AIDS and Behavior

, Volume 23, Issue 12, pp 3226–3236 | Cite as

A Latent Class Analysis of the Social Determinants of Health Impacting Heavy Alcohol Consumption Among Women Living with HIV in Canada: The Canadian HIV Women’s Sexual and Reproductive Health Cohort Study

  • Mostafa ShokoohiEmail author
  • Greta R. Bauer
  • Angela Kaida
  • Carmen H. Logie
  • Allison Carter
  • Ashley Lacombe-Duncan
  • Mona Loutfy
  • the CHIWOS Research Team
Original Paper


We used longitudinal data from the 2013–2017 Canadian HIV Women’s Sexual and Reproductive Health Cohort Study (N = 1422) to assess the clustered impact of social determinants of health (SDoH) on hazardous drinking. Two measures of alcohol use were defined: (i) weekly alcohol use, with > 7 drinks/week as heavy drinking, and (ii) monthly binge drinking (≥ 6 drinks at one sitting), with ≥ 1/month as frequent binging. Twelve SDoH indicators were classified using latent class analysis: no/least adversities, discrimination/stigma, economic hardship, and most SDoH adversities. Inverse-probability weighted multinomial logistic regression was used to report relative-risk ratio (RRR). Women living with HIV (WLWH) in no/least adversity class had a substantially lower likelihood of both heavy weekly alcohol use and frequent binging than those in discrimination/stigma, economic hardship, and most SDoH adversities classes, with RRR estimates ranging from 0.02 to 0.18. Findings indicate the need to address SDoH to reduce hazardous drinking among WLWH.


Women HIV Alcohol drinking Social determinants CHIWOS 


Utilizamos información del Estudio de Salud Sexual y Reproductiva de Mujeres viviendo con VIH en Canadá 2013-2017 (N = 1422) para evaluar el impacto agrupado de los determinantes sociales de la salud (DSS) sobre consumo riesgoso de alcohol. Se definieron dos medidas de consumo de alcohol: i) consumo abusivo de alcohol: uso de alcohol por semana, > de 7 bebidas/por semana y ii) consumo excesivo mensual (≥ 6 bebidas en una ocasión), con ≥ 1/mes como consumo excesivo frecuente. Utilizando el análisis de clases latentes se clasificaron doce indicadores de los DSS: no/menos adversidades, discriminación/estigma, dificultad económica, y la mayoría de las adversidades de los DSS. Para reportar el riesgo relativo (RR) se utilizó regresión logística multinomial ponderada de probabilidad-inversa. Mujeres viviendo con el VIH (MVCV) en la clase no/menos adversidad tuvieron menos probabilidad de ambos, consumo semanal abusivo de alcohol y de consumo excesivo frecuente, comparadas con aquellas en clases de discriminación/estigma, dificultad económica, y la mayoría de adversidades de los DSS, con estimaciones RR entre 0.02 a 0.18. Los hallazgos indican la necesidad de abordar los DSS para reducir el consumo riesgoso entre MVCV.



We would like to thank the following groups for their significant contributions to the Canadian HIV Women’s Sexual and Reproductive Health Cohort Study (CHIWOS), including women living with HIV who shared their experiences and provided valuable information on various aspects of their health, as well as Peer Research Associates (PRAs) for their engagement at every stage of this study and for recruiting participants, administering the survey and collecting data. We would also like to thank the members of the CHIWOS Research Team, the entire national team of Co-Investigators, Collaborators, the three provincial Community Advisory Boards, the national CHIWOS Indigenous Advisory Board, CHIWOS African, Caribbean and Black Advisory Board, and all partnering organisations for their supports. We thank the BC Centre for Excellence in HIV/AIDS for CHIWOS data management and support.

