HIV/AIDS health services in Manaus, Brazil: patient perception of quality and its influence on adherence to antiretroviral treatment

Self-efficacy and consistent condom use by people living with HIV and seroconcordant and serodiscordant sexual partners in the Ceará, Brazil

The objectives were to assess the self-efficacy and consistent condom use by people living with HIV (PLHIV). A cross-sectional, comparative study was carried out in outpatient clinics in Ceará State, Brazil, with a sample of 190 PLHIV, 95 serodiscordant and 95 seroconcordant. Interviews were conducted using the Socio-Demographic, Clinical, Epidemiological and Vulnerability Form and the Condom Use Self-Efficacy Scale. Descriptive analysis, associations between variables, odds ratio and 95% confidence interval were determined. P < 0.05 was considered statistically significant. Of the sample, 43.1% consistently used condoms (50.5% serodiscordant and 35.7% seroconcordant). Serodiscordant PLHIV without guidance on HIV prevention (P = 0.027) and without access to testing (P = 0.002) had lower self-efficacy and 11.5 times more chances for inconsistent condom use (P = 0.006), while those satisfied with follow-up in health were less likely to use condoms inconsistently (P = 0.011). We conclude that there is low consistent use of condoms among PLHIV, which increases the risk of HIV transmission and the acquisition of other sexually transmitted infections. Consistent condom use was greater among serodiscordant individuals, although there was no difference in self-efficacy in condom use between the groups.

[Temporal pattern, spatial distribution, and factors associated with the incidence of HIV/AIDS among young people in BrazilPatrón temporal, distribución espacial y factores asociados a la incidencia de la infección por el VIH/sida en jóvenes en Brasil]

Objective

To describe temporal and spatial patterns and identify the factors associated with the incidence of HIV/AIDS among young people in Brazil.

Method

Ecological study of young Brazilians aged 15-24 years with reported HIV/AIDS, from 2001 to 2021. The Joinpoint method was used for the temporal analysis. Spatial clusters were detected using Bayesian methods, spatial autocorrelation, Getis-Ord Gi*, and scan techniques. Four non-spatial and spatial regression models were used to identify factors associated with the result. All statistical analyses considered p < 0.05.

Results

In Brazil, the average incidence was 12.29 per 100 000 inhabitants, with an annual increase of 7.3% in the period 2007-2014 and a subsequent 3.4% decrease in 2014-2021. A high-high pattern and hotspots were observed, mainly in municipalities in the South, Southeast, Central-West, and North regions. The primary cluster was located in 572 municipalities in Rio Grande do Sul and Santa Catarina, with the highest relative risks in Manaus (Amazonas) and Rondonópolis (Mato Grosso). The illiteracy rate (β = -0.08), GINI Index (β = -3.74) and Family Health Strategy coverage (β = -0.70) were negatively associated with the result. In contrast, the Firjan Municipal Development Index (β = 2.37), Social Vulnerability Index (β = 6.30), percentage of Bolsa Família recipients (β = 0.04), and per capita income (β = 0.008) showed a positive association.

Conclusion

There was an upward trend in the incidence of HIV/AIDS until 2014, followed by a decline until 2021. High-rate clusters were concentrated in municipalities in the North, South, Southeast and Central-West regions in particular. Indicators of socioeconomic vulnerability had positive or negative effects on the result, depending on the territory investigated.

Spatial analysis of HIV detection rates among Brazilian young men, 2007-2021

The main goal of this study was to spatially analyze the HIV epidemic scenario in young men in Brazil, 2007-2021. We used secondary data obtained from the Brazilian Information System for Notifiable Diseases. Individuals aged 15-29 years with permanent residence in Brazil who were diagnosed with HIV during the study period were included in the analysis. Municipality HIV age-adjusted detection rates were analyzed through spatial distribution, autocorrelation, and spatiotemporal risk analyses. During the study period, 108,392 HIV cases were reported in young Brazilian men. The HIV epidemic increased territorially in the northern, northeastern, midwestern, and southeastern regions but decreased in the southern region. Although the number of clusters comprising municipalities with high HIV detection rates (hotspots) decreased, new ones appeared, expanded, or stopped changing size. Hotspots and spatio-temporal risk zones (spatial areas with increased HIV detection in a specific period) comprised economically developed municipalities with high demographic density surrounded by less developed municipalities. The period of the spatiotemporal risk zones was between 2008 and 2021. Our study showed that HIV detection rates continue to increase among young Brazilian men, and health authorities should reinforce efforts mainly in capitals and surrounded municipalities in the north, northeast, southeast, and midwest regions.

