one's life and to overcome life challenges) and resided in states with laws that require serostatus disclosure were more likely to have better 30-day ART adherence than those who lived in states without such laws. However, in interviews with healthcare providers who counseled PLH about their state seropositive status disclosure law, most believed that the criminalization of HIV exposure could deter individuals from seeking HIV care (43).…”

“…Most studies addressed one or more of four central research questions: whether the criminalization of HIV exposure is effective as an structural-level HIV prevention strategy (31, 33, 40, 41, 47); whether criminalization inadvertently undermines public health HIV prevention efforts by discouraging serostatus disclosure (31, 40-43, 47, 48) or HIV testing (26, 32); whether criminalization hinders access to care, treatment and support (27, 43, 49); whether the laws exacerbate HIV-related stigma (30, 39-41, 43-45); and whether enforcement practices result in a disproportionate number of disadvantaged persons being arrested and prosecuted (6, 10). Most studies also addressed participants’ awareness (25, 27-30, 33, 38-44), understanding of (27-30, 38, 40, 41, 44), and attitudes toward (27-30, 33, 38, 40, 41, 43, 44) these laws.…”

“…For example, several quantitative studies have employed innovative methods to investigate the potential impact of the criminal laws such as using an economic model to identify an optimal law that is more likely to minimize nonconsensual HIV transmission (34) and using a mathematical model to evaluate the relative effectiveness of hypothetical laws (46). One study applied a theoretical framework to consider ART adherence in the context of PLH's social environment which included HIV exposure laws and prosecutions for HIV exposure (49). Three studies focused on the intersection of the criminalization of HIV exposure and medical and public health services (27, 43, 45).…”