Systemic barriers to health care access for U.S. women with HIV: the role of cost and insurance

Burnout Among Service Providers for People Living with HIV: Factors Related to Coping and Resilience

Individuals who provide services for people living with HIV (PLWH) face numerous work-related challenges, including psychosocial and structural factors affecting the quality of care that they provide. Little is known about the factors that relate to burnout among service providers for PLWH. The current study seeks to examine the factors associated with burnout and the role of resilience and coping in the context of burnout. Via convenience sampling, data was collected from 28 professionals (e.g., peer counselors, HIV testers, case managers/case workers, group facilitators, or social workers) serving PLWH in the USA. Participants completed quantitative measures on sociodemographics, organizational factors, discrimination, trauma, depression, and burnout. A sub-sample of 19 participants provided in-depth qualitative data via semi-structured interviews on burnout, coping, and resilience as a buffer against the effects of burnout. Thematic content analysis revealed themes on the factors related to burnout (e.g., discrimination, limited financial and housing resources, and COVID-19), rejuvenating factors, coping with burnout, and intervention strategies. Additionally, Pearson's product moment correlations revealed significant associations between mental health variables such as depressive and posttraumatic stress disorder symptomology with (a) discrimination and microaggressions and (b) burnout. The current study highlights challenges to providing HIV care, including structural barriers and discrimination that are doubly impactful to the professionals in this sample who share identities with the PLWH whom they serve. These findings may inform the development of an intervention targeting burnout among individuals providing services to PLWH and motivate change to remove structural barriers and improve quality of care for PLWH.

Enduring stigma and precarity: A review of qualitative research examining the experiences of women living with HIV in high income countries over two decades

The lived experience of HIV for women remains poorly understood. In particular, there has been little attention to the consequences for women living with HIV (WLHIV) of changing social, epidemiological, biomedical and policy contexts, or to the implications of long-term treatment and aging for the current generation of HIV-positive women. We reviewed qualitative research with WLHIV in selected high-income countries (Australia, Canada, New Zealand, the UK and the USA) to identify the most prevalent experiences of HIV for women and trends over time. Our synthesis highlights the relative consistency of experiences of a diverse sample of WLHIV, particularly the enduring prevalence of gendered HIV-related stigma, sociostructural barriers to healthcare and support, and negative encounters with health professionals. We also identified gaps in knowledge. Understanding women's experiences, particularly their changing needs and strategies for coping as they live long-term with HIV, is key to effective support and services for WLHIV.

An Examination of Geographic Differences in Social Determinants of Health Among Women with Diagnosed HIV in the United States and Puerto Rico, 2017

Objective:

To examine differences, at the census tract level, in the distribution of human immunodeficiency virus (HIV) diagnoses and social determinants of health (SDH) among women with diagnosed HIV in 2017 in the United States and Puerto Rico.

Background:

In the United States, HIV continues to disproportionately affect women, especially minority women and women in the South.

Methods:

Data reported in the National HIV Surveillance System (NHSS) of the Centers for Disease Control and Prevention were used to determine census tract-level HIV diagnosis rates and percentages among adult women (aged ≥18 years) in 2017. Data from the American Community Survey were combined with NHSS data to examine regional differences in federal poverty status, education level, income level, employment status, and health insurance coverage among adult women with diagnosed HIV infection in the United States and Puerto Rico.

Results:

In the United States and Puerto Rico, among 6,054 women who received an HIV diagnosis in 2017, the highest rates of HIV diagnoses generally were among those who lived in census tracts where the median household income was less than $40,000; at least 19% lived below the federal poverty level, at least 18% had less than a high school diploma, and at least 16% were without health insurance.

Conclusion:

This study is the first of its kind and gives insight into how subpopulations of women are affected differently by the likelihood of an HIV diagnosis. The findings show that rates of HIV diagnosis were highest among women who lived in census tracts having the lowest income and least health coverage.

Correlates of opioid and benzodiazepine co-prescription among people living with HIV in British Columbia, Canada: A population-level cohort study

BACKGROUND

Co-prescribing benzodiazepines and opioids is relatively contraindicated due to the possible overdose risk. However, people living with HIV (PLWH) may have concurrent psychiatric and/or chronic pain diagnoses that may lead to the use of opioids and/or benzodiazepines for symptomatic treatment. Consequently, some PLWH may be at-risk for the health harms associated with the co-prescribing of these medications. Given this, the objectives of this study were to first examine the prevalence of opioids and benzodiazepines co-prescribing, and second, to characterize patient factors associated with the co-prescribing of opioids and benzodiazepines among PLWH in British Columbia (BC), Canada.

