Titilola Labisi, MHA, MPH, on Viral Suppression Among Women Living With HIV

In this podcast, Titilola Labisi, MHA, MPH, speaks about factors associated with lack of viral suppression among women living with HIV in the United States, including keys to preventing sexual transmission, risk of drug resistance, and improving health outcomes for women living with HIV. She also presented a poster abstract on this topic at IDWeek 2021.

Additional resource:

Titilola Labisi, MHA, MPH, is a PhD student and graduate research assistant at The University of Nebraska Medical Center in Omaha, Nebraska. 



Jessica Bard: Hello everyone, and welcome to another installment of "Podcast 360," your go‑to resource for medical news and clinical updates. I'm your moderator Jessica Bard with Consultant360 Specialty Network.

More than 7,000 women received an HIV diagnosis in the United States and dependent areas in 2018 according to the Centers for Disease Control and Prevention.

Titilola Labisi is here to speak with us today about her team's research, Factors Associated With Lack of Viral Suppression Among Women Living With HIV in the United States: An Integrative Review presented at IDWeek 2021.

She's a PhD student and a graduate research assistant at the University of Nebraska Medical Center in Omaha, Nebraska.

Thank you for joining us today. Where did your interest in working to end the HIV epidemic begin?

Titilola Labisi: My interest in HIV started back in Nigeria before I came to United States over 6 years ago. I've always been passionate about HIV. When you fear something, you want to learn about it. Also, I am a trained microbiologist. I'm interested in impacting the lives of many people, so that was why I went into public health to impact more people.

When I was in the lab, I didn't believe in the HIV numbers, I was like these cases are not real, these numbers are not real. When I saw the specimens coming into the lab and everything, I thought, "Oh, it's real, and because I fear the virus, I want to curve the spread." I'm committed to ending the HIV epidemic to help people and manage their condition and control the spread.

Jessica: You're presenting Factors Associated With Lack of Viral Suppression Among Women Living With HIV in the United States: An Integrative Review at IDWeek 2021. Can you please give us an overview of this research?

Titilola: Thank you. First of all, I would like to acknowledge other researchers who contributed to this research, so first of all I'll acknowledge, Dr. Keyonna King, Dr. Nada Fudo, Dr. Jason Coleman, and Dr. Anthony Podany. We all work together on this research.

I would like to give a brief background about HIV and women in the United States. Women account for 23 percent of those living with HIV in the United States. About 7,000 new cases of HIV among women in United States.

It's important to know that HIV is one of the top 10 leading causes of deaths among women, ages 25 to 44 in the United States. Transgender women are 4 to 9 times more likely to be infected with HIV than other groups.

That was just a brief background. Regarding how we came up with this study, we wanted to fill the gap. Women in HIV research have received less attention compared with men, because men have a higher risk than women. Women have received less attention. I wanted to fill the gap in the literature.

Our propose was to identify and synthesize peer‑reviewed journals reporting on factors affecting viral suppression among women. That was how we came up with the research.

Then there's a study that's been conducted in the United States. This study was published in 2018, but the study focused on African American women, and they looked at behavioral factors that affect HIV care adherence among African American women. They also looked at only interventional studies.

Our study builds on that by focusing on everybody, all women. We did not also limit our studies to interventional studies. We looked at cross‑sectional studies, interventional studies, and all.

Jessica: What were the findings of your study?

Titilola: When we started our search on 5 databases, CINAHL, PubMed, Scopus, PsycINFO, and Embase, we came up with 1,359 articles. Our eligibility criteria was studies that were conducted in the United States, studies focusing on women, studies that reported on viral suppression, and studies that were published after 2010.

After reviewing the 1,359 articles, we came down with 15 articles. 15 articles met our eligibility criteria. The 15 articles were the articles included in our integrative review of this study.

Among the 15 articles, 5 of them focused on pregnant women, 8 included women; all women regardless of gender, pregnancy status, or anything, 1 focused on African American women.

One transgender study was included in this review. Because a lot of studies, 5 out of 15, that’s significant­­, included only pregnant women. We decided to divide our results into 2; pregnancy‑related factors and non‑pregnancy‑specific factors contributing to viral load.

For the studies that included pregnant women, we found out all the studies reported their early engagements in HIV treatments is an important factor in viral suppression in women.

Out of the 15 studies, only 1was an interventional study. An interventional study was one of the studies that included only pregnant women. The interventional study found that prenatal care improves adherence, retention, and viral suppression in pregnant women.

There a lot of factors were also location. Women living in cities, we are more likely to be virally suppressed, although this study didn't find any difference in adherence to treatment or something like that, but they found out that women living in cities were more virally suppressed.

An interesting thing we found was that 1 study said being postpartum increases viral load. That was a factor they found that is a negative factor among pregnant women. They said, "this is due to immune activation."

There was a factor that was common across–– and what I mean by across is the studies that looked at all women and the studies that looked at only pregnant women–– and the factor is intimate partner violence.

They found that as a factor that contributed to high viral load in women, and other studies too also found that to contribute into high viral load in women. That's for the pregnant women.

For the 8 studies that looked at women in general, the most common reported factor was substance use.

The second top factor was social determinant of health. Health insurance was another factor in ways, specifically being African American was a factor that contributed to high viral load or lack of viral suppression in women.

Age. 2 studies found that being older, women living with HIV who are older, were more adherent to their treatment, and were more virally suppressed than younger women.

One study found income, and specifically income on all income below $24,000 as a factor. I found that interesting as a factor affecting lack of viral suppression in women.

Medication regimen and appeals was also another factor. For example, some of these women, their drug combination, or their regimen, or their treatment plan, require them to take multiple pills, and some they just take one pill. Those who take one pill were more virally suppressed than those who took multiple pills. That was one of our findings.

