Delays in seeking HIV care due to competing caregiver responsibilities

Gender-based stigma and the prevention and treatment of HIV/AIDS among older women: A scoping review protocol

INTRODUCTION

The population of women aged 50 years and older living with HIV is increasing. Older women face unique challenges in the prevention and management of HIV; however, they are often under engaged in HIV/AIDS research. One such challenge is gender-based stigma, which can be manifested through harmful gendered stereotypes, discrimination, prejudice, and sexism that could potentially hinder HIV care engagement among this population. We propose a scoping review to identify and synthesize evidence pertaining to how experiences of gender-based stigma impacts HIV prevention and care among older women.

MATERIALS AND METHODS

We will use the framework by Arksey and O'Malley and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR) to conduct this scoping review. We will search MEDLINE/PubMed, Web of Science, PsycINFO, CINAHL and Scopus for empirical literature published between January 1981 and the date of search commencement. Supplementary screening will be conducted using backwards citation chaining of the final list of included full-text articles. Two reviewers will independently screen all titles and abstracts for articles that meet the predetermined inclusion criteria. Two reviewers will also screen full-text articles and chart data using a standardized data collection form.

RESULTS

We will synthesize the findings through tables, charts, and narrative summaries. We will also identify gaps in the current literature and provide recommendations for future research. Findings will be shared at conferences and submitted to a peer-reviewed publication.

DISCUSSION

To our knowledge, this will be the first scoping review to examine gender-based stigma in relation to HIV prevention and care among older women. We anticipate that our results will be of interest to older women living with HIV, healthcare providers, policy makers, and community activists working to improve quality of life and care experiences for older women living with HIV.

'If I don't take care of me, then I can't be there for others:' a qualitative study of caregiving relationships among older women living with HIV

OBJECTIVE

The population of women ages 50 years and older living with HIV is increasing. Yet, little is known about the care networks that older women living with HIV (OWLH) use to manage their health. The goal of this study was to explore the caregiving and care receiving relationships among OWLH and how these relationships impact HIV management.

METHODS

OWLH aged 50 years and older were recruited from clinics and community-based organizations across the U.S. We conducted semi-structured, in-depth phone interviews and performed content and thematic analysis on transcripts.

RESULTS

Participants (N = 23) were on average 60 years old and had been living with HIV for an average of 23.7 years. Participants 1) relied on diverse care networks; 2) were caregivers for grandchildren and parents; 3) had pride and joy in being caregivers; and 4) were highly proactive in their own HIV management. Care networks promoted self-love and acceptance. However, concerns about aging with HIV were still highly prevalent.

CONCLUSION

Being a caregiver and care recipient are sources of meaning and strength to help OWLH manage HIV. Public health programs should consider engaging both OWLH and their care networks in healthcare discussions and educational efforts.

Lung Cancer in Women: The Past, Present, and Future

Lung cancer is the leading cause of cancer death for women in multiple countries including the United States. Women are exposed to unique risk factors that remain largely understudied such as indoor pollution, second-hand tobacco exposure, biological differences, gender differences in tolerability and response to therapy in lung cancer, and societal gender roles, that create distinct survivorship needs. Women continue to lack representation in lung cancer clinical trials and are typically treated with data generated from majority male patient study populations, which may be inappropriate to extrapolate and generalize to females. Current lung cancer treatment and screening guidelines do not incorporate sex-specific differences and physicians also often do not account for gender differences when choosing treatments or discussing survivorship needs. To best provide targeted treatment approaches, greater representation of women in lung cancer clinical trials and further research is necessary. Clinicians should understand the unique factors and consequences associated with lung cancer in women; thus, a holistic approach that acknowledges environmental and societal factors is necessary.

Long-Acting Injectable ART and PrEP Among Women in Six Cities Across the United States: A Qualitative Analysis of Who Would Benefit the Most

Long-acting injectable (LAI) modalities have been developed for ART and PrEP. Women face unique barriers to LAI use yet little research has examined women's perceptions of potential LAI HIV therapy candidates. We conducted 89 in-depth interviews at six Women's Interagency HIV Study (WIHS) sites with women living with HIV (n = 59) and HIV-negative women (n = 30) from 2017 to 2018. Interviews were recorded, transcribed, and analyzed using thematic content analysis. Participants identified specific sub-populations who could most benefit from LAI over daily pills: (1) young people; (2) women with childcare responsibilities; (3) people with adherence-related psychological distress; (4) individuals with multiple sex partners; and (5) people facing structural insecurities such as homelessness. Women are underserved by current HIV care options and their perspectives are imperative to ensure a successful scale-up of LAI PrEP and LAI ART that prioritizes equitable access and benefit for all individuals.

Racial, ethnic, and gender disparities in hospitalizations among persons with HIV in the United States and Canada, 2005-2015

OBJECTIVE

To examine recent trends and differences in all-cause and cause-specific hospitalization rates by race, ethnicity, and gender among persons with HIV (PWH) in the United States and Canada.