Time spent at health facility is a key driver of patient satisfaction, but did not influence retention to HIV care: A serial cross-sectional study in Mozambique

INTRODUCTION

Patient satisfaction with clinical services can have an effect on retention in HIV care and adherence to antiretroviral therapy. This study assessed patient satisfaction and its association with retention and viral suppression in Zambézia Province, Mozambique.

METHODS

Monthly exit interviews with persons living with HIV were completed from August 2017-January 2019 in 20 health facilities; clinical data were extracted from medical records. Regression analyses assessed the effect of satisfaction scores on retention and viral suppression, adjusting for age, sex, education, civil status, time on treatment, and site. Satisfaction scores were correlated with time spent at health facilities using generalized linear regression models.

RESULTS

Data from 4388 patients were analyzed. Overall median satisfaction score was 75% (IQR 53%-84%); median time spent at facilities (from arrival until completion of clinical services) was 2h54min (IQR 1h48min-4h). Overall satisfaction score was not associated with higher odds of retention or viral suppression, but association was seen between satisfaction regarding attention given to patient and respect and higher odds of viral suppression. Patient satisfaction was negatively associated with time spent in facility (Spearman's correlation -0.63). Increased time spent at facility (from 1 to 3 hours) was not associated with lower retention in care (OR 0.72 [95%CI:0.52-1.01] and 0.83 [95%CI: 0.63-1.09] at 6- and 12-months, respectively), nor with a lower odds of viral suppression (OR 0.96 [95%CI: 0.71-1.32]).

CONCLUSIONS

Strategies to reduce patient wait times at the health facility warrant continued prioritization. Differentiated models of care have helped considerably, but novel approaches are still needed to further decongest crowded health facilities. In addition, a good client-provider communication and positive attitude can improve patient satisfaction with health services, with an overall improved retention.

Individual satisfaction with HIV/AIDS care in Belo Horizonte, Brazil

Individual satisfaction is associated with increased retention in HIV/AIDS care services and adherence to treatment. This study assessed factors associated with individual satisfaction at the initiation of antiretroviral therapy and compared the proportions of satisfaction at the initiation of antiretroviral therapy and after three months of follow-up. Face-to-face interviews were carried out among 398 individuals of three HIV/ AIDS healthcare services in Belo Horizonte, Brazil. Variables included sociodemographic and clinical characteristics, perception about healthcare services, and domains of quality of life. Individuals that rated the quality of healthcare services as good or very good were classified as satisfied. A logistic regression analysis of the association between independent variables and individual satisfaction was performed. The proportion of individual satisfaction with healthcare services was 95.5% at the initiation of antiretroviral therapy and 96.7% after three months and these changes were not statistically significant (p = 0.472). The physical domain of quality of life was found to be associated with satisfaction at the initiation of antiretroviral therapy (OR = 1.38; CI = 1.11-1.71; p = 0.003). Training and supervision of health professionals for addressing the needs of individuals with lower levels of physical domain of quality of life may improve satisfaction with HIV/ AIDS care.

Satisfaction of Patients with HIV/AIDS Infection from the Care Provided in the Special Infection Unit of University General Hospital of Alexandroupoli

Background

C HIV/AIDS infection is characterized by a very low number of T lymphocytes (CD4), which makes sufferers vulnerable to various infections, and so they seek continuous care in Special Infections Units.

Objective

The purpose of the survey is to investigate the factors that contribute to the satisfaction derived from the health services provided to people living with the human immunodeficiency virus; and they are monitored at the Special Infections Unit of the University General Hospital of Alexandroupoli.

Methods

All patients who came to the Special Infections Unit of the University General Hospital of Alexandroupoli during the period June - July 2021 were asked to complete an anonymous questionnaire on satisfaction derived from the health services provided (E - PQ - SPCSS) and satisfaction derived from their work and quality of life (Occupational Stress Questionnaire, JCQ). The statistical package SPSS 19.0 was used for the statistical analysis of the data. With the help of the ANOVA statistical test, the differences between the variables were checked. P-Value in all audits was set at 0.05. Values showing equal to or less than 0.05 were considered statistically significant.

