Baseline social characteristics and barriers to care from a special projects of national significance women of color with HIV study: a comparison of urban and rural women and barriers to HIV care

Food insecurity is associated with greater difficulty accessing care among people living with HIV with or without comorbid non-communicable diseases in western Kenya

INTRODUCTION

The relationship between food insecurity and access to healthcare in low-resource settings remains unclear. Some studies find that food insecurity is a barrier to accessing care, while others report that food insecurity is associated with a greater need for care, leading to more care utilisation. We use data from the Harambee study in western Kenya to assess the association between food insecurity and difficulty accessing care among people living with HIV (PLWH) with or without comorbid non-communicable diseases (NCDs).

METHODS

The Harambee study is a cluster randomised trial that tested the effectiveness of delivering integrated HIV and NCD care for PLWH. In this cross-sectional analysis, we examined baseline data from Harambee participants to investigate the relationship between household food insecurity and difficulty accessing care, using multivariable logistic regression models, controlling for sociodemographic factors and care satisfaction. We tested for effect measure modification by gender and household wealth and stratified analyses by NCD status.

RESULTS

Among 1039 participants, 11.1% reported difficulty accessing care, and 18.9% and 51.9% of participants had moderate and severe food insecurity, respectively. Among those with difficulty accessing care, 73.9% cited transportation issues as the major barrier. Difficulty accessing care was greater with higher levels of food insecurity: among participants with low, moderate and severe food insecurity, 5.9%, 9.7% and 14.4% reported difficulty accessing care, respectively. After adjusting for confounders, severe food insecurity was independently associated with difficulty accessing care (adjusted OR=2.5, 95% CI 1.4 to 4.4). There was no statistical evidence for effect measure modification by gender or wealth.

CONCLUSIONS

We found that greater food insecurity was associated with greater difficulty accessing care among PLWH with or without NCDs in rural western Kenya. These findings suggest that addressing social determinants of health may be necessary when implementing integrated HIV and NCD care programmes.

Population Density and Health Outcomes in Women with HIV in the Southern United States: A Retrospective Longitudinal Analysis

Purpose: Published studies have revealed challenges for people with human immunodeficiency virus (HIV) living in rural areas compared to those in urban areas, such as poor access to HIV care, insufficient transportation, and isolation. The purpose of this study was to examine associations between population density and multiple psychosocial and clinical outcomes in the largest cohort of women with HIV (WWH) in the United States. Methods: Women's Interagency HIV Study (WIHS) participants from Southern sites (n = 561) in 2013-2018 were categorized and compared by population density quartiles. The most urban quartile was compared with the most rural quartile in several psychosocial and clinical variables, including HIV viral load suppression, HIV medication adherence, HIV care attendance, depression, internalized HIV stigma, and perceived discrimination in healthcare settings. Results: Although women in the lowest density quartile were unexpectedly more highly resourced, women in that quartile had greater odds of not attending an HIV care visit in the last six months (odds ratio [OR] = 0.64, 95% confidence interval [CI] [0.43-0.95]), yet higher odds for having fully suppressed HIV when compared to women in the highest density quartile (OR = 1.64, 95% CI [1.13-2.38]). Highly urban WWH had greater likelihood of unsuppressed HIV, even after controlling for income, employment, and health insurance, despite reporting greater HIV care adherence and similar medication adherence. Discussion: Further investigation into the reasons for these disparities by population density is needed, and particular clinical attention should be focused on individuals from high population density areas to help maximize their health outcomes.

Comparison of HIV Viral Suppression Between a Sample of Foreign-Born and U.S.-Born Women of Color in the United States

We investigate the association between nativity status (U.S.- vs foreignborn) and viral suppression among women of color (WOC) with HIV (HIV +) and whether this association was modified by education and housing.

METHODS

Data were from 549 HIV + WOC, who participated in the Health Resources and Services Administration-funded WOC Initiative 2009-2013. We used generalized estimating equation models to quantify the association between the respondents' nativity status and viral suppression.

RESULTS

After adjusting for covariates, foreign-born WOC were 2.2 times (95% confidence interval: 1.25, 3.85) more likely to achieve viral suppression than U.S.-born WOC. This association was not modified by education or housing status.

CONCLUSIONS

Despite facing barriers to care, foreign-born WOC were more likely to achieve viral suppression than U.S.-born WOC. Programs aiming to end the HIV epidemic and reduce HIV disparities in the U.S. should consider these findings as they provide a more nuanced understanding of HIV + WOC.