DESIGN

HIV clinical cohort consortium.

METHODS

We followed PWH at least 18 years old in care 2005-2015 in six clinical cohorts. We used modified Clinical Classifications Software to categorize hospital discharge diagnoses. Incidence rate ratios (IRR) were estimated using Poisson regression with robust variances to compare racial and ethnic groups, stratified by gender, adjusted for cohort, calendar year, injection drug use history, and annually updated age, CD4+, and HIV viral load.

RESULTS

Among 27 085 patients (122 566 person-years), 80% were cisgender men, 1% transgender, 43% White, 33% Black, 17% Hispanic of any race, and 1% Indigenous. Unadjusted all-cause hospitalization rates were higher for Black [IRR 1.46, 95% confidence interval (CI) 1.32-1.61] and Indigenous (1.99, 1.44-2.74) versus White cisgender men, and for Indigenous versus White cisgender women (2.55, 1.68-3.89). Unadjusted AIDS-related hospitalization rates were also higher for Black, Hispanic, and Indigenous versus White cisgender men (all P < 0.05). Transgender patients had 1.50 times (1.05-2.14) and cisgender women 1.37 times (1.26-1.48) the unadjusted hospitalization rate of cisgender men. In adjusted analyses, among both cisgender men and women, Black patients had higher rates of cardiovascular and renal/genitourinary hospitalizations compared to Whites (all P < 0.05).

CONCLUSION

Black, Hispanic, Indigenous, women, and transgender PWH in the United States and Canada experienced substantially higher hospitalization rates than White patients and cisgender men, respectively. Disparities likely have several causes, including differences in virologic suppression and chronic conditions such as diabetes and renal disease.

Trends and Sex Differences in Access to HIV Care with Scale Up of National HIV Treatment Guidelines in Pune, India

Test and treat is the current global standard, yet sex differences persist in access to HIV care. We assessed the differences in presentation and antiretroviral therapy (ART) uptake by sex and ART-eligibility period among ART-naive adults registered at a public ART center in India. Four ART eligibility periods were defined by programmatically determined CD4 criteria (periods I-IV: CD4 <200, <350, ≤500 cells/μL, and any CD4) between January 2005 and December 2017. Of 23 957 participants, 12 510 were male. Men consistently presented with lower median CD4 count (period I-IV, P < .05) and higher median age (period I-III, P < .001) than women. From period I to IV, median age increased in women (P < .0001), ART initiation time decreased in both sexes (P < .001), and median CD4 remained <200 cells/µL in men. Advanced HIV disease and increasing age at presentation are persistent sex-specific trends which warrant innovative HIV testing strategies in both sexes.

Telephone-delivered behavioral health interventions for people living with HIV: patients' perspectives from a qualitative study

People living with HIV (PLWH) often experience mental health concerns as well as difficulties with medication adherence; they also report barriers to receipt of health services. Telephone-delivered interventions can overcome some of these barriers. To obtain patients' perspectives on telephone-delivered behavioral health services, we conducted a qualitative study with patients who participated in one of two telephone-delivered interventions (mindfulness training, health coaching) in a research trial. Patients (N = 42; M age = 46 years, 50% female, 26% Black) participated in semi-structured qualitative interviews after completing the study. They identified several advantages (e.g., being able to schedule sessions more flexibly compared to in-person appointments, ease of developing rapport with interventionists) as well as occasional challenges of phone delivery (e.g., network connectivity). Overall, PLWH view telephone-delivery as a convenient and flexible method to engage in behavioral health interventions.

Gender Norms and HIV Testing/Treatment Uptake: Evidence from a Large Population-Based Sample in South Africa

How does the endorsement of different dimensions of gender norms by men and/or women influence their use of HIV testing and antiretroviral treatment? This question was examined using data from a 2014 population-based survey of 1053 women and 1004 men, ages 18–49, in rural South Africa. We used a global measure for views toward gender norms (the GEM Scale), plus four subsets of scale items (all reliabilities ≥ 0.7). In multivariate analyses using the global measure, endorsement of inequitable gender norms was associated with more testing (AOR 2.47, p < 0.01) and less treatment use (AOR 0.15, p < 0.01) among women but not men. When examining specific subsets of inequitable norms (e.g., endorsing men as the primary decision-maker), decreased odds of treatment use was found for men as well (AOR 0.18, p < 0.01). Careful attention to the role specific gender norms play in HIV service uptake can yield useful programmatic recommendations.

Hiring, training, and supporting Peer Research Associates: Operationalizing community-based research principles within epidemiological studies by, with, and for women living with HIV

BACKGROUND

A community-based research (CBR) approach is critical to redressing the exclusion of women-particularly, traditionally marginalized women including those who use substances-from HIV research participation and benefit. However, few studies have articulated their process of involving and engaging peers, particularly within large-scale cohort studies of women living with HIV where gender, cultural and linguistic diversity, HIV stigma, substance use experience, and power inequities must be navigated.

