Barriers and Facilitators to Retaining and Reengaging HIV Clients in Care: A Case Study of North Carolina

Post-immigration factors affecting retention in HIV care and viral suppression in Latin American and Caribbean immigrant populations in the United States: a systematic review

OBJECTIVES

To reduce disparities in HIV care outcomes among Latin American and Caribbean (LAC) immigrants living with HIV in the U.S., it is necessary to identify factors influencing HIV care in this population. A systematic review that provides a comprehensive understanding of factors influencing retention in HIV care and viral suppression among LAC immigrants living with HIV in the U.S. is lacking. This systematic review used the Immigrant Health Services Utilization theoretical framework to provide an understanding of these factors.

DESIGN

We searched for peer-reviewed publications in MEDLINE, EMBASE, CINAHL, PsycINFO, and ASSIA, from January 1996 to June 2020.

RESULTS

A total of 17 qualitative (n = 10) and quantitative (n = 7) studies were included in the review. The most commonly reported general and immigrant-specific factors appearing in studies were undocumented immigration status, HIV stigma, homophobia, cultural norms, values and beliefs, family and social support, language barriers, structure, complexity and quality of the U.S. healthcare delivery system, and patient-provider relationship.

CONCLUSION

These findings highlight the importance of considering immigrant-specific factors along with general factors to improve the provision of HIV care services and HIV care outcomes among LAC immigrant populations.

"Take care of their hierarchy of needs first": strategies used by data-to-care staff to address barriers to HIV care engagement

Data-to-Care (D2C) is a public health strategy designed to engage out-of-care (OOC) persons with HIV (PWH) in HIV care. OOC PWH are identified through review of state and local HIV data and engaged in care through individualized efforts that address barriers to HIV care. Perspectives of D2C program staff can contribute to D2C program development and sustainability. We conducted semi-structured interviews in 2017 with 20 D2C program staff from Louisiana (n = 10) and Virginia (n = 10), states with distinct D2C programs. We used content and thematic analysis to analyze interview transcripts. In both states, common barriers to care for OOC PWH include limited transportation, stigma, substance use, poverty, homelessness, and mental illness. To address these barriers and engage OOC clients in HIV care, staff and programs provided transportation vouchers and housing assistance, integrated substance use and mental health services into care engagement processes, provided empathy and compassion, and assessed and addressed basic unmet needs. Identifying and addressing social and structural barriers to HIV care is a critical and often a necessary first step in engaging OOC clients in HIV care. These findings can be used for D2C program design and implementation, facilitating engagement in HIV care for OOC PWH.

Perspectives on linkage to care for patients diagnosed with HIV: A qualitative study at a rural health center in South Western Uganda

Linkage to care for newly diagnosed human immunodeficiency virus (HIV) patients is important to ensure that patients have good access to care. However, there is little information about factors influencing linkage to care for HIV patients. We aimed to identify existing measures in place that promote linkage to care and to explore facilitators and barriers to linkage to care for clients diagnosed with HIV/acquired immune deficiency syndrome at a rural health center in Uganda. This descriptive qualitative study enrolled 33 purposively selected participants who included expert clients, linkage facilitators, heads of families with people living with HIV, and health workers. Data were collected using in-depth interviews that were audio-recorded, transcribed, and translated. The data were manually analyzed to generate themes. The following four themes were generated: 1) availability of services that include counseling, testing, treatment, follow-up, referral, outreach activities, and support systems. 2) Barriers to linkage to care were at the individual, health facility, and community levels. Individual-level barriers were socioeconomic status, high transport costs, fear of adverse drug effects, fear of broken relationships, and denial of positive results or treatment, while health facility barriers were reported to be long waiting time, negative staff attitude, and drug stock outs. Community barriers were mostly due to stigma experienced by HIV clients, resulting in discrimination by community members. 3) Facilitators to linkage to care were positive staff attitudes, access to information, fear of death, and support from others. 4) Suggestions for improving service delivery were shortening waiting time, integrating HIV services, increasing staff numbers, and intensifying outreaches. Our findings highlight the importance of stakeholder involvement in linkage to care. Access and linkage to care are positively and negatively influenced at the individual, community, and health facility levels. However, integration of HIV services and intensifying outreaches are key to improving linkage to care.