Determinants of HIV and Sexually Transmitted Infection Testing and Acquisition Among Female Victims of Intimate Partner Violence

The purpose of this study was to identify determinants of HIV and sexually transmitted infection (STI) testing and acquisition among female victims of intimate partner violence (IPV). Data were abstracted from intake and HIV/STI testing forms from a family justice center, to identify the socioeconomic and abuse characteristics associated with requesting and obtaining an HIV/STI test (n = 343) and acquisition of HIV/STIs (n = 111). Multiple logistic regression using forward selection was used to identify predictors of HIV/STI testing and acquisition. Females experiencing greater risk of lethality were at higher odds of requesting an HIV/STI test; however, risk of lethality did not predict the receipt of an HIV/STI test. A history of sexual assault was associated with higher odds of acquiring HIV/STIs in the past year. Interventions are needed to facilitate HIV/STI testing among female victims of IPV, especially those with higher risk of lethality and a history of sexual assault.

Challenges and Barriers to HIV Care for Mexican Born Men Living in Chicago

BACKGROUND

Latinx men are disproportionately impacted by HIV. Research often looks at Latinx people as a heterogeneous population. This paper describes baseline characteristics and barriers to HIV care among Mexican born men enrolled in an HIV care engagement intervention at a public health clinic in Chicago.

METHODS

Survey and medical chart data were collected.

RESULTS

66 Mexican born men enrolled in the project. Over half (60%) were newly diagnosed; 40% were reengaging in care or establishing care for the first time. Participants reported significant pre and postmigration concerns including poverty, social stigma, late entry to care, and concurrent health concerns, including 47% screening positive for depression. Barriers to care and mental health concerns were significantly related to Stage 3 HIV.

DISCUSSION

More prevention and intervention research is needed to ameliorate the negative socioeconomic and health ramifications of immigration and bolster mental and sexual health, reduce HIV transmission, and increase testing, linkage and care retention.

Strategies for engaging transgender populations in HIV prevention and care

PURPOSE OF REVIEW

Transgender (trans) populations are heavily impacted by HIV, yet face structural, social, and individual barriers to engagement in HIV prevention and care. In this review, we summarize the data on barriers and facilitators and discuss evidence-informed strategies to facilitate access to and engagement in HIV prevention and care by trans communities.

RECENT FINDINGS

Intersectional stigma and discrimination at structural, community, individual levels present substantial impediments to HIV prevention and optimal care. Access to gender-affirming health care is a priority for trans communities. Where trans communities are highly networked, these networks may provide a strong infrastructure for disseminating HIV innovations and reaching individuals who are not engaged in HIV services. Efforts to engage trans people in HIV prevention and care must address stigma, provide gender-affirming services, and build on community strengths and priorities to ensure trans populations achieve maximum benefit from advances in HIV prevention and care.

SUMMARY

Combination approaches that respond to the complex drivers of HIV in trans communities represent promising strategies for engaging trans people and their partners in HIV prevention and care.

Stigma and Disclosure in Patients With Inflammatory Bowel Disease

Stigma in patients suffering from chronic disease is associated with worse clinical outcomes and secondary medical issues such as depression, anxiety, and decreased quality of life. We believe various forms of stigma can have different clinical significance in patients with inflammatory bowel disease (IBD). With further insight and research, we suggest that these forms of stigma could be identified and targeted by researchers or clinicians to lessen the psychological disease burden in patients and to potentially improve their physical well-being. In the current review, we discuss public perceptions, knowledge, and stigmatization of IBD, the prevalence of various forms of IBD stigma, and the impact of such stigma on patient outcomes. We also discuss IBD disclosure, its association with stigma, and the tendencies and effects of such disclosures among youth and adult patient populations. We finish the review by highlighting possible modalities and research areas for future IBD interventions.

Urban and Rural Differences: Unmet Needs for Symptom Management in People Living With HIV in China

Access to HIV care has increased in China, but regional disparities for the unmet symptom management needs of people living with HIV remain. Little attention has been paid to these disparities, especially in rural areas. We describe unmet symptom management needs in 1,214 people living with HIV from five HIV hospitals in the eastern coast, middle, and southern regions of China. Insomnia, abnormal dreams, and fatigue were the most common unmet needs of patients in urban China, whereas cognitive problems and blurry vision were the most common in rural China. Self-management capacity, discrimination, and symptom severity predicted more unmet symptom management needs for patients in urban areas. Medication adherence, basic function, and symptom severity predicted more unmet needs among patients in rural areas. Our results have implications for nurses in HIV care and HIV policymakers. Separate interventions targeting the urban and rural areas must be implemented to meet patient symptom management needs.