Results

They were 85 patients who participated. Amongst them, they were mainly men (75.3%), the mean age was 35-50 years (50.6%), residents of Thrace (62.3%). 37.7% of the participants said they had some difficulty accessing SIU. Quality of life was positively correlated with education (p<0.001) where the higher reported level of education was, the higher satisfaction rates were. A positive correlation (p<0.001) was also observed amongst income rates where the higher incomes reported, the higher the satisfaction rates were. Lower incomes were significantly associated (p = 0.029) with mental disorders (anxiety, depression). Quality of life was positively associated with both satisfaction with medical as well as nursing care (p <0.008). The adequacy and clarity of the information the patients receive from SIU physicians during their visit shows a significant positive correlation (p<0.001). In addition, there is a significant correlation regarding the problems patients may have experienced in the last 6 months in terms of access to treatment (p<0.021).

Conclusion

Participants showed high satisfaction rates from the medical and nursing care provided at the SIU of the PGNA. The opportunity of expression given to users - patients through satisfaction studies promotes and creates a climate of trust between them and the decision-making teams of health units.

[Adherence to antiretroviral therapy by people living with HIV/AIDS in Florianópolis, Santa Catarina State, Brazil]

Adherence to antiretroviral therapy (ART) is essential to control HIV infections and avoid clinical complications and the development of resistant HIV strains. Several Brazilian municipalities have committed themselves to the 90-90-90 target, which aims at diagnosing 90% of HIV/AIDS cases, treating 90% of them, and virally suppressing 90% of them. However, only three Brazilian studies have assessed adherence to ART from secondary dispensing data. This study aimed to estimate the prevalence of adherence to treatment in the Municipality of Florianópolis, Santa Catarina State, Brazil, examining its association with demographic, health access, and clinical characteristics. A cross-sectional study was conducted using secondary national data from electronic medical records and Medication Logistic Control System (SICLOM) and Laboratory Test Control System (SISCEL) regarding people living with HIV/AIDS in the municipality from April 2020 to March 2021. We found an about 85% prevalence of adherence to ART. White men with follow-ups both in primary and secondary care showed greater adherence to treatment. Age and number of consultations directly related to adherence. Decentralizing care for users living with HIV/AIDS is the way to more comprehensive care but technical and ethical challenges still require solutions. Professional training, correct network referrals, and attention to confidentiality issues must be reinforced to expand treatment adherence.

AIDS-related mortality in Pará Province, Brazilian Amazon region: Spatial and temporal analysis

Despite considerable therapeutic advances in the care of people living with human immunodeficiency virus (HIV) and with the acquired immunodeficiency syndrome (AIDS) and an overall reduction of 47% in the AIDS mortality rate in the last decade, the AIDS-mortality rates remains high. The social determinants of health (SDH) have a direct influence on the dynamics of this phenomenon. However, changes in SDH caused by the implemented policies against HIV have been poorly investigated. Moreover, the Brazilian rainforest has had the highest and continuously increasing AIDS mortality rate in Brazil since the 1980s. In this study, AIDS mortality in a province of the Brazilian rainforest was examined by using temporal and spatial analyses.

METHODS

In this ecological study, data from 2007 to 2018 were extracted from the Mortality Information System provided by the State Department of Public Health of Pará. For the temporal analysis, the integrated autoregressive model of moving average (ARIMA) and locally weighted polynomial regression (STLF) were used to forecast AIDS mortality from 2019 to 2022. For the spatial analysis, spatial autocorrelation and geographically weighted regression (GWR) analyses were employed.

RESULTS

The samples consisted of 6,498 notifications for AIDS-related deaths. From 2007 to 2013, the AIDS mortality rates showed an upward trend, followed by a stabilization until 2018 and an upward forecasted trend from 2019 to 2022. High mortality rates and high-high clusters were found in economic pole municipalities. Furthermore, AIDS mortality risk was directly associated with per capita income and demographic density, except in the southwestern region of Pará, which exhibited an inverse association with population density.

CONCLUSION

Although the policies against HIV may have contributed to the stabilization of AIDS mortality rates from 2013 in Pará, the upward forecasted trend until 2022 raises an alert and concern to health authorities to provide reinforcement of the policies. The geographic variability of AIDS mortality promoted by SDH provides subsidies to health authorities to implement SDH-focused strategies for AIDS mortality reduction.

