Applying a Lifecourse Approach to Understanding Pathways from Childhood Protective Service Removal History to Clinical HIV Outcomes Among Adult Women Living with HIV in Canada: Longitudinal Cohort Findings

Background and Purpose: Life course epidemiology explores long-term health effects from childhood risk exposures. Adverse socio-environmental conditions may contribute to ‘chain reactions’ of risk, where a negative exposure can lead to another bad experience and these accumulate to elevate disease risk. Childhood protective service (CPS) out-of-home care is associated with poorer mental health trajectories. Mental health challenges are linked with poorer antiretroviral therapy (ART) outcomes, yet scant research has explored pathways from CPS histories to HIV clinical outcomes. We examined associations between CPS out-of-home care history with HIV outcomes, and tested the mediating role of mental health, among women living with HIV in Canada.

Methods: This three-wave longitudinal study with women living with HIV in Ontario, British Columbia and Quebec examined CD4 counts (<200, 200-500, >500 cells/mm³), current ART use, and viral load (VL) undetectability (<50 copies/mL) over five years. We used latent class growth analysis to identify outcome trajectories of ART use, CD4 counts, and VL outcomes across waves and assessed if CPS out-of-home care history was associated with class membership. We estimated a latent mental health construct (indicators: depression, post-traumatic stress disorder, SF-12 mental health, resilience). We then conducted mediation analysis to test whether mental health mediated the association between CPS history and HIV clinical outcome trajectories. We tested for the interaction of the predictor and mediator, controlled for potential confounders, and to account for the non-normality of the outcome, used 1000 bootstraps with bias-corrected 95% confidence intervals. We estimated odds ratios to assist with interpretation of results.

Results: Overall, 19% (n=272) of participants (n=1422, mean age: 42.8y) reported CPS out-of-home care histories. Four CD4 count trajectories included: consistently high (35%), consistently low (8%), consistently medium (15%), and U-shaped (42%). Individuals with CPS histories were 2-3 fold more likely to be in the ‘consistently low’ CD4 count class relative to any other class (βs=0.75–1.16, ps=0.002–0.02) and twice as likely to have a consistently detectable viral load (β=0.72, p=0.02). Current ART use did not vary over time. Mental health at baseline mediated pathways from CPS history to (1) consistently detectable viral load (β=0.02, 95% CI: 0.005, 0.04, p=0.02), accounting for 27% of this association; and (2) consistently low CD4 count trajectory (β=0.005, 95% CI: 0.001, 0.01, p=0.04), accounting for 24% of this association.

Conclusions and Implications: Nearly one-fifth of women living with HIV in this cohort have CPS out-of-home care histories, which is 14-fold higher than the Canadian prevalence (1.3%). CPS histories are associated with poorer HIV outcome trajectories (low CD4, detectable VL) through the mediating role of mental health challenges. Applying a life course epidemiological approach reveals that CPS history is a childhood risk factor linked with poorer adulthood clinical HIV outcome trajectories via mental health pathways. Findings have implications for multi-level social work interventions. Trauma-informed HIV prevention strategies can be tailored for youth with CPS involvement and can identify protective factors. For women living with HIV, a trauma-informed approach to integrated HIV and mental health care, and trauma-responsive interventions, hold the potential to improve wellbeing.