Self-reported depression and social support are associated with egocentric network characteristics of HIV-infected women of color

Background

We explore the social network characteristics associated with depressive symptoms and social support among HIV-infected women of color (WOC).

Methods

Network data were collected from 87 HIV-infected WOC at an academic Infectious Disease clinic in the United States (US) south. With validated instruments, interviewers also asked about depressive symptoms, social support, and treatment-specific social support. Linear regression models resulted in beta coefficients and 95% confidence intervals for the relationships among network characteristics, depression, and support provision.

Results

Financial support provision was associated with lower reported depressive symptoms while emotional support provision was associated with increased reported social support. Talking less than daily to the first person named in her network, the primary alter, was associated with a nearly 3-point decrease in reported social support for respondents. Having people in their social network who knew their HIV status was also important.

Conclusions

We found that both functional and structural social network characteristics contributed to perceptions of support by HIV-infected WOC.

Envisioning a Better U.S. Health Care System for All: Reducing Barriers to Care and Addressing Social Determinants of Health

The American College of Physicians (ACP) has long advocated for universal access to high-quality health care in the United States. Yet, it is essential that the U.S. health system goes beyond ensuring coverage, efficient delivery systems, and affordability. Reductions in nonfinancial barriers to care and improvements in social determinants of health are also necessary. This ACP position paper calls for ending discrimination based on personal characteristics; correcting workforce shortages, including the undersupply of primary care physicians; and understanding and ameliorating social determinants of health. The ACP calls for increased efforts to address urgent public health threats, including injuries and deaths from firearms; environmental hazards; climate change; maternal mortality; substance use disorders; and the health risks associated with nicotine, tobacco use, and electronic nicotine delivery systems in order to achieve ACP's vision for a better U.S. health care system.

Income Inequality, HIV Stigma, and Preventing HIV Disease Progression in Rural Communities

Antiretroviral therapies (ART) suppress HIV replication, thereby preventing HIV disease progression and potentially preventing HIV transmission. However, there remain significant health disparities among people living with HIV, particularly for women living in impoverished rural areas. A significant contributing factor to HIV-related disparities is a stigma. And yet, the relative contributions of stigma, gender, socio-economics, and geography in relation to health outcomes are understudied. We examined the associations of internalized stigma and enacted stigma with community-level income inequality and HIV viral suppression-the hallmark of successful ART-among 124 men and 74 women receiving care from a publicly funded HIV clinic serving rural areas with high-HIV prevalence in the southeastern US. Participants provided informed consent, completed computerized interviews, and provided access to their medical records. Gini index was collected at the census tract level to estimate community-level income inequality. Individual-level and multilevel models controlled for point distance that patients lived from the clinic and quality of life, and included participant gender as a moderator. We found that for women, income inequality, internalized stigma, and enacted stigma were significantly associated with HIV suppression. For men, there were no significant associations between viral suppression and model variables. The null findings for men are consistent with gender-based health disparities and suggest the need for gender-tailored prevention interventions to improve the health of people living with HIV in rural areas. Results confirm and help to explain previous research on the impact of HIV stigma and income inequality among people living with HIV in rural settings.

HIV infection among women in the United States: 2000-2017

Although HIV diagnoses among women have declined in recent years in the United States (U.S.), women accounted for 19% of new HIV diagnoses in 2016. In addition, women comprise 24% of the 973,846 persons living with HIV infection in the U.S. However, HIV prevention interventions targeting women are limited. We performed a review on HIV infection in women to increase awareness, improve overall care, and inform intervention development. A systematic literature review was conducted using literature published in PubMed, PsychINFO (EBSCO), and Scopus from July 2000 and June 2017. We included studies that: (1) were conducted in the U.S., (2) enrolled at least 50 HIV-positive women, and (3) utilized a case-control, cohort, or surveillance study design. Of 7497 articles, 48 articles met inclusion criteria. HIV diagnoses among women declined 32% between 2001 and 2016. In 2016, 61% of diagnoses in women were among African American women, and 56% were in the South. Women reported barriers to HIV care largely due to psychosocial challenges and social/structural determinants of health (SDH) barriers. Though new diagnoses among women have declined, racial and regional disparities remain. HIV prevention and research efforts with women are vital to inform interventions and reduce disparities.