PATIENT SATISFACTION WITH INTERPERSONAL COOPERATION AND HEALTH SERVICES AT THE LEVEL OF PRIMARY AND SECONDARY HEALTH CARE

Interprofessional cooperation and teamwork among health professionals in the health care system are crucial for improving patient satisfaction and quality of health services. The aim of the research is to examine the satisfaction of patients with interpersonal cooperation and health services provided at the level of primary and secondary health care. The research was done as a cross-sectional study and was conducted at the Niksic General Hospital and two health centers in Podgorica. The sample consisted of 154 respondents, both sexes. The research used a questionnaire for health care users designed for the purposes of this research. The questionnaire consists of a general and a specific part. Descriptive statistics measures and x2 test were used for statistical data processing. The results of the research show that there is a statistically significant correlation between gender and patient satisfaction with services χ² (2, N = 154) = 104.117, p = 0.000, as well as between age and patient satisfaction with services χ² (6, N = 154) = 139.294, p = 0.000. Understanding interpersonal cooperation is important for improving the efficiency of health care, its organization and customer satisfaction.

The Temporal and Spatial Epidemiology Employed in the Elimination of the HIV Epidemic in the Largest Capital of the Brazilian Rainforest

BACKGROUND

The main goal of this study was to analyze the human immunodeficiency virus (HIV) epidemic temporally and spatially in Belém from 2007 to 2018.

METHODS

The incidence rates were analyzed according to time using autoregressive integrated moving-average models, as well as spatially using spatial autocorrelation, Kernel density, scan statistics, and regression techniques.

RESULTS

During the study period, 6007 notifications of new cases of HIV/AIDS were reported. The time series analysis revealed a stabilized trend of incidence from 2007 to October 2016, followed by irregular fluctuations until the end of December 2018. Seasonal behavior was observed from 2019 to 2022. The high-high incidence clusters were found in the central and transition areas. An expansion of the number of new reported cases was observed in the central area. Three spatial risk zones were observed. The higher relative risk zone was concentrated in the transition area. The spatial regression showed that the incidence rates were positively correlated with the Family Health Strategy (FHS) coverage.

CONCLUSIONS

To eliminate HIV in Belém, it will be necessary to decentralize testing and ART and expand the coverage of FHS to ensure universal access to healthcare for citizens.

Involvement, Perception, and Understanding as Determinants for Patient-Physician Relationship and Their Association with Adherence: A Questionnaire Survey among People Living with HIV and Antiretroviral Therapy in Austria

BACKGROUND

The relationship between patients and healthcare professionals (physicians) is the cornerstone of successful long-term antiretroviral therapy for people living with human immunodeficiency virus (HIV).

PURPOSE

This study aimed to investigate the connection between involvement, perception, and understanding as the basis for the patient-physician relationship and drug adherence, measured as the probability of non-adherence.

METHODS

In an online survey, people with HIV were asked about their relationship with their physicians and the extent to which they felt involved in treatment-related decisions. A statistical analysis was conducted to determine whether a better patient-physician relationship was associated with higher adherence to therapy. This was performed by univariate group comparison (Mann-Whitney-U, Fishers Exact Test) and logistic regression.

RESULTS

A total of 303 persons living with HIV participated in the survey, and 257 patients were included in the analysis. Overall, 27.6% were classified as non-adherent and self-reporting based on whether an antiretroviral therapy (ART) was taken in the past or how often the ART was interrupted. This proportion was significantly higher among patients aged 50-74 years (39.7%) and those with a longer therapy duration (9-15 years: 46.6%; from 15 years on: 55.8%). Therapy-non-adherent patients showed significantly lower scores in the relationship aspects understanding (2.68 vs. 3.03), participation (2.63 vs. 3.07), and perception (3.00 vs. 3.24) compared to adherent patients. Logistic regression analysis confirms that higher scores for understanding, involvement, and perception are strongly associated with a reduction in the risk of becoming non-adherent. This was true for all examined regression models, regardless of whether they were adjusted for the length of therapy and socio-demographic characteristics.

CONCLUSION

The results reinforce the need for awareness among health care professionals (HCP) regarding understanding, involvement, and perception as important aspects to improve the quality of the patient-physician relationship for high adherence levels with maximized non-adherence in ART management by PLWH.

