HIV positive Hispanic/Latinos who delay HIV care: analysis of multilevel care engagement barriers

Structural and intermediary determinants in sexual health care access in migrant populations: a scoping review

OBJECTIVES

Addressing migrant population's sexual health needs is essential, given the high vulnerability of this population, especially during migratory trajectories and when accessing health care in destination countries. The aim of this scoping review is to identify and describe the structural and intermediary determinants and their dimensions, which negatively influence sexual healthcare access in migrant population in the world in the last 20 years.

STUDY DESIGN

Scoping review.

METHODS

The search strategy was carried out in the databases PubMed/MEDLINE, Web of Science, EMBASE, and CINAHL. The inclusion criteria were primary studies published in English or Spanish from 2000 to 2022, describing determinants or barriers to access to sexual health for international migrants, refugees, and asylum seekers. The construction of the results was based on the social determinants of health framework.

RESULTS

A total of 44 studies were included. Thirteen categories that negatively affect access to sexual health in migrants were identified-structural determinants: language and communication barriers, religious and cultural values, VIH stigma and discrimination, irregular migration status, financial constraints, racism and discrimination, gender inequalities, and lack of knowledge and awareness about sexuality and sexual health; and intermediary determinants: financial health coverage, privacy and confidentiality, health system navigation; health system and facilities, and psychosocial factors.

CONCLUSION

The most relevant dimensions identified as barriers to access to health services were "culture and societal values" and "health system". Identifying the determinants that affect migrants' access to sexual health is relevant for the formulation of public policies with sociocultural relevance and an intersectional and human rights approach.

"If They Give Their Mind to HIV, They Don't Last as Long": An Explanatory Model of HIV Infection in a Limited-Resource Setting Informs Person-Centered Care

Explanatory models describe individuals’ perceptions of their illness experiences, which can guide culturally relevant care. We constructed an explanatory model of the experience of living with human immunodeficiency virus (HIV) in the Dominican Republic. Following qualitative descriptive methodology, we conducted interviews in Spanish using a semi-structured interview guide developed using Kleinman’s explanatory model framework. Two bilingual researchers coded interview transcripts following conventional content analysis. We used deductive codes from Kleinman’s framework and inductive codes external to the framework to construct the codebook. We arranged codes by shared meaning into categories and constructed themes that reflected shared findings from inductive categories and deductive codes. Twenty-six persons living with HIV participated. They provided rich descriptions of their experiences represented by four cross-cutting themes, which informed the explanatory model. By incorporating this in-depth understanding of patients’ illness experiences into care delivery, nurses can cultivate culturally meaningful and trusting patient-centered partnerships that improve health.

From Theory to Application: A Description of Transnationalism in Culturally-Appropriate HIV Interventions of Outreach, Access, and Retention Among Latino/a Populations

Interventions aiming to improve access to and retention in HIV care are optimized when they are tailored to clients' needs. This paper describes an initiative of interventions implemented by ten demonstration sites using a transnational framework to tailor services for Mexicans and Puerto Ricans living with HIV. Transnationalism describes how immigrants (and their children) exist in their "receiving" place (e.g., continental U.S.) while simultaneously maintaining connections to their country or place of origin (e.g., Mexico). We describe interventions in terms of the strategies used, the theory informing design and the tailoring, and the integration of transnationalism. We argue how applying the transnational framework may improve the quality and effectiveness of services in response to the initiative's overall goal, which is to produce innovative, robust, evidence-informed strategies that go beyond traditional tailoring approaches for HIV interventions with Latino/as populations.

Improving HIV Care Engagement in the South from the Patient and Provider Perspective: The Role of Stigma, Social Support, and Shared Decision-Making

Initial linkage to medical care is a critical step in the HIV care continuum leading to improved health outcomes, reduced morbidity and mortality, and decreased HIV transmission risk. We explored differences in perspectives on engagement in HIV care between people living with HIV who attended (Arrived) their initial medical provider visit (IMV) and those who did not (Missed), and between patients and providers. The study was conducted in two large majority/minority HIV treatment centers in the United States (US) south, a geographical region disproportionately impacted by HIV. The Theory of Planned Behavior informed semistructured interviews eliciting facilitators and barriers to engagement in care from 53 participants: 40 patients in a structured sample of 20 Missed and 20 Arrived, and 13 care providers. Using Grounded Theory to frame analysis, we found similar perspectives for all groups, including beliefs in the following: patients' control over care engagement, a lack of knowledge regarding HIV within the community, and the impact of structural barriers to HIV care such as paperwork, transportation, housing, and substance use treatment. Differences were noted by care engagement status. Missed described HIV-related discrimination, depression, and lack of social support. Arrived worried what others think about their HIV status. Providers focused on structural barriers and process, while patients focused on relational aspects of HIV care and personal connection with clinics. Participants proposed peer navigation and increased contact from clinics as interventions to reduce missed IMV. Context-appropriate interventions informed by these perspectives are needed to address the expanding southern HIV epidemic.