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.

Access and engagement in HIV care among a national cohort of women living with HIV in Canada

Attrition along the cascade of HIV care poses significant barriers to attaining the UNAIDS targets of 90-90-90 and achieving optimal treatment outcomes for people living with HIV. Understanding the correlates of attrition is critical and particularly for women living with HIV (WLWH) as gender disparities along the cascade have been found. We measured the proportion of the 1425 WLWH enrolled in the Canadian HIV Women's Sexual and Reproductive Health Cohort Study (CHIWOS) who had never accessed HIV medical care, who reported delayed linkage into HIV care (>3 months between diagnosis and initial care linkage), and who were not engaged in HIV care at interview (<1 visit in prior year). Correlates of these cascade indicators were determined using univariate and multivariable logistic regression. We found that 2.8% of women had never accessed HIV care. Of women who had accessed HIV care, 28.7% reported delayed linkage and 3.7% were not engaged in HIV care. Indigenous women had higher adjusted odds of both a lack of access and delayed access to HIV care. Also, a younger age, unstable housing, history of recreational drug use, and experiences of everyday racism emerged as important barriers to ever accessing care. Programmatic efforts to support early linkage to and engagement in care for WLWH in Canada must address several social determinants of health, such as housing insecurity and social exclusion, and prioritize engagement of Indigenous women through culturally safe and competent practices.

Pain is Associated with Missed Clinic Visits Among HIV-Positive Women

Pain is highly prevalent among HIV-positive individuals, with women representing a large subset of those with pain. However, little is known about the relationship between pain and retention in HIV medical care. Among a cohort of HIV-positive women of color, we evaluated the association between pain and retention in care, as measured by missed clinic visits. The Health Resources and Services Administration's Women of Color Initiative was a multi-site observational cohort study evaluating demonstration projects to engage HIV-positive women in medical care. From November 2010 to July 2013, 921 women were enrolled in the study across nine U.S. sites; baseline interviews collected data on socio-demographic, clinical, and risk behavior characteristics. Pain was assessed at baseline based on number of days in pain over the last 30 days and was categorized as no pain (0 days), infrequent pain (1-13 days), and frequent pain (14-30 days), with 14 days being the median. Missed visits over the one-year follow-up period, evaluated by chart abstraction, were dichotomized as ≤1 missed visit versus >1 missed visit. We conducted multivariate logistic regression to assess the association between pain at baseline and missed visits, adjusting for pertinent covariates. Among our sample (N = 862), 52.2 % of women reported no pain, 23.7 % reported infrequent pain and 24.1 % reported frequent pain. Forty-five percent had >1 missed visit during the one-year follow-up period. Overall, we did not find a significant association between pain and missed visits (aOR 2.30; 95 % CI 1.00-5.25). However, in planned stratified analyses, among women reporting current substance use at baseline, reporting frequent pain was associated with a higher odds of missed visits as compared with reporting no pain (aOR 15.14; 95 % CI 1.78-128.88). In our overall sample, pain was not significantly associated with missed visits. However, frequent pain was associated with missed visits among HIV-positive women of color who reported substance use at baseline. A better understanding of the relationship between pain and missed visits could guide efforts to improve retention in care in this population.

Differences in Selected HIV Care Continuum Outcomes Among People Residing in Rural, Urban, and Metropolitan Areas-28 US Jurisdictions

PURPOSE

The HIV care continuum is used to monitor success in HIV diagnosis and treatment among persons living with HIV in the United States. Significant differences exist along the HIV care continuum between subpopulations of people living with HIV; however, differences that may exist between residents of rural and nonrural areas have not been reported.

METHODS

We analyzed the Centers for Disease Control and Prevention's National HIV Surveillance System data on adults and adolescents (≥13 years) with HIV diagnosed in 28 jurisdictions with complete reporting of HIV-related lab results. Lab data were used to assess linkage to care (≥1 CD4 or viral load test ≤3 months of diagnosis), retention in care (≥2 CD4 and/or viral load tests ≥3 months apart), and viral suppression (viral load <200 copies/mL) among persons living with HIV. Residence at diagnosis was grouped into rural (<50,000 population), urban (50,000-499,999 population), and metropolitan (≥500,000 population) categories for statistical comparison. Prevalence ratios and 95% CI were calculated to assess significant differences in linkage, retention, and viral suppression.

