Mental Health Mediates the Association between Gender-Based Violence and HIV Treatment Engagement in U.S. Women.

BACKGROUND Gender-based violence (GBV) is associated with poorer engagement in HIV care and treatment. However, there is a dearth of research on the psychological (e.g., mental health) and structural (e.g., food insecurity) factors that mediate and moderate this association. GBV could lead to poor mental health, which in turn impacts adherence, while food insecurity could worsen the effect of GBV on engagement in care. This study uses data from the Women's Interagency HIV Study to address these gaps. METHODS Women completed six assessments from 2013-16 on GBV, mental health, food insecurity, adherence to antiretroviral therapy, and missed HIV care appointments in the past six months. Multi-level logistic regression models estimated associations between GBV and engagement in care, and whether associations were mediated by depression, generalized anxiety disorder (GAD), and post-traumatic stress disorder (PTSD), and moderated by food insecurity. RESULTS GBV was associated with higher odds of suboptimal adherence (AOR: 1.88; 95% CI: 1.24-2.87) and missed appointments (AOR: 1.76; 95% CI: 1.16-2.67). The association between GBV and adherence was mediated by depressive symptoms, GAD, and PTSD, accounting for 29.7%, 15.0% and 16.5% of the total association. The association between GBV and missed appointments was mediated by depression and GAD, but not PTSD, with corresponding figures of 25.2% and 19.7%. Associations did not differ by food insecurity. CONCLUSIONS GBV is associated with suboptimal engagement in care, which may be explained by mental health. Interventions should address women's mental health needs, regardless of food insecurity, when improving engagement in HIV care.