CHIWOS research team Rahma Abdul-Noor (Women’s College Research Institute), Aranka Anema (University of British Columbia), Jonathan Angel (Ottawa Hospital Research Institute), Jean-Guy Baril (Clinique du Quartier Latin), Fatimatou Barry (Women’s College Research Institute), Kerrigan Beaver (Women’s College Research Institute), Denise Becker (Positive Living Society of British Columbia), Anita Benoit (Women’s College Research Institute), Jason Brophy (Children’s Hospital of Eastern Ontario), Lori Brotto (University of British Columbia), Ann Burchell (Ontario HIV Treatment Network), Claudette Cardinal (Simon Fraser University), Allison Carlson (Women’s College Research Institute), Allison Carter (British Columbia Centre for Excellence in HIV/AIDS and Simon Fraser University), Angela Cescon (British Columbia Centre for Excellence in HIV/AIDS), Lynne Cioppa (Women’s College Research Institute), Jeffrey Cohen (Windsor Regional Hospital), Guillaume Colley (British Columbia Centre for Excellence in HIV/AIDS), Tracey Conway (Women’s College Research Institute), Curtis Cooper (Ottawa Hospital Research Institute), Jasmine Cotnam (Women’s College Research Institute), Janette Cousineau (Women’s College Research Institute), Janice Dayle (McGill University Health Centre), Marisol Desbiens (Women’s College Research Institute), Hania Dubinsky (McGill University Health Centre), Danièle Dubuc (McGill University Health Centre), Janice Duddy (Pacific AIDS Network), Brenda Gagnier (Women’s College Research Institute), Jacqueline Gahagan (Dalhousie University), Claudine Gasingirwa (Women’s College Research Institute), Nada Gataric (British Columbia Centre for Excellence in HIV/AIDS), Saara Greene (McMaster University), Trevor Hart (Ryerson University), Catherine Hankins (UNAIDS), Bob Hogg (British Columbia Centre for Excellence in HIV/AIDS and Simon Fraser University), Terry Howard (Positive Living Society of British Columbia), Shazia Islam (Women’s College Research Institute), Evin Jones (Pacific AIDS Network),Charu Kaushic (McMaster University), Alexandria Keating (ViVA and Southern Gulf Islands AIDS Society), Logan Kennedy (Women’s College Research Institute), Mary Kestler (Oak Tree Clinic, BC Women’s Hospital and Health Centre), Maxime Kiboyogo (McGill University Health Centre), Marina Klein (McGill University Health Centre), Gladys Kwaramba (Women’s College Research Institute), Andrea Langlois (Pacific AIDS Network), Melanie Lee (Simon Fraser University), Rebecca Lee (CIHR Canadian HIV Trials Network), Lynne Leonard (University of Ottawa), Johanna Lewis (Women’s College Research Institute),Viviane Lima (British Columbia Centre for Excellence in HIV/AIDS), Elisa Lloyd-Smith (Vancouver Coastal Health), Carmen Logie (University of Toronto), Shari Margolese (Women’s College Research Institute), Carrie Martin (Native Women`s Shelter of Montreal), Renee Masching (Canadian Aboriginal AIDS Network), Lyne Massie (Université du Québec à Montréal), Melissa Medjuck (Positive Women’s Network), Brigitte Ménard (McGill University Health Centre), Cari Miller (Simon Fraser University), Deborah Money (Women’s Health Research Institute), Marvelous Muchenje (Women’s Health in Women’s Hands), Mary Mwalwanda (Women’s College Research Institute), Mary (Muthoni) Ndung’u (Women’s College Research Institute), Valerie Nicholson (Simon Fraser University), Illuminée Nzikwikiza (McGill University Health Centre), Kelly O’Brien (University of Toronto), Nadia O’Brien (McGill University Health Centre and McGill University), Gina Ogilvie (British Columbia Centre for Disease Control), Susanna Ogunnaike-Cooke (Public Health Agency of Canada), Joanne Otis (Université du Québec à Montréal), Ali Palmer (Simon Fraser University), Sophie Patterson (Simon Fraser University), Doris Peltier (Canadian Aboriginal AIDS Network), Yasmeen (Ashria) Persad (Women’s College Research Institute), Neora Pick (Oak Tree Clinic, BC Women’s Hospital and Health Centre), Alie Pierre, McGill University Health Centre), Jeff Powis (Toronto East General Hospital), Karène Proulx-Boucher (McGill University Health Centre), Corinna Quan (Windsor Regional Hospital), Janet Raboud (Ontario HIV Treatment Network), Anita Rachlis (Sunnybrook Health Science Centre), Edward Ralph (St. Joseph’s Health Care), Stephanie Rawson (Simon Fraser University, BC), Eric Roth (University of Victoria), Danielle Rouleau (Centre Hospitalier de l’Université de Montréal), Sean Rourke (Ontario HIV Treatment Network), Sergio Rueda (Centre for Addiction and Metal Health), Mercy Saavedra (Women’s College Research Institute), Kate Salters (Simon Fraser University), Margarite Sanchez (ViVA and Southern Gulf Islands AIDS Society), Roger Sandre (Haven Clinic), Jacquie Sas (CIHR Canadian HIV Trials Network), Paul Sereda (British Columbia Centre for Excellence in HIV/AIDS), Fiona Smaill (McMaster University), Stephanie Smith (Women’s College Research Institute), Marcie Summers (Positive Women’s Network), Tsitsi Tigere (Women’s College Research Institute), Wangari Tharao (Women’s Health in Women’s Hands), Jamie Thomas-Pavanel (Women’s College Research Institute), Christina Tom (Simon Fraser University, BC), Cécile Tremblay (Centre Hospitalier de l’Université de Montréal), Benoit Trottier (Clinique l’Actuel), Sylvie Trottier (Centre Hospitalier Universitaire de Québec), Christos Tsoukas (McGill University Health Centre), Anne Wagner (Ryerson University), Sharon Walmsley (Toronto General Research Institute), Kath Webster (Simon Fraser University), Wendy Wobeser (Kingston University), Jessica Yee (Native Youth Sexual Health Network), Mark Yudin (St-Michael’s Hospital), Wendy Zhang (British Columbia Centre for Excellence in HIV/AIDS). All other CHIWOS Research Team Members who wish to remain anonymous.