A Critical Review and Commentary on the Challenges in Engaging HIV-Infected Latinos in the Continuum of HIV Care

Antiretroviral therapy for treatment of HIV infection has become increasingly effective. Persistent poor HIV outcomes in racial and ethnic minority populations in the US call for a closer examination into why Latinos are at significant risk for acquiring and dying from HIV. To improve clinical outcomes and achieve an AIDS-free generation, HIV research must address disparities in HIV outcomes in Latinos, the largest ethnic/racial minority population in the US. Immigrant status as well as cultural factors influence HIV care utilization and are essential to highlight for effective intervention development in Latinos. A better understanding of these individual and contextual factors is critical to developing tailored approaches to engaging Latinos in HIV care. Based on a comprehensive literature review, we offer a framework for understanding what is needed from clinical practice and research to improve engagement in HIV care for US-based Latinos. These findings may have implications for other minority populations.

"Where It Falls Apart": Barriers to Retention in HIV Care in Latino Immigrants and Migrants

Latino immigrants in the United States are disproportionately affected by HIV. Barriers to consistent attendance (retention) in HIV primary care constrain opportunities for HIV treatment success, but have not been specifically assessed in this population. We conducted semistructured interviews with 37 HIV-infected Latinos (aged ≥18 years and born in Puerto Rico or a Latin American Spanish-speaking country) and 14 HIV providers in metropolitan Boston (total n = 51). The Andersen Model of Healthcare Utilization informed a semistructured interview guide, which bilingual research staff used to explore barriers to HIV care. We used thematic analysis to explore the processes of retention in care. Six ubiquitous themes were perceived to influence HIV clinic attendance: (1) stigma as a barrier to HIV serostatus disclosure; (2) social support as a safety net during negative life circumstances; (3) unaddressed trauma and substance use leading to interruption in care; (4) a trusting relationship between patient and provider motivating HIV clinic attendance; (5) basic unmet needs competing with the perceived value of HIV care; and (6) religion providing a source of hope and optimism. Cultural subthemes were the centrality of family (familismo), masculinity (machismo), and trusting relationships (confianza). The timing of barriers was acute (e.g., eviction) and chronic (e.g., family conflict). These co-occurring and dynamic constellation of factors affected HIV primary care attendance over time. HIV-infected Latino immigrants and migrants experienced significant challenges that led to interruptions in HIV care. Anticipatory guidance to prepare for these setbacks may improve retention in HIV care in this population.

Deportation history among HIV-positive Latinos in two US-Mexico border communities

Health-related vulnerabilities associated with deportation are understudied. We conducted a cross-sectional study to identify factors associated with history of deportation from the US to Mexico among HIV-positive Latinos. From 2009 to 2010, we recruited a convenience sample from HIV clinics in San Diego, US and Tijuana, Mexico. Of 283 participants, 25% reported a prior deportation. Factors independently associated with increased odds of deportation history were being male [adjusted odds ratio (AOR) 2.77; 95% CI 1.18-6.48], having ≤high-school education (AOR 3.87; 95% CI 1.84-8.14), ever using cocaine (AOR 2.46; 95% CI 1.33-4.57), and reporting personalized HIV-stigma: "some have told me HIV is what I deserve for how I lived" (AOR 2.23; 95% CI 1.14-4.37). Lower self-reported antiretroviral medication adherence (AOR 0.35; 95% CI 0.12-0.96) and perceiving HIV-stigma: "most people believe a person who has HIV is dirty" (AOR 0.49; 95% CI 0.25-0.94) were associated with decreased odds of deportation history. Deportation is associated with specific socioeconomic indicators that are known to impact the health of individuals living with HIV.

Individual and community factors associated with geographic clusters of poor HIV care retention and poor viral suppression

BACKGROUND

Previous analyses identified specific geographic areas in Philadelphia (hotspots) associated with negative outcomes along the HIV care continuum. We examined individual and community factors associated with residing in these hotspots.

METHODS

Retrospective cohort of 1404 persons newly diagnosed with HIV in 2008-2009 followed for 24 months after linkage to care. Multivariable regression examined associations between individual (age, sex, race/ethnicity, HIV transmission risk, and insurance status) and community (economic deprivation, distance to care, access to public transit, and access to pharmacy services) factors and the outcomes: residence in a hotspot associated with poor retention-in-care and residence in a hotspot associated with poor viral suppression.

