Intersectionality Can Shape the Support Networks of Older Women with HIV

Abstract:

Older women living with HIV are an especially vulnerable population due to their experience of multiple stigmas resulting from intersectional identities. Using an intersectional convoy model to conceptualize social relations, we consider how HIV-related stigma, age, gender, race/ethnicity, and socioeconomic position shape access to support resources through personal networks. We briefly review existing research on how intersecting identities and structural inequities might influence the structure, composition, and function of support networks among older people with HIV. Potential applications of the intersectional convoy model and implications for research and practice are discussed.

Key Words:

HIV, gender, isolation, race and ethnicity, stigma, support networks

Integration within supportive social networks is widely considered to be a key component of healthy aging and essential for older adults’ health and well-being. Efforts to identify protective factors, such as support networks, and the mechanisms whereby they promote healthy aging among people living with HIV (PLWH) are increasingly important as this population grows worldwide. Though nascent, there is a growing body of work focused on the structural and functional aspects of social ties among people aging with HIV. Social support is a protective factor against many negative consequences of HIV, as it can buffer against HIV stigma (Emlet, 2006a), and it is associated with a number of health-promoting behaviors among PLWH, including care engagement and medication adherence (Chandran et al., 2019). Thus, it is important to understand the factors that shape older PLWH’s access to and use of informal support resources.

Stigma double jeopardy. Decades of research have highlighted the effects of HIV stigma on social relations. Aging with HIV represents a “double stigma” (Emlet, 2006b), whereby risk of social isolation is exacerbated by the lack of social support and internalization of harmful ageist stereotypes (e.g., loneliness being an inevitable part of aging), as well as structural ableism. Structural ableism related to HIV serostatus can range from discrimination and lack of access to services to more serious human rights infringements, such as criminalization based on HIV status. Emlet (2006b) found that most older PLWH experience ageism and ableist HIV-related stigma, which intersect in their reports of rejection, stereotyping, and social isolation.

Older PLWH may be more socially isolated and have smaller social networks for several reasons (Poindexter & Shippy, 2008; Shippy & Karpiak, 2005). Disclosure of HIV status can result in the loss of important social ties, like family relationships or embeddedness in communities, which contributes to social isolation among PLWH. Stigma may discourage people from disclosing their serostatus and seeking support, which are socially isolating experiences. However, PLWH demonstrate resilience in adapting their networks to meet social needs. In terms of social network composition, friends or “families of choice” have long been considered a staple of PLWH’s social networks, particularly among gay and bisexual men (Emlet, 2006a). Adopting a strengths-based perspective, this feature of the social networks of PLWH is an important adaptation as the shared experience of HIV can be an invaluable source of support and the basis for community-building within these “alternate families” (Warren-Jeanpiere et al., 2017).

Older women living with HIV. Research on the support networks of PLWH and on aging with HIV more generally has focused on men, especially gay and bisexual men, as they have historically made up the majority of those affected by the HIV epidemic. Older women make up 12.5% of all PLWH in the United States. Out of all women living with HIV (WLWH), more than half (54%) are older than age 50 (Centers for Disease Control and Prevention, 2022).

HIV, like many chronic diseases, is not randomly distributed but disproportionately impacts certain groups. Black and Latina women, for instance, make up 77% of all WLWH in the United States. Thus, the majority of older WLWH live at the intersection of multiple marginalized identities, navigating sexism, racism, ableism, and ageism in systems and social structures such as healthcare and social services, which are designed without their needs in mind.

Aging among older WLWH is a unique experience that results from cumulative negative effects of oppressive systems that encompass sexism, ableism, ageism, racism, and poverty (Rubtsova et al., 2017). These intersections manifest in a range of stigma experiences (e.g., fear of HIV disclosure, social rejection, social isolation, inadequate social support) that ultimately affect the health and well-being of older WLWH. This makes older WLWH an especially invisible and vulnerable population. Here, we examine the unique and interactive roles of HIV stigma, age, gender identity, race/ethnicity, and socioeconomic position (SEP) in shaping older WLWH’s informal support resources.

