The 3- and 6-month interview guides were shorter and focused on changes in life situations, health practices, social capital, substance use, and resilience that were observed in their quantitative measures. These guides were designed to help us understand any changes in our variables of interest and how they influenced self-management behaviors.Data analysis of the qualitative and quantitative data occurred at the same time, but were not integrated until both types of data were analyzed. In analyzing the quantitative data, we first assessed the distribution of all quantitative variables . We summarized baseline characteristics by using means, standard deviations, medians, interquartile ranges, and counts and percentages of women by substance use group , depending on the variable’s distribution. We used GEEs with an identity link function and an unstructured correlation structure to describe how social capital and substance use influences HIV self-management across the three time points. Separate models were fit for each HIV self-management outcome. In addition to the effect of social capital and substance use, we examined independent effects of age, discrimination, and traumatic events by adding these covariates to GEE models. All statistical analyses were conducted using Stata 14.0 with p values < .05 considered statistically significant. Qualitative data were managed using the qualitative data analysis program Dedoose and was analyzed by the research team using qualitative description methodology . Data were transcribed and examined by two research team members who coded the data using the constant comparative method, identifying patterns and themes . These team members met regularly during coding to discuss consistencies and inconsistencies in the data. A priori codes related to social capital, substance use,greenhouse grow tables and self-management based on our literature review were initially applied, and then inductive codes were applied.

Transcripts were revisited in a series of iterative steps to confirm coding classification and that theoretical saturation was reached. Variations on the themes and negative cases were identified to help understand the full range of data within codes. A final codebook of themes, definitions, and exemplar codes was created to aid analysis. Data were coded and analyzed using Dedoose version 8.0.42 . Study procedures are presented consistent with the Good Reporting of a Mixed Methods Study standards .In our mixed methods study examining the influence of social capital on HIV self-management among WLHIV, we observed that social capital is important for self-management, and we were able to integrate new qualitative data on how social capital does this. Social capital has consistently been linked to improved health outcomes among adults living with HIV, but what has been missing from the literature is how it does that. Our quantitative data are consistent with this literature and clearly demonstrate that better social capital is associated with better self-management in WLHIV. Yet by qualitatively examining the components of social capital in-depth, we describe how three key components of social capital can improve HIV self-management in this population–trust as a powerful yet scarce resource, a WLHIV’s community directly influences that trust, and having a strong value of self. Each of these components required that WLHIV actively and positively engage with their social network. However, for women trying to overcome a substance addiction, this can be particularly challenging since aspects of her social network can trigger substance use either directly or via social capital mechanisms we describe. Furthermore, being identified as a current or former substance user may fracture existing social networks or prevent WLHIV from being more connected to their community, which could influence their access to certain types of social capital.

Our qualitative data suggest that rebuilding a strong social network, one that enhances trust in others and in oneself, increases engagement with her community, and ultimately helps a WLHIV believe in her value as a person. Our data also provide insight into how nurses can help enhance social capital in this population, including having members of the health care team spend the time necessary to earn and keep the trust of WLHIV. Our quantitative data suggest that such efforts may help to improve HIV self-management behavior in this population. Recently, investigators described the importance of building trust in HIV care and engagement over time . Our data support those findings and highlight that the long-term trust-building process is critical for those living with chronic HIV infection, and perhaps this process may be even more critical among highly vulnerable populations. However, our qualitative data also reveal other ways to improve social capital, and obtain the benefits derived from it, that are more challenging to implement. We saw clear evidence that physical community can improve a WLHIV’s health behaviors. Whether offering tangible goods, information, kindness, or effective use of the school infrastructure, our participants derived much-needed resources from their community, which led to an increased sense of value. This increased sense of value motivated WLHIV to engage in HIV self-management behaviors to help improve their health. These data suggest that continuing to advocate for policies and resources to connect neighbors to one another and emphasizing our similarities can help improve the health of WLHIV. We also found quantitative evidence that WLHIV face challenges to engaging in HIV self-management that may be influenced by recent traumatic events. While this is consistent with other studies that highlight that levels of trauma exposure influence HIV outcomes, lifetime trauma is also ubiquitous in this population. In high-resource settings, such as ours, trauma and interpersonal violence are estimated to be experienced by 68% to 95% of WLHIV . Recognizing the influence of trauma on poor health outcomes in WLHIV and recognizing that trauma can be successfully treated, clinicians and advocates are adopting trauma-informed care models for HIV care. Trauma-informed care models emphasize that both the clinician’s and the individual’s recognition of and response to trauma and create an environment that is safe and empowering for WLHIV .