RESULTS

In total, 24.4% and 13.7% of persons resided in hotspots associated with poor retention and poor viral suppression, respectively. For persons residing in poor retention hotspots, 28.3% were retained in care compared with 40.4% of those residing outside hotspots (P < 0.05). Similarly, for persons residing in poor viral suppression hotspots, 51.4% achieved viral suppression compared with 75.3% of those outside hotspots (P < 0.0.05). Factors significantly associated with residence in poor retention hotspots included female sex, lower economic deprivation, greater access to public transit, shorter distance to medical care, and longer distance to pharmacies. Factors significantly associated with residence in poor viral suppression hotspots included female sex, higher economic deprivation, and shorter distance to pharmacies.

CONCLUSIONS

Individual and community-level associations with geographic hotspots may inform both content and delivery strategies for interventions designed to improve retention-in-care and viral suppression.

Development and validation of a computer-based algorithm to identify foreign-born patients with HIV infection from the electronic medical record

OBJECTIVE

To develop and validate an efficient and accurate method to identify foreign-born patients from a large patient data registry in order to facilitate population-based health outcomes research.

METHODS

We developed a three-stage algorithm for classifying foreign-born status in HIV-infected patients receiving care in a large US healthcare system (January 1, 2001-March 31, 2012) (n = 9,114). In stage 1, we classified those coded as non-English language speaking as foreign-born. In stage 2, we searched free text electronic medical record (EMR) notes of remaining patients for keywords associated with place of birth and language spoken. Patients without keywords were classified as US-born. In stage 3, we retrieved and reviewed a 50-character text window around the keyword (i.e. token) for the remaining patients. To validate the algorithm, we performed a chart review and asked all HIV physicians (n = 37) to classify their patients (n = 957).We calculated algorithm sensitivity and specificity.

RESULTS

We excluded 160/957 because physicians indicated the patient was not HIV-infected (n = 54), "not my patient" (n = 103), or had unknown place of birth (n = 3), leaving 797 for analysis. In stage 1, providers agreed that 71/95 foreign language speakers were foreign-born. Most disagreements (23/24) involved patients born in Puerto Rico. In stage 2, 49/50 patients without keywords were classified as US-born by chart review. In stage 3, token review correctly classified 55/60 patients (92%), with 93% (CI: 84.4, 100%) sensitivity and 90% (CI: 74.3, 100%) specificity compared with full chart review. After application of the three-stage algorithm, 2,102/9,114 (23%) patients were classified as foreign-born. When compared against physician response, estimated sensitivity of the algorithm was 94% (CI: 90.9, 97.2%) and specificity 92% (CI: 89.7, 94.1%), with 92% correctly classified.

CONCLUSION

A computer-based algorithm classified foreign-born status in a large HIV-infected cohort efficiently and accurately. This approach can be used to improve EMR-based outcomes research.

Healthcare provider perspectives on barriers to HIV-care access and utilisation among Latinos living with HIV in the US-Mexico border

Latinos living with HIV residing in the US-Mexico border region frequently seek care on both sides of the border. Given this fact, a border health perspective to understanding barriers to care is imperative to improve patient health outcomes. This qualitative study describes and compares experiences and perceptions of Mexican and US HIV care providers regarding barriers to HIV care access for Latino patients living in the US-Mexico border region. In 2010, we conducted in-depth qualitative interviews with HIV care providers in Tijuana (n = 10) and San Diego (n = 9). We identified important similarities and differences between Mexican and US healthcare provider perspectives on HIV care access and barriers to service utilisation. Similarities included the fact that HIV-positive Latino patients struggle with access to ART medication, mental health illness, substance abuse and HIV-related stigma. Differences included Mexican provider perceptions of medication shortages and US providers feeling that insurance gaps influenced medication access. Differences and similarities have important implications for cross-border efforts to coordinate health services for patients who seek care in both countries.

The Hispanic HIV Epidemic

The Hispanic population in the U.S. has been dramatically affected by the HIV epidemic. The impact not only is related to the infection itself and its complications, but also is driven by social factors that lead to increased disparity in health-care access and cultural modeling and to increased social stigma, which leads to marginalization and exacerbates the existing gaps in medical care. Hispanics infected with HIV more frequently receive delayed diagnoses and more often present with AIDS, concomitant opportunistic infections, or coinfections related to their country of origin. The unique characteristics that define the HIV epidemic in Hispanics need further analysis in order to identify new opportunities to improve linkage to health care, increase efficacy in health-care provision, and decrease social disparities related to the Hispanic population.