Women with HIV infection: a model of university-based care, training and research

Women-centred HIV care: a scoping review to understand the current state of service delivery for women living with HIV globally

Women living with HIV (WLWH) face unique barriers and require specialized, integrated care that focuses on women's specific needs. We conducted a scoping review to examine factors important for a women-centred HIV care (WCHC) approach. We included published peer-reviewed articles which featured WCHC services as their central focus; included study populations of girls and WLWH aged 14 years of age or older; and contributed to the understanding of WCHC for WLWH. Seven databases were reviewed and yielded 15,332 references, of which 21 fit our inclusion criteria for the scoping review. Research findings were categorized into characteristics of the study, recommendations, and target audiences. Findings revealed WCHC as care which includes the involvement of WLWH in decisions; person-centred integrated care; integrated services including mental health; sexual and reproductive health services; trauma-informed and safe space practices; healthcare provider training; and women's care self-management. In general, current systems of care do not meet the unique needs of WLWH.

Mapping HIV-related services for women in Eastern Canada: A qualitative study

Background:

Geographic health disparities have been well described in parts of Canada; however, little is known about the experiences of women living with HIV in the Maritime Provinces. This article focuses on the complex health system women living with HIV navigate geographically to access care in New Brunswick and Nova Scotia, Canada.

Method:

This study includes interviews with 10 women living with HIV and 39 community-based workers whose organizations provide services to this group of women in New Brunswick and Nova Scotia. Purposive sampling was used to recruit both women living with HIV and community workers. Interviews were recorded and transcribed into a Microsoft word document. Transcripts were imported into NVivo 11 for thematic analyses and used to map the services women with HIV were accessing in their communities in ArcGIS 10.2 for Windows.

Results:

The study found that there are a number of barriers women with HIV face in the Maritime Provinces, including the low number of specialist physicians, long travel distances to major urban centers for care, and the loss of HIV-specific supports and resources. In response to these difficulties, community-based organizations are leading efforts in their communities to increase outreach programs and the number of available peer workers to improve the health outcomes of women living with HIV. Furthermore, it showed that women living with HIV and community workers were interested in creating a women-centered HIV care system in the Maritime Provinces, but were uncertain how to move forward with this initiative.

Conclusion:

There is a need for women-centered HIV services. This study proposes streamlining the healthcare pathway and decreasing obstacles to increase women’s access to care in the Maritime Provinces.

A systematic review of contemporary models of shared HIV care and HIV in primary care in high-income settings

HIV shared care is uncommon in the UK although shared care could be a beneficial model of care. We review the literature on HIV shared care to determine current practice and clinical, economic and patient satisfaction outcomes. We searched MEDLINE, EMBASE, NICE Evidence, Cochrane collaboration, Google and websites of the British HIV Association, Aidsmap, Public Health England, World Health Organization and Terrence Higgins Trust using relevant search terms in August 2014. Studies published after 2000, from healthcare settings comparable to the UK that described links between primary care and specialised HIV services were included and compared using principles of the Critical Appraisal Skills Programme and Authority, Accuracy, Coverage, Objectivity, Date, Significance frameworks. Three of the nine included models reported clinical or patient satisfaction outcomes but data collection and analyses were inadequate. None reported economic outcomes although some provided financial costings. Facilitators of shared care included robust clinical protocols, training and timely communication. Few published examples of HIV shared care exist and quality of evidence is poor. There is no consistent association with improved clinical outcomes, cost effectiveness or acceptability. Models are context specific, driven by local need, although some generalisable features could inform novel service delivery. Further evaluative research is needed to determine optimal components of shared HIV care.

Entry and retention in medical care among HIV-diagnosed persons: a meta-analysis

OBJECTIVE

A 'test and treat' strategy to reduce HIV transmission hinges on linking and retaining HIV patients in care to achieve the full benefit of antiretroviral therapy. We integrated empirical findings and estimated the percentage of HIV-positive persons in the United States who entered HIV medical care soon after their diagnosis; and were retained in care during specified assessment intervals.

