Electronic Thesis and Dissertation Repository

Thesis Format

Integrated Article


Doctor of Philosophy


Epidemiology and Biostatistics


Bauer, Greta R.


The objective of this doctoral research was two-fold: 1) to estimate inequalities in social determinants of health (SDoH), health-related quality of life, and substance use among women living with HIV (WLWH) compared to the general population of women; and 2) to assess the impact of the SDoH clusters on illicit drug use and heavy alcohol drinking among WLWH. For the first objective, estimates were obtained from 1,422 WLWH aged 16+ in the 2013-2015 Canadian HIV Women’s Sexual and Reproductive Health Cohort Study (CHIWOS, time-point 1), and then compared with their counterparts estimated in 46,831 general population women in the 2013-2014 Canadian Community Health Survey (CCHS), standardized to the age/ethnoracial group distribution of WLWH. For the second objective, we used longitudinal data from the 2013-2017 CHIWOS at time-point 1 (N=1,422) and time-point 2 (N=1,252). Findings showed that compared to general population women, a higher proportion of WLWH reported adversities regarding the social determinants and poor/fair self-rated health status, and greater cigarette smoking and illicit drug use, but similar to lower likelihood of binge drinking. Latent class analysis was used to determine the clustering of SDoH. We identified four distinct classes: no/least SDoH adversities, discrimination/stigma, economic hardship, and most SDoH adversities. Inverse-probability weighted regression models showed a substantial difference in illicit drug use, and heavy alcohol drinking between no/least SDoH class and other SDoH classes. These findings underscore the need for novel approaches to address socio-structural adversities and substance use among WLWH. We also discuss additional implications and future research directions.

Summary for Lay Audience

People with HIV now live longer. This is due to advances in HIV care and treatment services. But, these people continue to face challenges in their life. The two most important challenges are substance use and social adversities. In this study, we compared several social factors between women with and without HIV. We also compared the patterns of substance use between these two populations. We used two data sets: 1) 1,422 women with HIV and 2) 46,851 women without HIV. We showed that a higher proportion of women with HIV reported living with low income (70.3% versus 28.1%). Severe food insecurity was more common among women with HIV (54.1% versus 10.2%). Poor social support, gender discrimination, and race discrimination were also more common among women with HIV. Poor/fair health status was more frequent among women with HIV. Except for alcohol, the use of other substances was more prevalent among women with HIV. As shown, a higher proportion of women reported living with these challenges. In the next step, we examined whether social factors tend to co-occur among women with HIV. To do this, we used data of 12 social factors. Using statistical models, we identified four unique groups: a) no social adversities (group 1; 6.6%), b) mainly stigma and discrimination (group 2; 18.0%), c) mainly economic difficulties (group 3; 30.2%), and d) most social adversities (group 4; 45.2%). We finally examined the association of these groups with substance use. We found that illicit drug use was significantly lower among women in group 1 versus the other three groups. The same findings were observed for heavy alcohol use. Social vulnerabilities were shown to be significantly associated with a greater risk of substance use. To reduce harms due to substance use, social adversities are required to be addressed.