HIV epidemic among Brazilian women who have sex with women: An ecological study

The influences of public policies fighting HIV among women who have sex with women is scarcely studied. This study aimed to analyse the time series of human immunodeficiency virus (HIV) epidemic, between 2007 and 2020, among Brazilian women who have sex with women, in order to evaluate the effect of Brazilian policies for fighting HIV in this subpopulation compared to women who have sex with men (WSM). This ecological study employed HIV and acquired immunodeficiency syndrome (AIDS) new cases among women who have sex strictly with women (WSW), women who have sex with men and women (WSMW), and WSM reported to the Sistema de Informação de Agravos de Notificação from 2007 to 2020. Crude Brazilian and regional annual age-adjusted HIV/AIDS population-level incidence rates were calculated for WSW, WSMW and WSM. The rates were then analyzed using the Joinpoint regression model. A total of 102,890, 757, and 1,699 notifications of WSW, WSMW, and WSM living with HIV/AIDS were reported during the study period, respectively. South Brazilian region had the greatest HIV/AIDS incidence rates among WSM and bisexual women while the North region had the greatest incidence among WSW. In the WSM population, the temporal trends showed at least one stable or an increasing trend period from 2007 to 2013 or 2014, followed by one decreasing trend in all Brazilian regions. While among the WSMW most of the regions had a stable trend period from 2007 to 2020, in WSW group most of the trends had only one decreasing period. The decreasing trends were faster in WSM than in WSW. These results suggest a low efficiency of Brazilian policies for fighting HIV among WSW and WSMW and show the necessity of implementing new policies specific to this population.

Temporal and Spatial Analysis Techniques as Potential Tools for Combating the HIV Epidemic among Young Brazilian Amazonian People: An Ecological Study

BACKGROUND

The main goal of this study was to analyze the HIV epidemic temporally and spatially among young people living in Pará, Brazil, from 2007 to 2018.

METHODS

For the temporal analysis, we employed an integrated autoregression of moving averages model associated with the seasonal trend using the LOESS decomposition method, which allowed for predictions to be made. In the spatial analysis, the techniques of autocorrelation, spatial and spatio-temporal risk analysis, and geographically weighted regression were used.

RESULTS

During the study period, there were 8143 notifications of HIV/AIDS cases. The temporal prediction indicated a trend of growth in the incidence rate in the 20-24-year-old group from January 2019 to December 2022 and a trend of stability in the 15- to 19-year-old and 25- to 29-year-old groups. There was a territorial expansion of the HIV epidemic in Pará. Novo Progresso and the Metropolitan Region of Belém (RMB) were the zones with the highest spatial and spatio-temporal risk for HIV. Social determinants including the Basic Education Development Index, the number of physicians per 10,000 inhabitants, and the municipal high school abandonment rate in the municipalities were associated with the risk of HIV/AIDS among young people in Pará.

CONCLUSIONS

To eliminate HIV among young people in Pará, the access to treatment, diagnosis, and preventive healthcare services should be expanded. Sexual and reproductive health education should be reinforced in schools and communities. Furthermore, it is necessary to promote social equity and fight HIV stigma.

Perceived satisfaction with HIV care and its association with adherence to antiretroviral therapy and viral suppression in the African Cohort Study

Background

Increased availability of HIV care over the past decade has dramatically reduced morbidity and mortality among people living with HIV (PLWH) in sub-Saharan Africa. However, perceived and experienced barriers to care, including dissatisfaction with services, may impact adherence and viral suppression. We examined the associations between satisfaction with HIV care and antiretroviral therapy (ART) adherence and viral load suppression.

Methods

The African Cohort Study (AFRICOS) is a prospective observational study conducted at PEPFAR-supported clinics in four African countries. At enrollment and twice-yearly study visits, participants received a clinical assessment and a socio-behavioral questionnaire was administered. Participants were classified as dissatisfied with care if they reported dissatisfaction with any of the following: waiting time, health care worker skills, health care worker attitudes, quality of clinic building, or overall quality of care received. Robust Poisson regression was used to estimate prevalence ratios and 95% confidence intervals (CIs) for associations between satisfaction with care and ART adherence and between satisfaction with care and viral suppression (viral load < 1000 copies/mL).