METHODS

Using data derived from a longitudinal BC cohort, we used bivariable and multivariable generalized estimating equation models to establish the prevalence of a benzodiazepine and opioid co-prescription and determine factors associated with this practice.

RESULTS

Between 1996 and 2015, 14 484 PLWH were included in the study and were followed for the entire study period. At baseline, 548 people (4%) were co-prescribed opioids and benzodiazepines, 6593 (46%) were prescribed opioids only, 2887 (20%) were prescribed benzodiazepines only, and 4456 (31%) were prescribed neither medication. A total of 3835 (27%) participants were prescribed both medications at least once during the study period. Factors positively associated with concurrent opioid and benzodiazepine prescribing included: depression/mood disorder [adjusted odds ratio (AOR) = 1.32; 95% confidence interval (CI) = 1.22-1.43] and anxiety disorder (AOR = 1.45; 95% CI = 1.27-1.66), whereas female sex (AOR = 0.76; 95% CI = 0.64-0.91) and substance use disorder (SUD) (AOR = 0.82; 95% CI = 0.74-0.90) were negatively associated with the outcome.

CONCLUSION

Our findings indicate that co-prescription of opioids and benzodiazepines was seen at some point during study follow-up in over a quarter of PLWH. Given the known risks associated with this prescribing practice, future research can focus on the outcomes of co-prescribing among this patient population and the development of strategies to reduce the co-prescribing of opioids and benzodiazepines.

Barriers to health care services for migrants living with HIV in Spain

Background

In Spain, migrants are disproportionately affected by HIV and experience high rates of late diagnosis. We investigated barriers to health care access among migrants living with HIV (MLWH) in Spain.

Methods

Cross sectional electronic survey of 765 adult HIV-positive migrants recruited within 18 health care settings between July 2013 and July 2015. We collected epidemiological, demographic, behavioral and clinical data. We estimated the prevalence and risk factors of self-reported barriers to health care using multivariable logistic regression.

Results

Of those surveyed, 672 (88%) had information on health care access barriers: 23% were women, 63% from Latin America and Caribbean, 14% from Sub-Saharan Africa and 15% had an irregular immigration status. Men were more likely to report barriers than women (24% vs. 14%, P = 0.009). The main barriers were: lengthy waiting times for an appointment (9%) or in the clinic (7%) and lack of a health card (7%). Having an irregular immigration status was a risk factor for experiencing barriers for both men (OR: (4.0 [95%CI: 2.2-7.2]) and women (OR: 10.5 [95%CI: 3.1-34.8]). Men who experienced racial stigma (OR: 3.1 [95%CI: 1.9-5.1]) or food insecurity (OR: 2.1 [95%CI: 1.2-3.4]) were more likely to report barriers. Women who delayed treatment due to medication costs (6.3 [95%CI: 1.3-30.8]) or had a university degree (OR: 5.8 [95%CI: 1.3-25.1]) were more likely to report barriers.

Conclusion

Health care barriers were present in one in five5 MLWH, were more common in men and were associated to legal entitlement to access care, perceived stigma and financial constraints.

Health System Features That Enhance Access to Comprehensive Primary Care for Women Living with HIV in High-Income Settings: A Systematic Mixed Studies Review