Our quantitative and qualitative data suggest that promoting social capital both within the clinic setting and in the community may temper the negative impact of trauma and provide previously untapped avenues for addressing substance use with WLHIV. However, we also found differences between our findings and existing literature. A key difference is that we did not find diminished HIV medication adherence between current and previous substance users. Substance use is considered one of the main barriers to achieving higher rates of viral suppression when an HIV diagnosis is established . The use of different substances in individuals with HIV is associated with lower antiretroviral therapy adherence ,cannabis growing system increased missed clinic visits , and decreased knowledge of HIV status . This previous research suggests that fundamental resources such as money, time, and energy will mainly be used to acquire and use substances with little attention directed to self-care. While we observed a relationship between substance use and global HIV self-management, we did not observe a relationship between substance use and HIV medication adherence. There are several possible explanations for this. First, the field of HIV has done a phenomenal job of teaching all PLHIV of the primary need to take HIV medications every day. As the medications have improved and many PLHIV are taking one HIV medication once a day, it has gotten easier to adhere to these medications. So despite many WLHIV facing personal and structural barriers to HIV medication adherence, the importance of adherence coupled with simplified regimens may help them overcome these barriers. In addition, our sample of volunteer participants is small, and though we saw a negative effect of substance use on HIV medication adherence, our study may have been under powered to detect a statistically significance effect. In addition to our small sample size, there are several other limitations that should be considered. First, all WLHIV were recruited from a single site in the Midwestern United States.We also did not use member checking to help enhance the rigor of our findings. However, we tried to overcome these limitations by employing several strategies including triangulating both qualitative and quantitative data, having prolonged engagement between the community of WLHIV and research team, and having multiple team members engaged in our data integration. Integration of quantitative data with our rich qualitative data led to new insights into how social capital can be fostered among WLHIV and how it can be used to overcome challenges faced by them. This would not have been possible without data integration. In conclusion, social capital was associated with better HIV self-management and HIV medication adherence over time, perhaps offsetting the negative effects of substance use.

Social capital increased trust, fostering a strong sense of community, and helped WLHIV feel valued. These findings enhance understanding of how nurses can support WLHIV who are addicted to illicit substances and to help them maintain sobriety and improve their HIV self-management.HIV infection is a global pandemic and the population is growing due to successful treatment with highly active antiretroviral therapy. Although rates of HIV have been reduced in the United States among most groups as a result of successful public health efforts , sexual risk behavior and subsequent acquisition and/or spread of HIV and other sexually transmitted infections are still of concern among men who have sex with men as well as drug using populations. Thus, it is evident that, despite research and efforts to understand and curb sexual risk behavior within these vulnerable populations, additional work employing novel approaches are needed. Sexual risk behaviors can be viewed as a composite of numerous behaviors that collectively make-up a complex behavioral phenotype. As with most complex phenotypes, sexual risk behavior is heterogeneous and several factors contribute to the variance that can be observed from one individual to another. To date, a majority of work examining risk factors for sexual risk behavior phenotypes have primarily focused on psychosocial factors and/or other complex/heterogeneous behavioral phenotypes such as substance use behaviors as indicators for current or future sexual risk behavior. Ultimately these indicators, upon sufficient replication, become candidates for public health interventions that aim to prevent and reduce sexual risk behaviors. However, the trouble with many of these candidates is that they are too proximal to sexual risk behaviors and often cooccur, making it difficult to disentangle temporal precedence and ultimately limit prevention efforts. One relatively novel approach is to examine intermediate phenotypes or endophenotypes such as neurocognitive factors as well as biological factors. These factors are more distal to the onset of sexual risk behavior and thus are potentially more advantageous candidates for identifying vulnerable individuals and informing prevention efforts for sexual risk behavior. Studies in literature examining neurocognitive and biological factors as indicators for sexual risk behaviors are limited. In fact, only two studies to date have examined neurocognitive factors and none to our knowledge have examined biological factors as potential indicators. Although this paucity of research is surprising given previous work linking both neurocognitive and genetic indicators to other health related behaviors, research has established the dopminergic system as a common link between neurocognitive functioning and sexual behavior. The dopminergic system has been shown to be involved in sexual arousal, motivation and the subsequent rewarding effect of sexual behavior . Furthermore, DA in the human brain, specifically in the prefrontal cortex , has been shown to be necessary for proper cognitive functioning to occur and high or low levels of DA in this brain region are known to contribute to individual cognitive differences in humans. The PFC is of particular importance when examining risk behavior in that executive functions such as decision-making, planning, self-monitoring as well as behavior initiation, organization, and inhibition are largely dependent on PFC integrity. Impairment in executive functioning may result in difficulties in assessing relationships between a person’s current behavior and future outcomes; thereby resulting in choices and/or responses on the premise of immediate rewards versus long term consequences and an ultimate potential increase in the likelihood for participation in sexual risk behaviors. Thus, mechanisms responsible for maintaining a dopamine balance within the brain and in particular the PFC would appear to be good biological candidates for further exploration of an association between executive dysfunction and sexual risk behavior. One such candidate is catechol-O-methyltransferease which is a mammalian enzyme involved in the metabolic degradation of released dopamine, particularly in the PFC.