Finding the Invisible Patient to Address Substance Use, Violence, and Depression in Women Living with HIV

In the United States, women account for one-fourth of people living with HIV. Most women living with HIV are Black or Hispanic and acquired HIV from heterosexual contact. Many face significant barriers to appropriate medical care, with lower retention in care and viral suppression than men who acquire HIV from male-to-male sexual contact. Many factors contribute to these disparities, including high rates of alcohol abuse, substance use, intimate partner violence, depression, and socioeconomic marginalisation. HIV, substance use, and violence each contribute independently to the collective health burden on women. The co-occurrence of these factors, termed the SAVA (substance abuse, violence, and HIV/AIDS) syndemic, is particularly hard to address, as the conditions act synergistically to negatively influence health outcomes. In addition, mental health conditions frequently coexist and further contribute to adverse outcomes. Unfortunately, clinician knowledge of this syndemic is low, and patients living with HIV and other elements of SAVA, including depression, are not recognised and referred for appropriate services. In this paper we describe our pilot educational and quality improvement program and the subsequent educational program we developed to increase knowledge of SAVA with the goal of improving health outcomes for women living with HIV.