Women living with HIV in high-income settings continue to experience modifiable barriers to care. We sought to determine the features of care that facilitate access to comprehensive primary care, inclusive of HIV, comorbidity, and sexual and reproductive healthcare. Using a systematic mixed studies review design, we reviewed qualitative, mixed methods, and quantitative studies identified in Ovid MEDLINE, EMBASE, and CINAHL databases (January 2000 to August 2017). Eligibility criteria included women living with HIV; high-income countries; primary care; and healthcare accessibility. We performed a thematic synthesis using NVivo. After screening 3466 records, we retained 44 articles and identified 13 themes. Drawing on a social-ecological framework on engagement in HIV care, we situated the themes across three levels of the healthcare system: care providers, clinical care environments, and social and institutional factors. At the care provider level, features enhancing access to comprehensive primary care included positive patient-provider relationships and availability of peer support, case managers, and/or nurse navigators. Within clinical care environments, facilitators to care were appointment reminder systems, nonidentifying clinic signs, women and family spaces, transportation services, and coordination of care to meet women's HIV, comorbidity, and sexual and reproductive healthcare needs. Finally, social and institutional factors included healthcare insurance, patient and physician education, and dispelling HIV-related stigma. This review highlights several features of care that are particularly relevant to the care-seeking experience of women living with HIV. Improving their health through comprehensive care requires a variety of strategies at the provider, clinic, and greater social and institutional levels.

Strategies for improving the lives of US women aged 40 and above living with HIV/AIDS: an evidence map

BACKGROUND

While in its early years the HIV epidemic affected primarily the male and the young, nowadays, the population living with HIV/AIDS is approximately 24% women, and its age composition has shifted towards older ages. Many of the older women who live with HIV/AIDS also live with the medical and social conditions that accompany aging. This work aims to identify and characterize empirical studies of strategies for the comprehensive management of women over 40, including transgender women, who live with HIV/AIDS. Forty was chosen as an operational age cutoff to identify premenopausal women who are less likely to bear children, as well as peri- and postmenopausal women.

METHODS

We conducted a literature search after discussions with a diverse panel of content experts and other stakeholders and developed an evidence map that identified 890 citations that address questions having to do with programs and barriers to engaging with programs, as well as the role of insurance and comorbidities, and have enrolled older women who live with HIV/AIDS.

RESULTS

Of these, only 37 (4%) reported results of interest for women over 40 who live with HIV/AIDS, or examined interactions between gender and older age that would allow predictions in this subgroup. Few of the 37 eligible studies focused on women facing obvious challenges, such as immigrants, transgender, physically abused, or those recently released from prison. No studies focused on women caring for dependents, including children and grandchildren, or those diagnosed after age 40.

CONCLUSION

The evidence base that is directly applicable to women over 40 who live with HIV/AIDS in the USA is limited, and the research need is broad. We propose research prioritization strategies for this population.

The Association Between HIV Disclosure Status and Perceived Barriers to Care Faced by Women Living with HIV in Latin America, China, Central/Eastern Europe, and Western Europe/Canada

Generally, women are less likely than men to disclose their HIV status. This analysis examined the relationship between HIV disclosure and (1) perceived barriers to care and (2) quality of life (QoL) for women with HIV. The ELLA (EpidemioLogical study to investigate the popuLation and disease characteristics, barriers to care, and quAlity of life for women living with HIV) study enrolled HIV-positive women aged ≥18 years. Women completed the 12-item Barriers to Care Scale (BACS) questionnaire. QoL was assessed using the Health Status Assessment. BACS and QoL were stratified by dichotomized HIV disclosure status (to anyone outside the healthcare system). Multilevel logistic regression analysis was used to identify factors associated with disclosure. Of 1945 patients enrolled from Latin America, China, Central/Eastern Europe, and Western Europe/Canada between July 2012 and September 2013, 1929 were included in the analysis (disclosed, n = 1724; nondisclosed, n = 205). Overall, 55% of patients lived with a husband/partner, 53% were employed, and 88% were receiving antiretroviral therapy. Patients who were with a serodiscordant partner were more likely to disclose (p = 0.0003). China had a disproportionately higher percentage of participants who did not disclose at all (nearly 30% vs. <15% for other regions). Mean BACS severity scores for medical/psychological service barriers and most personal resource barriers were significantly lower for the disclosed group compared with the nondisclosed group (p ≤ 0.02 for all). Compared with the disclosed group, the nondisclosed group reported statistically significantly higher (p ≤ 0.03) BACS item severity scores for 8 of the 12 potential barriers to care. The disclosed group reported better QoL. Overall, HIV nondisclosure was associated with more severe barriers to accessing healthcare by women with HIV.

Enroling and retaining human immunodeficiency virus (HIV) patients in their care: A metasynthesis of qualitative studies

OBJECTIVES

To report the findings of a metasynthesis review of qualitative studies on patient and provider experiences and perspectives on linkage and retention in HIV care.

