Structural Barriers to Women's Sustained Engagement in HIV Care in Southern California

Exploring experiences of HIV care to optimize patient-centred care in Conakry, Guinea: a qualitative study

Introduction

Studies on the organisation of care and the power dynamic between providers and patients with HIV in sub-Saharan Africa are rare. This study aims to describe the patient-provider relationship and explore the challenges to optimal and patient-centred care for HIV patients.

Methods

This was a qualitative exploratory descriptive study using in-depth individual interviews and focus group discussions. In total, 17 individual interviews and 5 focus group discussions were conducted. This was conducted in four urban health facilities in Conakry, the capital of Guinea. Three group of participants were included in this study namely patients with HIV; health providers including facilities and services managers; and psychosocial counsellors. Psychosocial counsellors provide emotional and psychosocial support to HIV patients. Their role in the organization care in Guinea is new and they contribute to strengthening adherence of patients with HIV to ARV treatment.

Results

Patients with HIV, health providers, and psychosocial counsellors have a positive perception of the patient-provider relationship. This relationship was characterized essentially by maintaining confidentiality of HIV status disclosure, caring attitudes towards patients (being available, adjusting locations for accessing ART, based on patients' preferences), and participating in HIV patient's social life. However, scolding and miscommunication about the interpretation of viral load tests were reported. The shortage of human resources, low salaries of health staff, poor infrastructure, and the financial burden borne by patients with HIV impede the implementation of optimal patient-centred care.

Conclusion

Integrating psychosocial counsellors in HIV care organization, improving access to ARV, infrastructure, increasing human resources, and removing the financial burden for HIV patients are needed to optimal patient-centred care in Guinea.

What's in Your Dataset? Measuring Engagement in HIV Care Using Routinely Administered Items with a Population Disproportionately Burdened by HIV

We evaluated the psychometric properties of a measure consisting of items that assess current HIV care continuum engagement based on established definitions in the United States. At baseline, participants in this longitudinal study, which included three time points from 2015 to 2020, were 331 young Black sexual minority men ages 18-29 living with HIV in the southern United States residing in two large southern cities. Self-report items reflected four aspects of HIV care continuum engagement as binary variables: seeing a healthcare provider for HIV care, being on antiretroviral treatment, being retained in HIV care, and being virally suppressed. Of these, the following three variables loaded onto a single factor in exploratory factor analysis: being on antiretroviral treatment, being retained in HIV care, and being virally suppressed. A one-dimensional factor structure was confirmed using confirmatory factor analyses at separate time points. Additionally, the three items collectively showed measurement invariance by age, education level, employment status, and income level. The three-item measure also showed reliability based on coefficient omega and convergent validity in its associations with indicators of socioeconomic distress, depression, resilience, and healthcare empowerment. In sum, the items performed well as a single scale. The study demonstrated the potential psychometric strength of simple, feasible, commonly administered items assessing engagement in the HIV care continuum.

Systematic Review of Neighborhood Factors Impacting HIV Care Continuum Participation in the United States

Social determinants have been increasingly implicated in accelerating HIV vulnerability, particularly for disenfranchised communities. Among these determinants, neighborhood factors play an important role in undermining HIV prevention. However, there has been little research comprehensively examining the impact of neighborhood factors on HIV care continuum participation in the US. To address this, we conducted a systematic review (PROSPERO registration number CRD42022359787) to determine neighborhood factors most frequently associated with diminished HIV care continuum participation. Peer-reviewed studies were included if published between 2013 - 2022, centralized in the US, and analyzed a neighborhood factor with at least one aspect of the HIV care continuum. The review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. Study quality was guided by LEGEND (Let Evidence Guide Every New Decision) evaluation guidelines. Systematic review analysis was conducted using Covidence software. There were 3,192 studies identified for initial screening. Forty-four were included for review after eliminating duplicates, title/abstract screening, and eligibility assessment. Social and economic disenfranchisement of neighborhoods negatively impacts HIV care continuum participation among persons living with HIV. In particular, five key neighborhood factors (socioeconomic status, segregation, social disorder, stigma, and care access) were associated with challenged HIV care continuum participation. Race moderated relationships between neighborhood quality and HIV care continuum participation. Structural interventions addressing neighborhood social and economic challenges may have favorable downstream effects for improving HIV care continuum participation.