Then mental health was a major issue. Depression, stress, and anxiety were significantly associated with lack of viral suppression in women. Like I mentioned, intimate partner violence was also reported.

For the study that included African American women, they found most of what I mentioned in women, the only thing that was specific among African American women was gender and racial discrimination.

For the transgender study, just one study, they found transgender women who weren't in relationships were less virally suppressed than those who are in relationship.

Transphobic experience was also a factor that was associated with lack of viral suppression. And gender satisfaction–– those who were satisfied with their gender were more virally suppressed than those who were not.

Adherence to hormone therapy. The ultimate goal of HIV treatment is via suppression, and when someone is adhering to their treatments.

We can see that among transgender women, those who were adherent to their hormone therapy were found to be more virally suppressed. Lack of adherence to a hormone therapy was associated with lack of viral suppression among transgender women.

Jessica: Do any of these findings surprise you?

Titilola: That's an interesting question. Yes. One major thing that stood out to me was the cutoff for viral load. The CDC recommends viral loads below 200 cells per millimeter cube, but surprisingly, some studies had cut off as high as 400. Some studies had 80. There was one that had 20. There was one that had 50.

One even had two different cut‑offs, and the rationale for two different cut‑offs was the kits they used for the testing or something. That stood out to me the inconsistency in viral load cutoffs.

Another thing that surprised me in our finding, was that there's a study here in United States, and it is called the Women Intra Agency HIV Study, it's the largest prospective cohort study on women in the United States. This study has been going on since the '90s, I think '93 or 1994.

We've been following women since then. What I found surprising is that 15 studies were revealed, 7 use this data. I understand that they will be able to get a lot of a large sample size by using this data.

Then this study does not have participants in all parts of the United States. The women in this study are from the big cities like Bronx, Brooklyn, Atlanta, San Francisco, you understand what I mean. Several of them using that data, they will not be able to capture the entire United States.

Then if a few other studies used study data or some patient's health records, and all, that was what surprised me in our findings.

Jessica: How will these results impact clinical practice among women living with HIV in the United States?

Titilola: That's a very interesting question, an important question. HIV prevention, through testing, and viral suppression remains the gateway to ending the HIV epidemic. When a person is virally suppressed, it's unlikely that they will transmit the virus to someone else.

Also, when someone is adhering to the medication age, they're virally suppressed, and have undetectable viral load. They'll have improved health outcomes, and even their longevity to be longer than people who are not virally suppressed.

Most importantly, among women who are virally suppressed, they'll be at less risk of transmitting the virus to their babies. I think that's why this research is important. It also contributes in handling the HIV epidemic because like I said, someone who is virally suppressed is unlikely to transmit the virus to someone else.

Jessica: Are there any knowledge gaps that exist in this area of study?

Titilola: Yes, I'll say a big yes. [laughs] Unfortunately, women are less virally suppressed in the United States. According to 2018 data, 63 percent of women, even with HIV were virally suppressed, compared to 68 percent among men.

Secondly, women are less researched in this field. The received less attention compared with men. Researchers been looking at men, fine, we understand that men at higher risk, and men make up 70 percent of the new HIV cases.

Then we shouldn't forget that women account for 23 percent of people living with HIV/AIDS in the United States. Also, there's lack of interventional study in this area. Myself and my team we're looking at conducting a similar review, integrative review for interventions out there.

We are focusing on women and factors like interventional studies to address this problem. It was difficult to come up with studies. We only came up with about 5, and that was too small. That shows a huge gap.

Similarly, we can also see that in the findings of this study that only one study was an interventional study. The problem has been identified that there are factors associated with vast oppression in women, right? But there are no interventional studies out today addressing this problem. That's huge.

Also, transgender women are 49 times more likely to be infected with HIV, than older groups. Yet, in our review, only one transgender study met our eligibility criteria.

Jessica: With that being said, what's next for research in this topic?

Titilola: A lot still needs to be done in this area. For instance, both in pregnant women and in the general women population we found intimate partner violence as a common factor about lack of viral suppression. Most of these should look into that.

Then also, there was a death of knowledge, or there was a paucity of information on transgender women. More studies should look into factors affecting because they're at very high risk of acquiring HIV.

Transgender women is another important population that future studies should look at because they're at very high risk of acquiring HIV compared to other groups. Then interventional studies are needed in this area to address the factors found in these studies.

Then, also, COVID‑19 studies have reported increase in intimate partner violence during COVID. For example, people during the lockdown period or due to the restrictions, people had to stay indoors with their partners, and studies have found increase in intimate partner violence being reported during those periods.

It's important to look at the impact of COVID on this population. Also, mental health, the 2 studies that I read, 1 of them found increase in anxiety and depression among women, 38 percent among women compared to 24 percent among men.

Also, another study–– and this is an Italian study–– the second study found that women were 3 times more likely to be distressed during the lockdown. The mental health impact; I mentioned earlier mental health, anxiety, depression, were some of the factors associated with viral suppression.

With COVID‑19 studies finding higher rates of mental health issues among women now, or elevated levels of anxiety, depression, and distress among women, I'm afraid there might be more severe outcomes in this population, post‑COVID‑19.

Jessica: What would you say are the overall take‑home messages from your session?

Titilola: This is the era of COVID. I'd like to say that the impact of COVID may not be immediate, we might see increase in mental health needs among this population. There's evidence of increased risk of lack of viral suppression among women experiencing mental health issues.

I would say HIV should be prioritized alongside COVID so that we do not jeopardize 40‑years of effort of handling the HIV epidemic.

Jessica: I think that's really powerful. Thank you for all of your work on this.

Titilola: Thank you.

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