METHODS

We comprehensively searched databases and bibliographic lists to identify studies that collected data from May 1995 through 2009. Separate meta-analyses were conducted for entry into care and retention in care (having multiple HIV medical visits during specified assessment intervals) stratified by methodological variables. All analyses used random-effects models.

RESULTS

Overall, 69% [95% confidence interval (CI) 66-71%, N = 53 323, 28 findings] of HIV-diagnosed persons in the United States entered HIV medical care averaged across time intervals in the studies. Seventy-two percent (95% CI 67-77%, N = 6586, 12 findings) entered care within 4 months of diagnosis. Seventy-six percent (95% CI 66-84%, N = 561, 15 findings) entered care after testing HIV-positive in emergency/urgent care departments and 67% (95% CI 64-70%, N = 52 762, 13 findings) entered care when testing was done in community locations. With respect to retention in care, 59% (95% CI 53-65%, N = 75 655, 28 findings) had multiple HIV medical care visits averaged across assessment intervals of 6 months to 3-5 years. Retention was lower during longer assessment intervals.

CONCLUSION

Entry and retention in HIV medical care in the United States are moderately high. Improvement in both outcomes will increase the success of a test and treat strategy.

Development of Stage of Readiness and decisional balance instruments: tools to enhance clinical decision-making for adherence to antiretroviral therapy

This study presents the development of Stage of Readiness (SOR) and decisional balance instruments based on the Transtheoretical Model of Behavior Change (TTM) to improve adherence to antiretroviral therapy (ART). These instruments were tested on HIV positive women who enrolled in an adherence support study at a women's HIV clinic at a mid-western medical school. The decisional balance instrument was analyzed and 8 of 11 items were retained. These items were validated by follow-up administration of the instrument. Baseline stage of change and decisional balance scores prospectively predicted 1-year viral load level, thus identifying participants in need of adherence support interventions. Use of these instruments can give a provider added objective data on which to base a decision to either prescribe ART immediately or to first implement an intervention tailored to enhance this patient's readiness to adhere.

System and patient barriers to appropriate HIV care for disadvantaged populations: the HIV medical care provider perspective

Little is known about the perception of system and patient barriers to adequate HIV care by an essential resource in the provision of HIV care, HIV medical care providers. To evaluate such perceptions, between November 2000 and June 2001 a survey was mailed to 526 HIV medical care providers who cared for HIV-infected individuals in Atlanta, Baltimore, Los Angeles, and Miami. Logistic regression analysis of survey results revealed significant differences in perceptions of system barriers between Black and Hispanic providers versus White providers and non-medical doctor providers versus medical doctor providers. Female providers differed significantly from male providers in assessing the importance of certain system and patient barriers. The authors observed that there are seeming disparities in perceptions of system and patient barriers to HIV medical care by providers of different race/ethnic groups, genders, and professions. More research needs to be conducted to determine if these disparities reflect differences in the provision of adequate HIV care for disadvantaged individuals.

Literature on integrated HIV care: a review

With a significant proportion of HIV-infected patients now presenting with co-occurring substance abuse disorders and mental disorders, interest in integrated HIV care is growing. However, no review of integrated HIV care has been conducted. Using relevant key word searches of the Medline and Psychlit databases, the authors identified about 450 publications. The few evaluations of integrated models tended to focus on measurements of engagement and retention in medical care, and their findings indicated an association between integrated HIV care and increased service utilization. No random assignment controlled studies were identified, except in the peripheral area of integrated care (without HIV primary care) for persons with co-occurring substance abuse disorders and mental disorders. The majority of reviewed articles described integrated models operating in the field and various aspects of implementation and sustainability. Overall, they supported use of a wide range of primary and ancillary services delivered by a multidisciplinary team that employs a 'biopsychosocial' approach. Despite the lack of scientific knowledge regarding the effects of integrated HIV care, those wanting to optimize treatment for patients with multiple interacting disorders can gain useful and practical knowledge from this literature.