Young people living with HIV (YPLWH), including emerging adults age 18-29, are at high risk for poor self-management of HIV and detectable viral load, with implications for individual health and HIV transmission. Comorbid alcohol use is common among YPLWH and negatively impacts all stages of the HIV treatment and prevention cascade. Interventions to boost self-management of alcohol use and HIV care are critical but have had limited success. Improving and targeting self-management interventions requires understanding pathways to self-management failure among YPLWH and must account for developmental, behavioral and cultural characteristics unique to this population and stress and trauma conferred by these characteristics.
YPLWH are disproportionately racial, ethnic and sexual minorities who experience higher rates of chronic and complex sources of stress and trauma throughout their lives. Additionally, there are oppressive sources of stress and trauma related to their racial, ethnic, sexual, and gender identities and HIV status, such as discrimination, microaggressions, and stigma as a result of systemic structural and societal inequities. Intersectionality may compound oppressive sources of stress and trauma for individuals who are multiply-marginalized. For the purposes of this proposal, cumulative stress will be defined as the compounded experiences and symptoms of stress resulting from chronic, complex, oppressive, and intersectional stress and trauma across the lifespan (e.g., childhood adversity and traumatic stress, stress and trauma from discrimination, microaggressions, and stigma). The impact of cumulative stress and its role in self-management of either substance use or HIV care has not been studied among this vulnerable population.
Although stress, generally, has been linked to alcohol use and disease management, the pathways underlying these links among YPLWH are poorly understood. Similar to stress in general, cumulative stress will likely have both direct and indirect associations with alcohol and HIV self-management. Evidence suggests several modifiable factors that may play a role in these indirect pathways. An important but understudied pathway is the link among YPLWH between stress and sleep problems, which may impact alcohol use and HIV self-management through the effect that poor sleep has on emotion regulation. Behavioral regulation (e.g., decision-making, inhibitory control), is a core component of self-management and is similarly associated with both cumulative stress and alcohol use. Of importance, these pathways with HIV outcomes have not been examined among YPLWH.
The overall goal of the proposed P01 is to improve self-management of alcohol use and HIV care among YPLWH. Consistent with the NIH translational behavioral science model of intervention development (stage T01àT1), the proposed longitudinal cohort study will define developmentally and culturally relevant, modifiable intervention targets in causal pathways between cumulative stress and self-management outcomes among YPLWH most of whom are subject to intersectional sources of stress and trauma. With the P01 Community Engagement Core, we will use innovative outreach methods to enroll 300 diverse YPLWH age 18-29 to complete surveys of cumulative and intercurrent stress and trauma, sleep health (i.e., survey and ecological momentary analysis [EMA] using an electronic sleep diary), emotion and behavioral regulation, and substance use and HIV outcomes at baseline, 9 and 18 months. Further, minority YPLWH are less likely to be screened for or have access to available interventions. In the fifth year, we will use a mixed methods approach in collaboration with community members to develop a toolkit of scalable measures for intervention targeting. The resulting knowledge and tools have the potential to improve health outcomes and quality of life for underserved youth who often may not benefit from advances in HIV care through addressing factors uniquely relevant to them.