An Examination of Sex Differences In Socio-Structural Factors Influencing HIV Vulnerability Among People Who Inject Drugs In Rural Appalachia

Background: People who inject drugs (PWID) experience disparities driven by socio-structural vulnerabilities that increase their likelihood of HIV acquisition, including needle sharing, healthcare barriers, poverty, and unmet housing needs. Studies suggest that social assets like social support (SS) and resilience (RES) mitigate these risks, yet sex-specific variations in these assets remain understudied. According to syndemic theory, there are interrelationships between social determinants, social assets (e.g., social support/ networks and resilience), and health behaviors that expose PWID to HIV vulnerability. We analyzed the difference between male and female PWID on socio-structural factors and social assets (i.e., SS and RES) associated with HIV vulnerability. We hypothesized that female PWIDs would report greater HIV vulnerabilities and lower social assets.

Methods: We conducted secondary analysis of a NIDA-funded pilot study (November 2022-October 2023) that evaluated brief interventions to enhance PrEP uptake among 80 PWID in Appalachian Kentucky. Our bivariate Chi-square analysis examined sex differences (male vs. female) in socio-structural vulnerabilities (i.e., educational attainment, primary drug injected, mental health disorders, violent victimization, stigma, HIV-related behaviors, and social assets (SS and RES). We obtained the total scores from the Medical Outcomes Study Social Support (MOS SS) short-form scale(α=0.92) and the 10-item Connor-Davidson RES Scale (α=0.714). SS scale ranged from 0-100; Mean=73.2; SD=27.4, while RES scale ranged from 9-40; Mean=29.6; SD=6.4. At the 66^th percentile, the weighted average for the SS scale was 90.6, while the RS scale was 33.0. Based on prior studies, we categorized the SS scale around the mean [low SS=0-73 vs. high SS >73] and RES scale at the 66th percentile [low RES <66th percentile vs. high RES ≥ 66th percentile]. A p-value (p ≤ 0.05) indicated statistical significance.

Results: Our results highlighted differences in proportions on various socio-structural factors related to HIV vulnerability between males and females. Notably, a smaller proportion of female PWID (42.9%) completed high school compared to males (50.0%). Additionally, female PWID reported higher rates of lifetime polyvictimization, past year severe mental health disorders (MHD), substance use stigma in the past year, and needle sharing as compared to male PWID (81.0% vs. 64.8%; 85.7% vs. 76.3%; 95.8% vs. 79.2%, respectively). Furthermore, a smaller proportion of females reported high SS (59.5%) and resilience scores (23.8%) than males (71.1% and 52.6%, respectively). However, RES was the only factor statistically associated with sex differences in our PWID sample (Chi-square = 7.071 [df1], p = 0.008).

Conclusion: The findings revealed notable differences in socio-structural HIV vulnerabilities and significant variations in resilience between female and male PWID. These disparities highlight the need for tailored, sex-differentiated approaches to enhance resilience among female PWID. For instance, it is crucial to explore the experiences of socio-structural vulnerabilities and psychosocial factors that may contribute to lower resilience scores among female PWID. Furthermore, additional research with larger sample sizes is necessary to investigate the complex interactions between structural and psychosocial factors associated with HIV vulnerabilities among PWID by sex.