We begin by introducing a theoretical framework to guide this review, the intersectional convoy model. Focusing on older PLWH, we highlight the influences of HIV-related stigma and ageism before considering gender, race/ethnicity, and SEP, first individually and then in combination through a discussion of the social networks of older WLWH. We aim to address both strengths and vulnerabilities of these social networks, including the amount, source, and types of support available to older WLWH as well as how HIV stigma is a barrier to support and high-quality social ties.

Intersectional Convoy Model

The convoy model of social relations provides a flexible and adaptive framework for conceptualizing social networks and social support (Fuller et al., 2020). Convoys, or social/personal networks, can be thought of as the constellation of social ties surrounding an individual as they move through the life course. When functioning optimally, convoys are meant to protect against stress and provide individuals with the resources needed to adapt to life’s challenges. The convoy model describes social relations as multidimensional, encompassing structure, function, and quality. Convoy structure refers to objective characteristics, like size (i.e., number of close and important others) and composition (e.g., based on kinship, gender, race, etc.). Convoy function encompasses various types of social support (i.e., instrumental/tangible, emotional, feelings of belonging and affirmation). Quality, or support adequacy, describes the gap between desired and perceived levels of support. Social networks might be considered “inadequate” when there is a mismatch between one’s desired level, type, or source of support and one’s perception of these dimensions.

Although there are widely used metrics for each of these dimensions (e.g., family vs. friend network composition), we broaden our perspective to also consider HIV-related characteristics that might be related to stigma. For example, in the context of HIV, measures of network composition may include HIV seroconcordance, or the proportion of other PLWH in one’s network. Similarly, HIV disclosure among network members can be considered an indicator of emotional closeness or support (Messer et al., 2020).

Each of these dimensions has an influence on health and well-being across the lifespan and is shaped by personal and situational factors (Fuller et al., 2020). There are well-documented differences in the structure and function of personal networks by age, gender, race, and SEP. Most discussions of the factors shaping social relations consider them independently. However, it is difficult to parse their independent effects and important to acknowledge the intersectionality of identities in shaping convoy structure and function. The five corners intersectionality model captures how the convergence of race, SEP, gender identity, age, and HIV stigma shape the experiences of people living with HIV (Porter & Brennan-Ing, 2019). This model can be applied to relationship experiences and social ties, too.

We draw from both theoretical frameworks to propose an intersectional convoy model that considers how different personal and situational factors, including HIV-stigma, age, gender identity, race/ethnicity, and SEP interact to shape the social networks of PLWH (see Figure 1, below). We review variations in network structure, composition, social support, and relationship quality. After establishing the independent effects of these factors on older PLWH’s social convoys, we apply the intersectional convoy model to demonstrate how these characteristics intersect to shape older WLWH’s social relations.

Figure 1. Intersectional Convoy Model

HIV Stigma and Age

In general, older adults report smaller, less conflictual, and more emotionally close and satisfying social networks compared to younger adults. They are less likely to maintain peripheral, role-based social ties, opting instead for emotionally close and stable ones (Carstensen, 2021). Depending upon other factors, namely health and physical functioning, some older adults may withdraw from social engagement. One major distinction between aging with and without HIV is that PLWH are more likely to have multiple age-related chronic conditions, like cardiovascular disease, as well as conditions related to HIV and its treatments.

Older PLWH have been found to be more socially isolated than their younger peers, highlighting the intersecting effects of age-related and HIV-related stigmas (Emlet, 2006a, 2006b). Older PLWH tend to have smaller support networks dominated by friends, rather than spouses or children as is often expected of older people (Cantor et al., 2009). Compared to those without HIV, older PLWH reported less availability of support from network members. Shippy and Karpiak (2005) found that most older PLWH report inadequate emotional and instrumental support and have “fragile networks”; further, 79% of the sample reported living alone.

Similarly, Brennan-Ing and colleagues (2016) used network composition and contact with network members to identify network typologies of older PLWH, including “isolated,” “friend-centered,” and “integrated,” finding that the isolated group had inadequate social care resources and poorer psychosocial functioning. Importantly, these findings mirror the network typologies that have been identified in older adult samples without HIV (e.g., Ali et al., 2022), suggesting that HIV serostatus is only one of multiple characteristics that shape social networks and other social identities may in fact be more prominent. In the following sections, we describe how gender, race/ethnicity, and socioeconomic status factor into the social convoys of older PLWH.