Results

As of 1 March 2020, 2928 PLWH were enrolled and 2311 had a year of follow-up visits. At the first annual follow-up visit, 2309 participants responded to questions regarding satisfaction with quality of care, and 2069 (89.6%) reported satisfaction with care. Dissatisfaction with waiting time was reported by 177 (7.6%), building quality by 59 (2.6%), overall quality of care by 18 (0.8%), health care worker attitudes by 16 (0.7%), and health care worker skills by 15 (0.7%). After adjusting for age and site, there was no significant difference in viral suppression between those who were satisfied with care and those who were dissatisfied (aPR: 1.03, 95% CI 0.97–1.09). Satisfaction with HIV care was moderately associated with ART adherence among AFRICOS participants (aPR: 1.09; 95% CI 1.00–1.16).

Conclusions

While patient satisfaction in AFRICOS was high and the association between perceived quality of care and adherence to ART was marginal, we did identify potential target areas for HIV care improvement, including reducing clinic waiting times.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12981-021-00414-3.

Immunologic biomarkers, morbidity and mortality among HIV patients hospitalised in a Tertiary Care Hospital in the Brazilian Amazon

Background

The irregular use of antiretroviral therapy (ART) and late diagnosis still account for a large part of HIV-associated mortality in people living with HIV (PLHIV). Herein, we describe HIV-associated morbidity among hospitalised HIV/AIDS patients with advanced immunosuppression and assess the comorbidities, laboratory parameters, and immunological markers associated with mortality.

Methods

The cross-sectional study was conducted at the Fundação de Medicina Tropical Doutor Heitor Vieira Dourado (FMT-HVD) in Manaus, Brazil. In all, 83 participants aged between 12 and 70 years were enrolled by convenience within 72 h of their hospitalisation. Clinical and laboratory data were obtained from electronic medical records. We prospectively measured the cytokines Th1/Th2/Th17 and inflammatory cytokines IL-8, IL-1β, and IL-12 using cytometric bead array, and the soluble CD14 using in-house enzyme-linked immunosorbent assay.

Results

The HIV/AIDS inpatients presented a scenario of respiratory syndromes as the most prevalent comorbidity. Almost all patients had CD4 T counts below 350 cells/mL and the mortality rate was 20.5%. Pulmonary tuberculosis, neurotoxoplasmosis and oropharyngeal–esophageal candidiasis were the most prevalent opportunistic infections. TB and weight loss were more prevalent in HIV/AIDS inpatients who died. The Mann Whitney analysis showed that those who died had higher platelet distribution width (PDW) on admission, which is suggestive for platelet activation. The Poisson multivariate analysis showed the prevalence of TB, digestive syndrome and increases in IL-8 and lactate dehydrogenase (LDH) associated to death.

Conclusions

The advanced immunosuppression characterized by the opportunistic infections presented in these HIV/AIDS inpatients was the major factor of mortality. The role of platelet activation in worse outcomes of hospitalisation and the IL-8 associated with the context of advanced immunosuppression may be promising markers in the prediction of mortality in HIV/AIDS patients.

Client Satisfaction with Community Health Workers in HIV Care Teams

Community health workers (CHWs) integrated in human immunodeficiency virus (HIV) care teams undertake a variety of tasks to help patients navigate health care, develop care plans, and address social needs. Given the broad role of CHWs in HIV care, we sought to understand which client attributes are associated with various dimensions of CHW satisfaction using a sample of 204 people with HIV (PWH) from various geographic regions across the United States. Multivariable linear regressions were used to determine which client attributes were associated with complete satisfaction with CHWs using 10 validated measures. The mean age of participants was 40.6 years old (SD = 12.8) and over 70% were Black or African American. Adjusted models reveal clients who were female, have marginal health literacy, or have a substance use disorder diagnosis were more likely to not be completely satisfied across multiple dimensions (p ≤ .05). Conversely, being housed and having a mental health diagnosis were associated with being more likely to be completely satisfied (p ≤ .04). Clients' sociodemographic characteristics and health conditions may be indicative of unique needs, leading to differing expectations of CHWs. CHW training modalities should consider the complex interplay of care needs based upon different client backgrounds and experiences among PWH. Addressing unique needs resulting from social determinants of health and that arise from conditions co-occurring with HIV, such as substance use disorders, should be incorporated into CHW service delivery.