Why do patients interrupt and return to antiretroviral therapy? Retention in HIV care from the patient's perspective in Johannesburg, South Africa

BACKGROUND

Retention in care is required for optimal clinical outcomes in people living with HIV (PLHIV). Although most PLHIV in South Africa know their HIV status, only 70% are on antiretroviral therapy (ART). Improved retention in care is needed to get closer to sustained ART for all. In January 2019, Anova Health Institute conducted a campaign to encourage patients who had interrupted ART to return to care.

METHODS

Data collection was conducted in one region of Johannesburg. This mixed methods study consisted of two components: 1) healthcare providers entered data into a structured tool for all patients re-initiating ART at nine clinics over a nine-month period, 2) Semi-structured interviews were conducted with a sub-set of patients. Responses to the tool were analysed descriptively, we report frequencies, and percentages. A thematic approach was used to analyse participant experiences in-depth.

RESULTS

562 people re-initiated ART, 66% were women, 75% were 25-49 years old. The three most common reasons for disengagement from care were mobility (30%), ART related factors (15%), and time limitations due to work (10%). Reasons for returning included it becoming easier to attend the clinic (34%) and worry about not being on ART (19%). Mobile interview participants often forgot their medical files and expressed that managing their ART was difficult because they often needed a transfer letter to gain access to ART at another facility. On the other hand, clinics that had flexible and extended hours facilitated retention in care.

CONCLUSION

In both the quantitative data, and the qualitative analysis, changing life circumstances was the most prominent reason for disengagement from care. Health services were not perceived to be responsive to life changes or mobility, leading to disengagement. More client-centred and responsive health services should improve retention on ART.

Effect of Case Management on HIV Outcomes for Community Corrections Population: Results of an 18-Month Randomized Controlled Trial

BACKGROUND

Evidence-based interventions that engage community-dwelling, justice-involved, people living with HIV (PLWH) in care are urgently needed. Project Bridge, an intensive case management intervention, has demonstrated efficacy for linking PLWH to care transitioning from prison to the community. We assessed whether a modified Project Bridge model was effective for increasing rates of HIV treatment engagement, antiretroviral therapy receipt, and adherence for community-dwelling individuals supervised on probation and parole.

SETTING

Baltimore, Maryland.

METHODS

In this study, the 18-month outcomes of a randomized controlled trial in which PLWH were also on probation or parole received either Project Bridge (n = 50) or treatment as usual (n = 50) were assessed. HIV treatment engagement (primary outcome), antiretroviral therapy prescription, and adherence (secondary outcomes) are evaluated using the intent-to-treat approach.

RESULTS

There were no statistically significant differences in rates of HIV treatment engagement, antiretroviral therapy prescription receipt, or adherence between groups over the 18-month study period. Across groups, participants were 5.6 times more likely to receive HIV care, 5.8 times more likely to receive an antiretroviral therapy prescription, and 4 times more likely to report antiretroviral therapy adherence at each follow-up period.

CONCLUSIONS

Future research is needed to identify potentially less-intensive interventions that target the unique needs of PLWH under community supervision.

Improving Engagement in HIV Care Using a Data-to-Care and Patient Navigation System in Louisiana, United States

An estimated 57% of persons living with HIV (PLWH) in the United States are not connected to regular medical care or have lapsed from regular care (Centers for Disease Control and Prevention, 2018), increasing risk of HIV progression and transmission and delaying viral suppression. The state of Louisiana has consistently ranked in the top five US states for HIV case rates. We evaluated the impact of a combined data-to-care and patient navigation system that was implemented in 3 cities in Louisiana from 2013 to 2015. The program, LA Links, used a surveillance system to identify PLWH who were not in regular health care and connected them to a patient navigator. During the intervention period, persons who lapsed from care were 17% more likely to reengage in care than persons in the comparison group, and persons newly diagnosed during the intervention period were 56% more likely to link to care.

Practical and Ethical Concerns in Implementing Enhanced Surveillance Methods to Improve Continuity of HIV Care: Qualitative Expert Stakeholder Study

BACKGROUND

Retention in HIV care is critical to maintaining viral suppression and preventing further transmission, yet less than 50% of people living with HIV in the United States are engaged in care. All US states have a funding mandate to implement Data-to-Care (D2C) programs, which use surveillance data (eg, laboratory, Medicaid billing) to identify out-of-care HIV-positive persons and relink them to treatment.