CHIWOS is supported by funding from the Canadian Institutes of Health Research (CIHR) (Grant No: MOP-111041; FDN154325), the CIHR Canadian HIV Trials Network (CTN 262), the Academic Health Science Centres (AHSC) Alternative Funding Plans (AFP) Innovation Fund, the Ontario HIV Treatment Network, and the Institute of Gender, Sex, and Health. Ontario Trillium Scholarship supports the first author (MS). AK is supported by a Canada Research Chair (Tier 2).

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study.

Supplementary material

10461_2019_2454_MOESM1_ESM.docx (434 kb)
Supplementary material 1 (DOCX 435 kb)


  1. 1.
    Cook RL, Zhu F, Belnap BH, et al. Longitudinal trends in hazardous alcohol consumption among women with human immunodeficiency virus infection, 1995–2006. Am J Epidemiol. 2009;169(8):1025–32.PubMedPubMedCentralCrossRefGoogle Scholar
  2. 2.
    Carter A, Roth EA, Ding E, et al. Substance use, violence, and antiretroviral adherence: a latent class analysis of women living with HIV in Canada. AIDS Behav. 2018;22(3):971–85.PubMedCrossRefPubMedCentralGoogle Scholar
  3. 3.
    Shokoohi M, Bauer GR, Kaida A, et al. Substance use patterns among women living with HIV compared with the general female population of Canada. Drug Alcohol Depend. 2018;191:70–7.PubMedCrossRefPubMedCentralGoogle Scholar
  4. 4.
    National Institute on Alcohol Abuse and Alcoholism. Rethinking drinking: alcohol and your health. Bethesda, MD: National Institute on Alcohol Abuse and Alcoholism; 2010. Accessed June 2018.
  5. 5.
    National Institute on Alcohol Abuse and Alcoholism. NIAAA council approves definition of binge drinking; 2004. Accessed June 2018.
  6. 6.
    Monroe AK, Lau B, Mugavero MJ, et al. Heavy alcohol use is associated with worse retention in HIV care. J Acquir Immune Defic Syndr. 2016;73(4):419–25.PubMedPubMedCentralCrossRefGoogle Scholar
  7. 7.
    Barai N, Monroe A, Lesko C, et al. The association between changes in alcohol use and changes in antiretroviral therapy adherence and viral suppression among women living with HIV. AIDS Behav. 2017;21(7):1836–45.PubMedPubMedCentralCrossRefGoogle Scholar
  8. 8.
    Monnig MA, Kahler CW, Cioe PA, et al. Alcohol use predicts elevation in inflammatory marker soluble CD14 in men living with HIV. AIDS Care. 2016;28(11):1434–40.PubMedPubMedCentralCrossRefGoogle Scholar
  9. 9.
    Molina PE, Bagby GJ, Nelson S. Biomedical consequences of alcohol use disorders in the HIV-infected host. Curr HIV Res. 2014;12(4):265–75.PubMedPubMedCentralCrossRefGoogle Scholar
  10. 10.
    Bagby GJ, Amedee AM, Siggins RW, Molina PE, Nelson S, Veazey RS. Alcohol and HIV effects on the immune system. Alcohol Res. 2015;37(2):287–97.PubMedPubMedCentralGoogle Scholar
  11. 11.
    Neblett RC, Hutton HE, Lau B, McCaul ME, Moore RD, Chander G. Alcohol consumption among HIV-infected women: impact on time to antiretroviral therapy and survival. J Womens Health. 2011;20(2):279–86.CrossRefGoogle Scholar
  12. 12.
    Public Health Agency of Canada. HIV and AIDS in Canada: surveillance report to December 31, 2014. Ottawa: Minister of Public Works and Government Services Canada; 2015.Google Scholar
  13. 13.
    Cook RL, Zhu F, Belnap BH, et al. Alcohol consumption trajectory patterns in adult women with HIV infection. AIDS Behav. 2013;17(5):1705–12.PubMedPubMedCentralCrossRefGoogle Scholar
  14. 14.
    Kelso-Chichetto NE, Plankey M, Abraham AG, et al. Association between alcohol consumption trajectories and clinical profiles among women and men living with HIV. Am J Drug Alcohol Abuse. 2018;44(1):85–94.PubMedCrossRefPubMedCentralGoogle Scholar
  15. 15.
    Ghebremichael M, Paintsil E, Ickovics JR, et al. Longitudinal association of alcohol use with HIV disease progression and psychological health of women with HIV. AIDS Care. 2009;21(7):834–41.PubMedPubMedCentralCrossRefGoogle Scholar
  16. 16.
    Bilal U, McCaul ME, Crane HM, et al. Predictors of longitudinal trajectories of alcohol consumption in people with HIV. Alcohol Clin Exp Res. 2018;42(3):561–70.PubMedPubMedCentralCrossRefGoogle Scholar
