Utilizing a Life Course Approach to Examine Pathways from Childhood Abuse to Adulthood Mental Health Outcomes Among Women Living with HIV: Findings from a Longitudinal Canadian Cohort Study

Background: Childhood abuse elevates risks for long-term mental health challenges. Knowledge gaps remain, however, regarding the mechanisms accounting for this association, particularly among women living with HIV. As histories of violence and abuse are established risk factors for HIV acquisition, better understanding long term consequences of abuse can inform tailored HIV care and support programming. Life course epidemiology provides theoretical frameworks that connect physical or social exposures in gestation, childhood, and adolescence to health outcomes later in adult life. Informed by the ‘chain of risk’ life course approach, we examined pathways from childhood abuse to mental health among a cohort of women living with HIV in Canada.

Methods: This five-year longitudinal study with a cohort of women living with HIV in Ontario, British Columbia and Quebec, Canada collected data on history of childhood abuse (sexual, physical, verbal) and poverty (income, food insecurity, housing insecurity) at time 1 (T1), substance use and past 3-month (recent) violence at time 2 (T2), and mental health challenges (depression, PTSD, mental functioning) at time 3 (T3). Trained peer research associates, who included women living with HIV and women from highly affected communities, recruited participants using purposive sampling methods and venue-based recruitment. After conducting descriptive analyses of variables, we used confirmatory factor analyses to determine whether the constructs of childhood abuse, poverty, substance use, and mental health could each be well represented by single latent factors. We conducted a path analysis using maximum likelihood estimation and a theta parametrization to examine total, direct, and indirect effects from childhood abuse to adult mental health outcomes via poverty, substance abuse, and violence.

Findings: Most (n=897, 68%) participants (n=1,315) with childhood abuse history data reported at least one type of childhood abuse. Model fit was good (CFI=0.95, RMSEA=0.04). Childhood abuse was associated with time 1 (T1) poverty (β=0.17, p<0.001), time 2 (T2) violence (β=0.16, p=0.005) and substance use (β=0.18, p<0.001), and time 3 (T3) mental health challenges (β=0.13, p=0.01). T1 poverty was also positively associated with T2 substance use (β= 0.27, p < 0.001), and T3 mental health challenges (β=0.32, p<0.001), but negatively associated with violence (β= -0.15, p=0.02). Substance use did not predict mental health challenges (β= -0.05, p=0.70), yet significantly predicted violence (=β=0.70, p<0.001), which was associated with mental health challenges (β=0.30, p<0.001). The total standardized effect of history of childhood abuse on T3 mental health challenges was 0.27 (p<0.001); half of this effect was accounted for by a direct effect (β=0.13, p = 0.01) and half by indirect effects (β=0.13, p<0.001). Poverty (β=0.06, p=0.003) and violence (=β=0.05, p=0.02) accounted for 43% and 35% of total indirect effects, respectively.

Discussion: Over two-thirds of women living with HIV in this Canadian cohort study experienced childhood abuse, double the women’s national prevalence (31%). Consequences of this childhood trauma are numerous, including effects on adulthood mental health directly and indirectly via poverty, violence, and substance use. Findings emphasize the need for violence and trauma-aware care across the HIV care cascade to optimize health and wellbeing among women living with HIV.