OBJECTIVE

The purpose of this qualitative study was to identify and describe practical and ethical considerations that arise in planning for and implementing D2C.

METHODS

Via purposive sampling, we recruited 43 expert stakeholders-including ethicists, privacy experts, researchers, public health personnel, HIV medical providers, legal experts, and community advocates-to participate in audio-recorded semistructured interviews to share their perspectives on D2C. Interview transcripts were analyzed across a priori and inductively derived thematic categories.

RESULTS

Stakeholders reported practical and ethical concerns in seven key domains: permission and consent, government assistance versus overreach, privacy and confidentiality, stigma, HIV exceptionalism, criminalization, and data integrity and sharing.

CONCLUSIONS

Participants expressed a great deal of support for D2C, yet also stressed the role of public trust and transparency in addressing the practical and ethical concerns they identified.

Multi-level Determinants of Clinic Attendance and Antiretroviral Treatment Adherence Among Fishermen Living with HIV/AIDS in Communities on Lake Victoria, Uganda

This cross-sectional study assessed determinants of HIV clinic appointment attendance and antiretroviral treatment (ART) adherence among 300 male fisherfolk on ART in Wakiso District, Uganda. Multi-level factors associated with missed HIV clinic visits included those at the individual (age, AOR = 0.98, 95% CI 0.97-0.99), interpersonal (being single/separated from partner, AOR: 1.25, 95% CI 1.01-1.54), normative (anticipated HIV stigma, AOR: 1.55, 95% CI 1.05-2.29) and physical/built environment-level (travel time to the HIV clinic, AOR: 1.11, 95% CI 1.02-1.20; structural-barriers to ART adherence, AOR: 1.27, 95% CI 1.04-1.56; accessing care on a landing site vs. an island, AOR: 1.35, 95% CI 1.08-1.67). Factors associated with ART non-adherence included those at the individual (age, β: - 0.01, η2 = 0.03; monthly income, β: - 0.01, η2 = 0.02) and normative levels (anticipated HIV stigma, β: 0.10, η2 = 0.02; enacted HIV stigma, β: 0.11, η2 = 0.02). Differentiated models of HIV care that integrate stigma reduction and social support, and reduce the number of clinic visits needed, should be explored in this setting to reduce multi-level barriers to accessing HIV care and ART adherence.

Characteristics of Out-of-Care Patients Who Required a Referral for Re-engagement Services by Public Health Bridge Counselors Following a Brief Clinic-Based Retention Intervention

The NC-LINK Project initiated both clinic-based retention services and state public health bridge counselor-based (SBCs) re-engagement services to retain and re-engage people living with HIV infection (PLWH) in care. The goal of this project is to compare efforts between clinic-based retention and SBC re-engagement services to determine whether patients are more or less likely to remain in HIV care services. Clinic appointment data were used to identify patients who were last seen more than 6-9 months prior. Patients either received clinic-based retention services only or were subsequently referred to the SBC re-engagement intervention if the retention services were unsuccessful. The frequency of re-engagement in care (180 days) and HIV suppression (VLS, within 1 year) was examined for patients in these two groups. The SBC group was less likely to have VLS at the visit prior to referral (adjusted OR 2.04, 95% CI 1.53, 2.72). Patients who were referred to the SBC were less likely to re-engage in care within 180 days as compared to those who received clinic-based retention services only (adjusted OR 0.29, 95% CI 0.21, 0.41).

Past Care Predicts Future Care in Out-of-Care People Living with HIV: Results of a Clinic-Based Retention-in-Care Intervention in North Carolina

Poor retention in care is associated with higher viral load (VL) results and decreased rates of viral load suppression (VS) in people living with HIV (PLWH). Therefore, improving retention in HIV care is a priority of national significance. The NC-LINK Retention Project utilized a systematic approach to identify, locate, and attempt to return to care patients who did not attend a clinic appointment for 6-9 months. Clinical and surveillance data were used to evaluate associations between patient characteristics and VL outcomes. Between January 1, 2013 and December 31, 2014, 1118 patients at participating clinics were identified as out-of-care and referred to retention staff. Of these, 712 (64%) were located in North Carolina. Patients with recent prior medical care (aPR 1.43, 95% CI 1.25, 1.66) and recent VS (aPR 1.28, 95% CI 1.16, 1.41) were more likely to be located. Of located patients, 58% re-engaged in care within 90 days of retention referral. Patients who achieved VS within 180 days were more likely to be 40-49 years (aPR 1.19 95% CI 1.01-1.40; compared with 18-29 age group), had insurance at their last visit (aPR 1.19 95% CI 1.01-1.77), had a care visit in the prior year (aPR 1.37 95% CI 1.05-1.77), and had VS at the prior care visit (aPR 2.54 95% CI 1.98-3.25). Clinic-based retention efforts may be effective at helping PLWH decrease out-of-care periods, but prior patterns of care usage persist.