  17. 17.
    Commission on Social Determinants of Health (CSDH). Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. Geneva: World Health Organization; 2008. Accessed 26 March 2018.
  18. 18.
    Mikkonen J, Raphael D. Social determinants of health: the Canadian facts. Toronto: York University School of Health Policy and Management; 2010.Google Scholar
  19. 19.
    Logie CH, Wang Y, Marcus N, et al. Factors associated with the separate and concurrent experiences of food and housing insecurity among women living with HIV in Canada. AIDS Behav. 2018;22(9):3100–10.PubMedCrossRefGoogle Scholar
  20. 20.
    Shokoohi M, Bauer GR, Kaida A, et al. Patterns of social determinants of health associated with drug use among women living with HIV in Canada: a latent class analysis. Addiction. 2019. Scholar
  21. 21.
    Singer M. Introduction to syndemics: a critical systems approach to public and community health. San Francisco: Jossey-Bass; 2009.Google Scholar
  22. 22.
    Loutfy M, de Pokomandy A, Kennedy VL, et al. Cohort profile: the Canadian HIV women’s sexual and reproductive health cohort study (CHIWOS). PLoS ONE. 2017;12(9):e0184708.PubMedPubMedCentralCrossRefGoogle Scholar
  23. 23.
    Webster K, Carter A, Proulx-Boucher K, et al. Strategies for recruiting women living with human immunodeficiency virus in community-based research: lessons from Canada. Prog Community Health Partnersh. 2018;12(1):21–34.PubMedCrossRefPubMedCentralGoogle Scholar
  24. 24.
    Read JP, Beattie M, Chamberlain R, Merrill JE. Beyond the “Binge” threshold: heavy drinking patterns and their association with alcohol involvement indices in college students. Addict Behav. 2008;33(2):225–34.PubMedCrossRefPubMedCentralGoogle Scholar
  25. 25.
    VanderWeele TJ, Robinson WR. On the causal interpretation of race in regressions adjusting for confounding and mediating variables. Epidemiology. 2014;25(4):473–84.PubMedPubMedCentralCrossRefGoogle Scholar
  26. 26.
    Williams DR, Yan Y, Jackson JS, Anderson NB. Racial differences in physical and mental health: socio-economic status, stress and discrimination. J Health Psychol. 1997;2(3):335–51.PubMedCrossRefPubMedCentralGoogle Scholar
  27. 27.
    McLaughlin KA, Hatzenbuehler ML, Keyes KM. Responses to discrimination and psychiatric disorders among Black, Hispanic, female, and lesbian, gay, and bisexual individuals. Am J Public Health. 2010;100(8):1477–84.PubMedPubMedCentralCrossRefGoogle Scholar
  28. 28.
    Wright K, Naar-King S, Lam P, Templin T, Frey M. Stigma scale revised: reliability and validity of a brief measure of stigma for HIV+ youth. J Adolesc Health. 2007;40(1):96–8.PubMedCrossRefPubMedCentralGoogle Scholar
  29. 29.
    Gjesfjeld CD, Greeno CG, Kim KH. A confirmatory factor analysis of an abbreviated social support instrument: the MOS-SSS. Res Soc Work Pract. 2008;18(3):231–7.CrossRefGoogle Scholar
  30. 30.
    McCoy SI, Strauss RP, MacDonald PD, Leone PA, Eron JJ, Miller WC. Social support and delays seeking care after HIV diagnosis, North Carolina, 2000–2006. AIDS Care. 2009;21(9):1148–56.PubMedPubMedCentralCrossRefGoogle Scholar
  31. 31.
    Heckman TG, Somlai AM, Peters J, et al. Barriers to care among persons living with HIV/AIDS in urban and rural areas. AIDS Care. 1998;10(3):365–75.PubMedCrossRefPubMedCentralGoogle Scholar
  32. 32.
    Johnson M, Samarina A, Xi H, et al. Barriers to access to care reported by women living with HIV across 27 countries. AIDS Care. 2015;27(10):1220–30.PubMedPubMedCentralCrossRefGoogle Scholar
  33. 33.
    Vozoris NT, Tarasuk VS. Household food insufficiency is associated with poorer health. J Nutr. 2003;133(1):120–6.PubMedCrossRefPubMedCentralGoogle Scholar
  34. 34.
    Wagnild G. A review of the resilience scale. J Nurs Meas. 2009;17(2):105–13.PubMedCrossRefPubMedCentralGoogle Scholar
  35. 35.
    Lanza ST, Dziak JJ, Huang L, Wagner A, Collins LM. PROC LCA & PROC LTA users’ guide (Version 1.3.2). University Park: The Methodology Center, Penn State; 2015.Google Scholar
  36. 36.