FINDINGS

Although greater linkage to care was found for rural residents (84.3%) compared to urban residents (83.3%) and metropolitan residents (81.9%), significantly lower levels of retention in care and viral suppression were found for residents of rural (46.2% and 50.0%, respectively) and urban (50.2% and 47.2%) areas compared to residents of metropolitan areas (54.5% and 50.8%).

CONCLUSIONS

Interventions are needed to increase retention in care and viral suppression among people with HIV in nonmetropolitan areas of the United States.

Individual Factors of Social Acceptance in Patients Infected With Human Immunodeficiency Virus (HIV) at the Yazd Behavioral Consultation Center in Iran

Background:

A considerable number of patients infected with HIV also have mental health problems. Individual psychotherapy is an effective way to treat these issues. Lack of social acceptance is a barrier to patients receiving proper medication and emotional/psychological support.

Objectives:

The purpose of this study was to examine the individual factors of social acceptance in patients infected with human immunodeficiency virus.

Patients and Methods:

Fifty HIV-infected patients who were registered in the Behavioral Consultation Center entered the study. Each of them filled out a questionnaire based on the Crown-Marlow social acceptance scale. Their answers were evaluated according to the questionnaire key.

Results:

Forty-five patients (90%) were male and five (10%) were female. Their ages ranged between 28 and 52 years old. Other variables researched in this study include patients’ age, sex, education, occupation, place of living, marital status, family history of HIV, and family history of psychological disorders. Employed patients experienced more social acceptance than housewives and people who were unemployed or retired.

Conclusions:

This study showed that HIV-infected patients with jobs enjoy a great deal of acceptance from the people around them and a higher quality of life in general. It also led to suggestions for further study with the purpose of finding more effective solutions for HIV prevention and better strategies for dealing with psychological disorders. Such research could also help in providing an enhanced understanding of the potential psychological impact that AIDS has on patients in Iran.

Young Women Living with HIV: Outcomes from a Targeted Secondary Prevention Empowerment Pilot Trial

Women account for 1 in 5 new HIV infections in the US, make up 24% of people living with HIV, and represent a quarter of AIDS diagnoses. Despite the need for continued prevention among young women living with HIV, there is very little in the literature on how best to reduce sexual risk and increase the health and well-being of young women living with HIV. This article explores the primary and secondary outcomes of a randomized controlled pilot trial of an intervention entitled

EVOLUTION

Young Women Taking Charge and Growing Stronger. This behavioral intervention aimed to decrease sexual risk and empower young women living with HIV by enhancing young women's knowledge and skills pertaining to HIV risk reduction as well as to the factors that increase women's vulnerability, such as sexual inequality, gender, and power imbalances. Findings from this trial demonstrate that group-based behavioral interventions for young women living with HIV have promise to reduce the total number of sexual partners and reduce unprotected vaginal and anal intercourse. However, more work is needed to understand how best to address the challenges young women face in their day to day lives that impact their sexual risk as well as their overall health and access to care and treatment.

Violence screening and viral load suppression among HIV-positive women of color

Recent research suggests intimate partner violence (IPV) is commonly experienced by many people living with HIV/AIDS, which can complicate their care. We introduce a novel approach to screening for history of violence among 102 women of color living with HIV and receiving care at an outpatient public health clinic. Using a composite measure composed of data from a variety of screening tools, we were able to determine that 70.6% of the women had a history of violence using the composite measure, and that 43% screened positive using multiple screening tools. Although overall viral load suppression rate was high at 81.4%, women with a history of violence were less likely to be virally suppressed when compared to those without such a history (76.4% versus 93.3%, p<0.05). Our findings suggest using a variety of screening questions at entry and at follow-up care appointments may be key to identifying and supporting women survivors who may not disclose violence when first asked. Future research should foster further development, analysis, and use of a variety of screening tools such as those used in this study.