DESIGN

The review is an extraction, aggregation, interpretation and synthesis of qualitative findings based on the Sandelowski and Barroso method.

DATA SOURCES

A search of the literature was conducted in the databases Cumulative Index to Nursing and Allied Health, PubMed and PsycInfo for articles published from 2008 to 2013. Inclusion criteria were qualitative research articles published in English from across the world and in peer-reviewed journals. Literature reviews, conference abstracts and grey literature were excluded from this metasynthesis.

REVIEW METHODS

The review consisted of a) comprehensive search, b) study classification, c) abstraction of findings, d) synthesis. Of the 4640 citations screened, 69 articles were included for this metasynthesis.

RESULTS

69 unique articles from 44 countries were included. This metasynthesis takes into account the perspectives of at least 2263 HIV-positive participants (740 men, 1008 women, 78 transgender individuals and 437 unspecified sex) and 994 healthcare providers, family members and community members. The most salient barriers and facilitators to HIV linkage and retention in HIV care affirm ecological factors that are mostly beyond individual patients' control. Triadic streams of influence concurrently affect care engagement that include a person's psychological state upon diagnosis and their informational challenges (intrapersonal stream); one-on-one interactions with providers and their immediate community (social stream); and life demands, overall quality of care experiences and other structural barriers (cultural-attitudinal stream). Each stream's influence on HIV care engagement varies at any given point to reflect an individual's evolving and unique experiences with HIV infection throughout the illness trajectory.

CONCLUSION

There is sufficient evidence that detail how to best link and retain patients in HIV care. Themes identified indicate going beyond individual-level factors and towards shifting attention and resources to systems that patients navigate. Forceful structural-level actions are needed to correct these long-identified barriers and enhance care engagement facilitators.

Barriers to access to care reported by women living with HIV across 27 countries

Increased access to successful antiretroviral therapy (ART) is necessary in order to achieve an AIDS-free generation. Importantly, slightly over half of the people living with HIV are women. Small studies have described many barriers to accessing treatment and care among women living with HIV. This cross-sectional, non-interventional, epidemiological study assessed the prevalence of barriers to accessing care for women living with HIV across 27 countries, divided into four global regions. HIV-positive women attending routine clinical visits were offered the opportunity to participate in the study. Data describing the study sites and demographic characteristics of the participating women were collected. Participating women filled out questionnaires including the Barriers to Care Scale (BACS) questionnaire, on which they reported the extent to which they found each of the 12 potential barriers to accessing health care problematic. A total of 1931 women living with HIV were included in the study: 760 from Western Europe and Canada (WEC), 532 from Central and Eastern Europe (CEE), 519 from Latin America (LA), and 120 from China. The mean age of participating women was 40.1 ± 11.4 years. A total of 88.2% were currently taking ART. A total of 81.8% obtained HIV treatment under a government health plan. The most prevalent barrier to care was community HIV/AIDS stigma. Community HIV/AIDS knowledge, lack of supportive/understanding work environments, lack of employment opportunities, and personal financial resources were also highly prevalent barriers to accessing care. These findings indicate that, more than 30 years after the start of the AIDS epidemic, stigma is still a major issue for women living with HIV. Continued efforts are needed to improve community education on HIV/AIDS in order to maximize access to health care among women living with HIV.

Factors associated with retention and viral suppression among a cohort of HIV+ women of color

Access to sustained HIV medical care is critical to achieving viral suppression. However, a variety of factors may impede or facilitate retention in care or becoming virally suppressed. Though retention and suppression are often treated separately, this study examined both in a cohort of 921 HIV+ women of color who participated in eight demonstration programs across the US. For women who met the inclusion criteria, 83% (n = 587) were retained and 73% (n = 357) were virally suppressed. Average age of women retained was 40.9, and 41.9 for those virally suppressed. The majority were African American/Black or Hispanic/Latina, single, and had no children less than 18 years of age, had health insurance, a high school degree or higher, were stably housed, and unemployed. Some factors associated with retention in care were indecision about seeking HIV medical care (AOR = 0.42) and having children under the age of 18 (AOR = 0.59). Some factors associated with being virally suppressed were living with others (AOR = 0.58), current substance abuse (AOR = 0.38), and fair/poor health (AOR = 0.40). The findings suggest different processes and social mechanisms may influence retention and viral suppression. Interventions seeking to improve retention in care may require tailored program components and strategies that focus on improving viral suppression.

