A Multilevel Analysis of HIV Care Outcomes Across Age, Race, and Housing Among United States Women Veterans

Background: Women veterans with HIV represent a growing, diverse population within the Veterans Health Administration (VHA). This study examined HIV care continuum outcomes among women veterans using a multilevel intersectional approach. Methods: We conducted a retrospective analysis of 1154 women veterans with HIV in VHA care in fiscal year 2022, with outcomes assessed in fiscal year 2023. We applied Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy (MAIHDA) to evaluate how combinations of social positions (age, race/ethnicity, housing status) were associated with HIV outcomes. Results: MAIHDA models showed that younger age (<45 years) and being unhoused were consistently associated with lower odds of care engagement and viral suppression than midlife (45–64) and older (65+) housed women veterans. Additionally, predicted probability analyses revealed distinct clustering patterns. Younger non-Hispanic White women consistently ranked among the lowest performing strata across all outcomes, while midlife and older Hispanic and non-Hispanic Black women veterans clustered among the highest. Variance Partition Coefficients from null models were modest (1.8–3.0%). Fully adjusted models showed no remaining between-stratum variance, suggesting that the included social positions explained the observed differences in our dataset. Conclusions: These findings highlight disparities in HIV care engagement concentrated among specific groups and reinforce the importance of addressing individual- and system-level barriers to engagement and continuity of care among women Veterans in VHA care.