Health status of HIV-infected women entering care: baseline medical findings from the women of color initiative

The WOC Initiative is a prospective study of 921 women of color (WOC) entering HIV care at nine (three rural, six urban) sites across the US. A baseline interview was performed that included self-reported limitation(s) in activity, health conditions, and the CDC's health-related quality of life measures (Healthy Days). One-third of the WOC reported limiting an activity because of illness or a health condition and those with an activity limitation reported 13 physically and 14 mentally unhealthy days/month, compared with 5 physically and 9 mentally unhealthy days/month in the absence of an activity limitation. Age was associated with a three- to fourfold increased risk of an activity limitation but only for WOC in the urban sites. Diabetes was associated with a threefold increased risk of a limitation among women at rural sites. Cardiac disease was associated with a six- to sevenfold increased risk of an activity limitation for both urban and rural WOC. HIV+ WOC reported more physically and mentally unhealthy days than the general US female population even without an activity limitation. Prevention and treatment of diabetes and cardiovascular disease will need to be a standard part of HIV care to promote the long-term health and HRQOL for HIV-infected WOC.

Substance abuse, violence, and HIV/AIDS (SAVA) syndemic effects on viral suppression among HIV positive women of color

The combined epidemics of substance abuse, violence, and HIV/AIDS, known as the SAVA syndemic, contribute to the disproportionate burden of disease among people of color in the US. To examine the association between HIV viral load suppression and SAVA syndemic variables, we used baseline data from 563 HIV+ women of color treated at nine HIV medical and ancillary care sites participating in HRSA's Special Project of National Significance Women of Color (WOC) Initiative. Just under half the women (n=260) were virally suppressed. Five psychosocial factors contributing to the SAVA syndemic were examined in this study: substance abuse, binge drinking, intimate partner violence, poor mental health, and sexual risk taking. Associations among the psychosocial factors were assessed and clustering confirmed. A SAVA score was created by summing the dichotomous (present/absent) psychosocial measures. Using generalized estimating equation (GEE) models to account for site-level clustering and individual-covariates, a higher SAVA score (0 to 5) was associated with reduced viral suppression; OR (adjusted)=0.81, 95% CI: 0.66, 0.99. The syndemic approach represents a viable framework for understanding viral suppression among HIV positive WOC, and suggests the need for comprehensive interventions that address the social/environmental contexts of patients' lives.

Considering care-seeking behaviors reveals important differences among HIV-positive women not engaged in care: implications for intervention

We sought to examine characteristics of HIV-positive women with varying levels of engagement in care and care-seeking behaviors. From 2010 to 2013, in a multi-site US-based study of engagement in care among HIV-positive women, we conducted baseline interviews, which included socio-demographic, clinical, and risk behavior characteristics, and barriers to care. We used multinomial logistic regression to compare differences among three distinct categories of 748 women: engaged in care; not engaged in care, but seeking care ("seekers"); and not engaged in care and not seeking care ("non-seekers"). Compared with women in care, seekers were more likely to be uninsured and to report fair or poor health status. In contrast, non-seekers were not only more likely to be uninsured, but, also, to report current high-risk drug use and sexual behaviors, and less likely to report transportation as a barrier to care. Examining care-seeking behaviors among HIV-positive women not engaged in care revealed important differences in high-risk behaviors. Because non-seekers represent a particularly vulnerable population of women who are not engaged in care, interventions targeting this population likely need to address drug use and be community-based given their limited interaction with the health care system.

Simulating patterns of patient engagement, treatment adherence, and viral suppression: a system dynamics approach to evaluating HIV care management

System dynamics (SD) modeling belongs to the rapidly evolving, interdisciplinary field of system science research. This field adds value to more traditional health research by contributing to the design and testing of complex integrated models of change, to examine health system performance and patient outcomes. Using selected milestones in HIV care management to frame our simulation research, we created a SD model to examine three patient subgroups of women of color (WOC) represented in our multi-site cohort, classified by their health care seeking status at baseline. Asked to reflect on their circumstance 6 months prior to enrollment in the MSE cohort, 53% noted they were receiving some care (In Care, n = 341), 31% that they had been seeking care (Seeking Care, n = 201), and 16% that they were undecided about seeking care (i.e., answered that they may or may not look for care) for treatment of their HIV (May or May Not Seek Care, n = 103). Our SD model compared simulated patterns of patient retention over 24 months in relation to: (1) access to antiretroviral therapy (ART), (2) adherence to ART, and (3) viral suppression. Assessed patterns yielded insights about system capacities and constraints in the context of the SPNS initiative under evaluation.