The North Carolina HIV Bridge Counselor Program: Outcomes From a Statewide Level Intervention to Link and Reengage HIV-Infected Persons in Care in the South

BACKGROUND

To improve the HIV continuum of care, a team of field service interventionists (State Bridge Counselors, SBC) was developed through a state public health system and provided brief (1-2) contacts for linkage of newly diagnosed persons with HIV and reengagement of persons living with HIV (PLWH) who were not in care.

SETTING

North Carolina, United States.

METHODS

Service data from January 2013 to June 2015 were analyzed to determine characteristics of clients referred to SBCs, proportions linked or reengaged in care, and/or achieved viral load suppression (VLs). We evaluated associations between client characteristics and outcomes using multivariable analyses and estimated odds ratios (OR) with 95% confidence intervals (CI).

RESULTS

SBCs provided linkage services to 299 newly diagnosed individuals and reengagement services to 606 PLWH throughout North Carolina. Among persons who received linkage services, 189 (63%) had evidence of care within 90 days of referral and 205 (69%) had VLs within a year. Among PLWH who received reengagement services, 278 (46%) had care within 90 days and 308 (51%) had VLs within a year. Persons aged 30-39 years (OR, 2.1; 95% CI, 1.1 to 3.9) and 40-49 years had an increased likelihood (OR, 2.4; 95% CI, 1.1 to 5.2) of linkage within 90 days compared with persons aged 18-29 years. Non-white PLWH had an increased OR of 1.7; (95% CI, 1.2 to 2.5) of reengagement compared with whites.

CONCLUSIONS

Our SBC program successfully implemented a "low-touch" approach to provision of linkage and reengagement services, demonstrating that public health resources can be used to address the HIV care continuum on a statewide level.

Psychiatric Symptoms and Barriers to Care in HIV-Infected Individuals Who Are Lost to Care

Past studies of barriers to HIV care have not comprehensively assessed psychiatric symptoms, and few have assessed barriers to care among people living with HIV (PLWH) who are lost to care (LTC). We examined psychiatric symptoms, barriers to HIV care, and immune functioning in PLWH who were retained in care (RIC; n = 21) or LTC (n = 21). Participants completed diagnostic interviews for posttraumatic stress disorder (PTSD) and other psychiatric disorders, self-report measures of HIV risk behaviors and psychiatric symptoms, and a blood draw to assess viral load. Compared to RIC participants, LTC participants met criteria for a greater number of psychiatric disorders and reported greater depressive symptoms and more barriers to HIV care. There were no group differences in PTSD severity, risk behaviors, or viral load, suggesting that LTC individuals experience greater psychiatric problems and perceive more barriers to care than RIC participants, but are not less likely to have achieved viral suppression.

Perspectives from the Field: HIV Testing and Linkage to Care in North Carolina

BACKGROUND

HIV testing and linkage to care are critical first steps along the care continuum. Targeted efforts are needed in the South to achieve the goals of the National HIV/AIDS Strategy, and qualitative examination of testing and linkage to care from the perspective of professionals in the field can provide nuanced insight into the strengths and limitations of a care system to inform improvement efforts. These issues are explored in North Carolina (NC), with potential applicability to other Southern states.

METHODS

Twenty-one interviews were conducted with professionals in the HIV prevention and care systems in NC. Interviews were analyzed for emergent themes.

RESULTS

Individuals' access barriers, aspects of clinics and clinical care, challenges for community-based organizations, stigma, and the role of the NC Department of Health and Human Services were identified as themes affecting testing and linkage.

DISCUSSION

These findings can inform efforts to address HIV testing and linkage to care in NC. This approach may provide beneficial insight for other systems of care.