STRUCTURAL AND HIDDEN BARRIERS TO A LOCAL PRIMARY HEALTH CARE INFRASTRUCTURE: AUTONOMY, DECISIONS ABOUT PRIMARY HEALTH CARE, AND THE CENTRALITY AND SIGNIFICANCE OF POWER

PURPOSE

To examine a local primary health care infrastructure and the reality of primary health care from the perspective of residents of a small, urban community in the southern United States.

METHODOLOGY/APPROACH

Data derive from 13 semi-structured focus groups, plus three semi-structured interviews, and were analyzed inductively consistent with a grounded theory approach.

FINDINGS

Structural barriers to the local primary health care infrastructure include transportation, clinic and appointment wait time, and co-payments and health insurance. Hidden barriers consist of knowledge about local health care services, non-physician gatekeepers, and fear of medical care. Community residents have used home remedies and the emergency department at the local academic medical center to manage these structural and hidden barriers.

RESEARCH LIMITATIONS/IMPLICATIONS

Findings might not generalize to primary health care infrastructures in other communities, respondent perspectives can be biased, and the data are subject to various interpretations and conceptual and thematic frameworks. Nevertheless, the structural and hidden barriers to the local primary health care infrastructure have considerably diminished the autonomy community residents have been able to exercise over their decisions about primary health care, ultimately suggesting that efforts concerned with increasing the access of medically underserved groups to primary health care in local communities should recognize the centrality and significance of power.

ORIGINALITY/VALUE

This study addresses a gap in the sociological literature regarding the impact of specific barriers to primary health care among medically underserved groups.

Meta-analysis of the safety, tolerability, and efficacy of lopinavir/ritonavir-containing antiretroviral therapy in HIV-1-infected women

PURPOSE

Women comprise ≯50% of HIV-infected patients, yet safety, tolerability, and efficacy data in women taking antiretrovirals (ARVs) are limited. Lopinavir/ ritonavir (LPV/r)-anchored regimens are globally the most widely prescribed HIV-1 protease inhibitor regimens. The objective was to investigate the safety and efficacy of LPV/r-based therapy in women.

METHODS

A database query yielded all available data in HIV-1-infected subjects receiving LPV/r-based triple-ARV regimens from randomized clinical trials lasting ≥48 weeks from Abbott or Abbott-supported AIDS Clinical Trials Group studies. Efficacy (HIV-1 RNA levels, CD4+ T-cell counts) and safety and tolerability (treatment discontinuation, treatment-related adverse events [AE], and clinical laboratory abnormalities) at 48 weeks were assessed for total women, women by age (≥50, <50 years) and body mass index (BMI; <25, ≥25 to <30, ≥30 kg/m2), and sex.

RESULTS

Nine hundred ninety-two women initiated LPV/r-based therapy (of whom 79.2% were ARV-naïve), with 83.6% completing 48 weeks of treatment. There were 75.5% of women who achieved a threshold of HIV RNA <400 copies/mL by intent-to-treat, non-completer equals failure (ITT, NC = F) analysis, with a mean ± SE CD4+ T-cell count increase of 191.6 ± 4.92 cells/mm3 from baseline. Women aged ≥50 versus <50 years had higher incidence of moderate-to-severe treatment-related AEs and certain laboratory abnormalities, better virologic response (HIV RNA <400 copies/mL by ITT, NC = F), similar immunologic responses, and similar overall incidence of treatment discontinuations. Higher incidences of certain moderate-to-severe treatment-related AEs and laboratory abnormalities occurred in women with BMI ≥30 kg/m2; however, no effect of BMI on efficacy or discontinuation was observed.

CONCLUSIONS

LPV/r-based regimens were efficacious and well-tolerated in women without marked differences based on age and BMI categories evaluated.

A cross-sectional description of social capital in an international sample of persons living with HIV/AIDS (PLWH)

Background

Social capital refers to the resources linked to having a strong social network. This concept plays into health outcomes among People Living with HIV/AIDS because, globally, this is a highly marginalized population. Case studies show that modifying social capital can lead to improvements in HIV transmission and management; however, there remains a lack of description or definition of social capital in international settings. The purpose of our paper was to describe the degree of social capital in an international sample of adults living with HIV/AIDS.