Gender. The social networks of men and women have been found to differ across many dimensions. Generally, women tend to have larger, more diverse, and more emotionally close networks than men (Ajrouch et al., 2005). These differences are primarily driven by societal norms and cultural expectations, rather than innate sex/gender differences. In one study, although there were no differences in network size, older WLWH were more likely to have a spouse they could rely upon for support than men and report greater functional support sources compared to men (Cantor et al., 2009). Some studies show the positive effect of HIV-positive peers on the mental health of WLWH (Cederbaum et al., 2017). In terms of convoy function, WLWH often report more adequate emotional support than men (Shippy & Karpiak, 2005). Still, the stigma that stems from older WLWH’s seropositivity represents a major challenge they must contend with in meeting their support needs (Durvasula, 2014).

Reluctance to disclose HIV status, which is perceived as particularly shameful among older women, is a fundamental barrier to seeking support (Grodensky et al., 2015). Depending upon the timing of seroconversion in their life course, older WLWH may be dealing with HIV stigma and implications for social relations for the first time. Few studies exclusively focus on the social networks of older WLWH, which may be larger and more burdensome or demanding than networks of other PLWH.

Older WLWH frequently are caregivers for spouses/partners, adult children, older parents, and grandchildren, and have other significant social responsibilities (Lee et al., 2021). Women make up the vast majority of informal caregivers worldwide. These responsibilities put additional strains on older women who are already managing their own chronic conditions and concomitant psychosocial sequelae. At the same time, older WLWH may not have access to traditional caregiving resources for themselves, such as spouses or children, despite significant care needs. Like many PLWH, some older WLWH consider family to be unreliable sources of support and often prefer support from friends, particularly HIV-positive peers (Warren-Jeanpiere et al., 2017). Still for others, close family, namely daughters and grandchildren, have been recognized as key support sources (Grodensky et al., 2015).

Race and ethnicity. There are well-documented differences in social convoys across race and ethnicity, particularly with regard to family composition (Ajrouch et al., 2001; Fuller et al., 2020). Older Black and Latinx individuals, for example, have smaller, more family-centric, and emotionally close networks than do their White peers (Ajrouch et al., 2001; Feng, 2023). Among older PLWH, one study found no differences in network size across racial/ethnic groups, though older Black and Latinx individuals reported more functional support sources than did White (Cantor et al., 2009). The significance of kinship ties, including “fictive kin,” is evident in the social convoys of older Black and Latinx individuals as a strategy against social isolation.

Older Black and Latinx PLWH may be at an advantage with social convoys composed of “family of choice” given that this aligns with cultural norms of including extended or more distantly related relatives in convoys. On the other hand, cultural attitudes rooted in religion, respect, and “simpatico” (i.e., keeping the peace) may exacerbate HIV-related stigma for older PLWH (Beaulaurier et al., 2009; Grodensky et al., 2015). Thus, the cultural aspects for older Black and Latinx adults living with HIV can serve as both protective and risk factors in their access to social support resources.

Socioeconomic position. SEP primarily influences convoy structure and composition, often through homophily—the tendency to form social ties with those who share similar characteristics. SEP can be captured through a variety of metrics, including educational attainment, income, wealth, occupational prestige, and social class. SEP is often linked to social capital—the resources, information, and other benefits that can be derived from personal networks. For example, those with greater educational attainment and occupational prestige tend to have larger and more diverse convoys, representing increased access to social resources (Ajrouch et al., 2005; Feng, 2023).

To some extent, high SEP can offset the disadvantages brought on by structural ableism, ageism, sexism, and racism for older PLWH by increasing access to resources, including informal support sources. The HIV epidemic, embedded in inequities, has always disproportionately affected lower SEP individuals and those in poverty, showing up in increased rates of infection and mortality and reduced access to treatment (Pellowski et al., 2013). Consequently, low SEP often amplifies the negative effects of other stigmas and inequities, which reduces access to informal supports.