    Dempster AP, Laird NM, Rubin DB. Maximum likelihood from incomplete data via the EM algorithm. J R Stat Soc B. 1977;39(1):1–38.Google Scholar
  37. 37.
    Akaike H. Factor analysis and AIC. Psychometrika. 1987;52(3):317–32.CrossRefGoogle Scholar
  38. 38.
    Schwartz G. Estimating the dimension of a model. Ann Stat. 1987;6:461–4.CrossRefGoogle Scholar
  39. 39.
    Sclove L. Application of model-selection criteria to some problems in multivariate analysis. Psychometrika. 1987;52(3):333–43.CrossRefGoogle Scholar
  40. 40.
    Brookhart MA, Schneeweiss S, Rothman KJ, Glynn RJ, Avorn J, Sturmer T. Variable selection for propensity score models. Am J Epidemiol. 2006;163(12):1149–56.PubMedPubMedCentralCrossRefGoogle Scholar
  41. 41.
    Howards PP, Schisterman EF, Heagerty PJ. Potential confounding by exposure history and prior outcomes: an example from perinatal epidemiology. Epidemiology. 2007;18(5):544–51.PubMedCrossRefGoogle Scholar
  42. 42.
    Groenwold RH, White IR, Donders AR, Carpenter JR, Altman DG, Moons KG. Missing covariate data in clinical research: when and when not to use the missing-indicator method for analysis. CMAJ. 2012;184(11):1265–9.PubMedPubMedCentralCrossRefGoogle Scholar
  43. 43.
    Hernan M, Robbins J. IP weighting and marginal structural models in Causal Inference. Boca Raton: Chapman & Hall/CRC. Archived by WebCite® at Accessed 01 April 2019.
  44. 44.
    Cole SR, Hernan MA. Constructing inverse probability weights for marginal structural models. Am J Epidemiol. 2008;168(6):656–64.PubMedPubMedCentralCrossRefGoogle Scholar
  45. 45.
    VanderWeele TJ, Ding P. Sensitivity analysis in observational research: introducing the E-value. Ann Intern Med. 2017;167(4):268–74.PubMedCrossRefPubMedCentralGoogle Scholar
  46. 46.
    Kaida A, Gormley R, Webster K, et al. High mortality among women living with HIV enrolled in Canada’s largest community-based cohort study. In: 22nd International AIDS Conference (AIDS 2018). Amsterdam, Netherlands; 2018.Google Scholar
  47. 47.
    Keyes KM, Hatzenbuehler ML, Hasin DS. Stressful life experiences, alcohol consumption, and alcohol use disorders: the epidemiologic evidence for four main types of stressors. Psychopharmacology. 2011;218(1):1–17.PubMedPubMedCentralCrossRefGoogle Scholar
  48. 48.
    Hutton H, Lesko CR, Chander G, Lau B, Wand GS, McCaul ME. Differential effects of perceived stress on alcohol consumption in moderate versus heavy drinking HIV-infected women. Drug Alcohol Depend. 2017;178:380–5.PubMedPubMedCentralCrossRefGoogle Scholar
  49. 49.
    Moore RD, Bartlett JG. Dramatic decline in the HIV-1 RNA level over calendar time in a large urban HIV practice. Clin Infect Dis. 2011;53(6):600–4.PubMedPubMedCentralCrossRefGoogle Scholar
  50. 50.
    Samji H, Cescon A, Hogg RS, et al. Closing the gap: increases in life expectancy among treated HIV-positive individuals in the United States and Canada. PLoS ONE. 2013;8(12):e81355.PubMedPubMedCentralCrossRefGoogle Scholar
  51. 51.
    Carter AJ, Bourgeois S, O’Brien N, et al. Women-specific HIV/AIDS services: identifying and defining the components of holistic service delivery for women living with HIV/AIDS. J Int AIDS Soc. 2013;16:17433.PubMedPubMedCentralCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Epidemiology and Biostatistics, Schulich School of Medicine & DentistryThe University of Western OntarioLondonCanada
  2. 2.Faculty of Health SciencesSimon Fraser UniversityBurnabyCanada
  3. 3.Factor-Inwentash Faculty of Social WorkUniversity of TorontoTorontoCanada
  4. 4.Women’s College Research Institute, Women’s College HospitalTorontoCanada
  5. 5.Epidemiology and Population Health Program, British Columbia Centre for Excellence in HIV/AIDSUniversity of British ColumbiaVancouverCanada
  6. 6.The Kirby InstituteUniversity of New South WalesSydneyAustralia
  7. 7.School of Social WorkUniversity of MichiganAnn ArborUSA
  8. 8.Faculty of MedicineUniversity of TorontoTorontoCanada
  9. 9.Dalla Lana School of Public HealthUniversity of TorontoTorontoCanada

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