Methods

We recruited PLWH at 16 sites from five countries including Canada, China, Namibia, Thailand, and the United States. Participants (n = 1,963) completed a cross-sectional survey and data were collected between August, 2009 and December, 2010. Data analyses included descriptive statistics, factor analysis, and correlational analysis.

Results

Participant's mean age was 45.2 years, most (69%) identified as male, African American/Black (39.9%), and unemployed (69.5%). Total mean social capital was 2.68 points, a higher than average total social capital score. Moderate correlations were observed between self-reported physical (r = 0.25) and psychological condition (r = 0.36), social support (r = 0.31), and total social capital. No relationships between mental health factors, including substance use, and social capital were detected.

Conclusions

This is the first report to describe levels of total social capital in an international sample of PLWH and to describe its relationship to self-reported health in this population.

The Prevalence of Undiagnosed HIV Infection in Those Who Decline HIV Screening in an Urban Emergency Department

Objective. To determine the prevalence of occult HIV infection in patients who decline routine HIV testing in an urban emergency department. Design, Setting, and Patients. Discarded blood samples were obtained from patients who had declined routine ED HIV testing. After insuring that the samples came from patients not known to be HIV positive, they were deidentified, and rapid HIV testing was preformed using 5 μL of whole blood. Main Outcome Measures. The prevalence of occult HIV infection in those who declined testing compared with prevalence in those who accepted testing. Results. 600 consecutive samples of patients who declined routine HIV screening were screened for HIV. Twelve (2%) were reactive. Over the same period of time, 4845 patients accepted routine HIV testing. Of these, 35 (0.7%) were reactive. The difference in the prevalence of HIV infection between those who declined and those who accepted testing was significant (P = .001). The relative risk of undetected HIV infection in the group that declined testing was 2.74 times higher (95% CI 1.44-5.18) compared with those accepted testing. Conclusion. The rate of occult HIV infection is nearly three-times higher in those who decline routine ED HIV testing compared with those who accept such testing. Interventions are urgently needed to decrease the opt-out rate in routine ED HIV testing settings.

Smoking cessation among women with and at risk for HIV: are they quitting?

BACKGROUND

Cigarette smoking is an important risk factor for adverse health events in HIV-infected populations. While recent US population-wide surveys report annual sustained smoking cessation rates of 3.4-8.5%, prospective data are lacking on cessation rates for HIV-infected smokers.

OBJECTIVE

To determine the sustained tobacco cessation rate and predictors of cessation among women with or at risk for HIV infection.

DESIGN

Prospective cohort study.

PARTICIPANTS

A total of 747 women (537 HIV-infected and 210 HIV-uninfected) who reported smoking at enrollment (1994-1995) in the Women's Interagency HIV Study (WIHS) and remained in follow-up after 10 years. The participants were mostly minority (61% non-Hispanic Blacks and 22% Hispanics) and low income (68% with reported annual incomes of less than or equal to $12,000).

MEASUREMENTS AND MAIN RESULTS

The primary outcome was defined as greater than 12 months continuous cessation at year 10. Multivariate logistic regression was used to identify independent baseline predictors of subsequent tobacco cessation. A total of 121 (16%) women reported tobacco cessation at year 10 (annual sustained cessation rate of 1.8%, 95% CI 1.6-2.1%). Annual sustained cessation rates were 1.8% among both HIV-positive and HIV-negative women (p = 0.82). In multivariate analysis, the odds of tobacco cessation were significantly higher in women with more years of education (p trend = 0.02) and of Hispanic origin (OR = 1.87, 95% CI = 1.4-2.9) compared to Black women. Cessation was significantly lower in current or former illicit drug users (OR = 0.42 95% CI = 0.24-0.74 and OR = 0.65, 95% CI = 0.49-0.86, respectively, p trend = 0.03) and women reporting a higher number of cigarettes per day at baseline (p trend < 0.001).

CONCLUSIONS

HIV-infected and at-risk women in this cohort have lower smoking cessation rates than the general population. Given the high prevalence of smoking, the high risk of adverse health events from smoking, and low rates of cessation, it is imperative that we increase efforts and overcome barriers to help these women quit smoking.