Application of the Intersectional Convoy Model

Intersectionality, or multiple identities, as well as the stereotypes and biases against them, are experienced simultaneously, which is one reason it is difficult to isolate the independent effects of personal and situational characteristics on convoy structure and function. This is especially true for older WLWH, the majority of whom are Black and Latina (Centers for Disease Control and Prevention, 2022).

In a recent study of HIV-positive women of color, Messer and colleagues (2020) examined structural (e.g., size, composition) and functional (e.g., different types of support) network characteristics and found that different dimensions are uniquely associated with one another, as well as with health outcomes. For example, although the majority of these women’s networks were composed of family, family ties were only associated with treatment-specific support. Further, network composition factors that were associated with lower depression included enumerating network members who were family and those who were HIV-positive. Findings from a qualitative study of older Black WLWH emphasize the role that these women often play as the family matriarch (Warren-Jeanpiere et al., 2017), who often sacrifices their own support and care needs for the well-being of their loved ones. The experience of providing informal care for others while managing their own chronic conditions may be especially evident among older Black WLWH, highlighting another prime example whereby intersecting identities impact the experience of aging with HIV.

For older Latina women, cultural attitudes like “simpatico,” preservation of traditional gender roles, and strong religious beliefs can amplify the negative effects of sexism, making them similarly vulnerable to HIV-related stigma and social isolation (Beaulaurier et al., 2009). Religion and spirituality, however, are also sources of resilience for older Black and Latina WLWH (Grodensky et al., 2015; Warren-Jeanpiere et al., 2017). Religious groups can function as supportive communities or barriers to support, as when HIV-related stigma that is rampant in these communities discourages HIV disclosure. Such cultural attitudes can make it especially difficult for older women to disclose HIV status and hinder support seeking.

The intersection of race/ethnicity and SEP is also evident for older WLWH, who are more socially disadvantaged than other groups (e.g., due to lifetime effects of low wages, occupational prestige, etc.). Low SEP can be a barrier to well-connected and well-structured social convoys with negative reciprocal effects on health and well-being. The stressors stemming from low SEP (e.g., low income, unemployment, unstable housing) contribute to “chronic burden,” which is further amplified by HIV serostatus for low-income, ethnic minority WLWH and associated with low levels of social support (Gurung et al., 2004). While some informal support resources may be more readily available for older ethnic minority WLWH (e.g., based on community and family structures), their support needs are also more pronounced for coping with structural inequities. Researchers, policy makers, and program planners must intentionally apply these intersectional frameworks to assess the strengths and vulnerabilities conferred by these multiple identities when considering older WLWH.

Implications and Conclusions

Although existing research on older WLWH’s support networks provides some information about their support needs and resources, it is unclear how their convoys are structured, what functions they fulfill, and antecedent factors. It is important to understand what social resources older WLWH have available to meet their support needs and know where to intervene. Personal characteristics play a role in facilitating or hindering older WLWH from constructing personal convoys that are maximally beneficial for their specific life circumstances and support needs. Implications for research are clear—increased attention to the experiences of older WLWH, including experiences with social relations, is warranted.

The intersectional convoy model we present provides a framework from which to systematically investigate the role of intersectional identities in shaping close social ties and their consequences. By systematically measuring different dimensions of social relations, researchers can gain a more comprehensive view of what aspects of social relations are universal versus those that differ within and across populations. Understanding these similarities and differences can shed light on when, where, and with whom to intervene.

Further, the intersectional convoy model provides an excellent framework for developing interventions because of its attention to personal and situational circumstances that are experienced simultaneously. Considering intersectionality as it relates to personal convoys allows us to identify potential cumulative vulnerabilities and strengths in social networks. Leveraging the strengths and adaptations that have manifested in social ties among older WLWH is a promising way to ensure healthy aging with HIV.

Jasmine Manalel, PhD, is a senior research associate at the Brookdale Center for Healthy Aging at Hunter College, City University of New York. Mark Brennan-Ing, PhD, is director of research and evaluation at the Brookdale Center for Healthy Aging. Manalel may be contacted at jm10927@hunter.cuny.edu.

Photo credit: Shutterstock/DisobeyArt

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