Understanding why racial/ethnic inequities along the HIV care continuum persist in the United States: a qualitative exploration of systemic barriers from the perspectives of African American/Black and Latino persons living with HIV

BACKGROUND

Racial/ethnic inequities along the HIV care continuum persist in the United States despite substantial federal investment. Numerous studies highlight individual and social-level impediments in HIV, but fewer foreground systemic barriers. The present qualitative study sought to uncover and describe systemic barriers to the HIV care continuum from the perspectives of African American/Black and Latino persons living with HIV (PLWH) with unsuppressed HIV viral load, including how barriers operated and their effects.

METHODS

Participants were African American/Black and Latino PLWH with unsuppressed HIV viral load (N = 41). They were purposively sampled for maximum variability on key indices from a larger study. They engaged in semi-structured in-depth interviews that were audio-recorded and professionally transcribed. Data were analyzed using directed content analysis.

RESULTS

Participants were 49 years old, on average (SD = 9), 76% were assigned male sex at birth, 83% were African American/Black and 17% Latino, 34% were sexual minorities (i.e., non-heterosexual), and 22% were transgender/gender-nonbinary. All had indications of chronic poverty. Participants had been diagnosed with HIV 19 years prior to the study, on average (SD = 9). The majority (76%) had taken HIV medication in the six weeks before enrollment, but at levels insufficient to reach HIV viral suppression. Findings underscored a primary theme describing chronic poverty as a fundamental cause of poor engagement. Related subthemes were: negative aspects of congregate versus private housing settings (e.g., triggering substance use and social isolation); generally positive experiences with health care providers, although structural and cultural competency appeared insufficient and managing health care systems was difficult; pharmacies illegally purchased HIV medication from PLWH; and COVID-19 exacerbated barriers. Participants described mitigation strategies and evidenced resilience.

CONCLUSIONS

To reduce racial/ethnic inequities and end the HIV epidemic, it is necessary to understand African American/Black and Latino PLWH's perspectives on the systemic impediments they experience throughout the HIV care continuum. This study uncovers and describes a number of salient barriers and how they operate, including unexpected findings regarding drug diversion and negative aspects of congregate housing. There is growing awareness that systemic racism is a core determinant of systemic barriers to HIV care continuum engagement. Findings are interpreted in this context.

Cisgender women with HIV in the United States: how have HIV care continuum outcomes changed over time? 2015-2020

OBJECTIVE

To evaluate HIV care continuum trends over time among women with HIV (WWH).

DESIGN

The Medical Monitoring Project (MMP) is a complex sample survey of adults with diagnosed HIV in the United States.

METHODS

We used 2015-2019 MMP data collected from 5139 adults with diagnosed HIV infection who identified as cisgender women. We calculated weighted percentages with 95% confidence intervals (CIs) for all characteristics and estimated annual percentage change (EAPC) and the associated 95% CI to assess trends. EAPCs were considered meaningful from a public health perspective if at least 1% with P values less than 0.05.

RESULTS

Among cisgender women with diagnosed HIV infection during 2015-2019, 58.8% were Black or African American (95% CI 54.4-63.3), 19% were Hispanic/Latina (95% CI 14.7-23.2), and 16% were Non-Hispanic White (95% CI 14.1-17.9) persons. There was a meaningful increase in the percentage who ever had stage 3 HIV disease from 55.8% (95% CI 51.0-60.5) in 2015 to 61.5% (95% CI 58.1-64.8) in 2019 (EAPC 1.7%; CI 1.5-1.9; P < 0.001). There were no meaningful changes over time among women, overall, in retention in care, antiretroviral therapy (ART) prescription, ART adherence, missed appointments, or recent or sustained viral suppression.

CONCLUSION

The HIV care continuum outcomes among WWH did not meaningfully improve from 2015 to 2019, raising a concern that Ending the HIV Epidemic in the US (EHE) initiative goals will not be met. To improve health and reduce transmission of HIV among WWH, multifaceted interventions to retain women in care, increase ART adherence, and address social determinants of health are urgently needed.

Measuring Unmet Needs among Persons Living with HIV at Different Stages of the Care Continuum

Unmet needs can impede optimal care engagement, impacting the health and well-being of people living with HIV (PLWH); yet, whether unmet needs differ by care engagement status is not well understood. Using surveys and qualitative interviews, we examined and compared unmet needs for PLWH (n = 172) at different levels of care engagement. Unmet needs varied only slightly by care status. Survey findings revealed that provision of housing, emergency financial assistance, employment assistance, and food security were the greatest unmet need; for those in care, housing was the greatest unmet need, whereas for those sporadically in care or out of care, employment assistance was the greatest unmet needs. Qualitative interviews likewise illustrated that a lack of financial resources including insurance, housing, employment, and transportation presented barriers to care engagement across all care groups. Our findings indicate that unmet needs among PLWH are complex and multi-faceted across care engagement status.