METHODS

Through our work on the Canadian HIV Women's Sexual and Reproductive Health Cohort Study (CHIWOS), Canada's largest community-collaborative longitudinal cohort of women living with HIV (n = 1422), we developed a comprehensive, regionally tailored approach for hiring, training, and supporting women living with HIV as Peer Research Associates (PRAs). To reflect the diversity of women with HIV in Canada, we initially hired 37 PRAs from British Columbia, Ontario, and Quebec, prioritizing women historically under-represented in research, including women who use or have used illicit drugs, and women living with HIV of other social identities including Indigenous, racialized, LGBTQ2S, and sex work communities, noting important points of intersection between these groups.

RESULTS

Building on PRAs' lived experience, research capacity was supported through a comprehensive, multi-phase, and evidence-based experiential training curriculum, with mentorship and support opportunities provided at various stages of the study. Challenges included the following: being responsive to PRAs' diversity; ensuring PRAs' health, well-being, safety, and confidentiality; supporting PRAs to navigate shifting roles in their community; and ensuring sufficient time and resources for the translation of materials between English and French. Opportunities included the following: mutual capacity building of PRAs and researchers; community-informed approaches to study the processes and challenges; enhanced recruitment of harder-to-reach populations; and stronger community partnerships facilitating advocacy and action on findings.

CONCLUSIONS

Community-collaborative studies are key to increasing the relevance and impact potential of research. For women living with HIV to participate in and benefit from HIV research, studies must foster inclusive, flexible, safe, and reciprocal approaches to PRA engagement, employment, and training tailored to regional contexts and women's lives. Recommendations for best practice are offered.

Resilience resources among African American women living with HIV in Southern United States

OBJECTIVES

African American women living with HIV (WLH) often face various challenges to access to and benefit from healthcare across the HIV treatment cascade. Despite experiencing multiple forms of ongoing adversity, some African American WLH are able to adapt and stand strong. The current study aims to identify resources at various socioecological levels that facilitate resilience and explore how these resources interact with each other.

DESIGN

Guided by the theories of resilience, we collected qualitative data through in-depth interviews with 14 African American WLH in South Carolina, United States.

METHODS

Participants were purposely recruited and interviewed in private settings in 2016. With appropriate consent, each interview was recorded and was transcribed verbatim. Data analysis was conducted using NVivo 11.0.

RESULTS

The participants described six major resilience resources including first, internal strength; second, religion and spirituality; third, hopefulness about life and future; fourth, self-awareness and self-care; fifth, social support from family and community; and sixth, HIV-related health facilities. The themes that occurred in qualitative data also show how resilience resources at the family/community level and institutional level affected individual resources, and how these resources collaborated with each other.

CONCLUSION

The findings suggest that resilient African American WLH maintain hope in the face of adversity and seek out and obtain social support. Self-care, social support, and health facilities are particularly critical resources for African American WLH. Comprehensive interventions are needed to integrate these resources across multiple socioecological levels to enhance resilience and treatment outcomes in African American WLH.

The barriers to linkage and retention in care for women living with HIV in an high income setting where they comprise a minority group

Women comprise a minority population of individuals living with HIV in Australia, and are often poorly represented in research and clinical trials so their needs remain largely unknown. Data suggests that they are diagnosed later than men and start antiretroviral therapy at a lower CD4 cell count. This raises the question whether there are sex specific barriers to linkage and retention in care. This study analyzed 484 surveys received from clinicians collecting demographic, virological, and reproductive health data along with perceived barriers to linkage and retention in care. Most women (67%) were estimated to have been linked into care within 28 days of diagnosis. For women who were not linked into care for more than 28 days, the most commonly reason cited was fear of disclosure to others, followed by fear of disclosure to their partner. The main reasons given for non-retention in care were related to transport, carer responsibilities, financial pressure, health beliefs and concern about stigma or disclosure.

Sexual dimorphism in HIV-1 infection

Sex-specific differences affecting various aspects of HIV-1 infection have been reported, including differences in susceptibility to infection, course of HIV-1 disease, and establishment of viral reservoirs. Once infected, initial plasma levels of HIV-1 viremia in women are lower compared to men while the rates of progression to AIDS are similar. Factors contributing to these sex differences are poorly understood, and range from anatomical differences and differential expression of sex hormones to differences in immune responses, the microbiome and socio-economic discrepancies, all of which may impact HIV-1 acquisition and disease progression. Ongoing research efforts aiming at controlling HIV-1 disease or reducing viral reservoirs need to take these sex-based differences in HIV-1 pathogenesis into account. In this review, we discuss established knowledge and recent findings on immune pathways leading to sex differences in HIV-1 disease manifestations, with focus on HIV-1 latency and the effect of female sex hormones on HIV-1.

The experiences of caregivers of children living with HIV and AIDS in Uganda: a qualitative study

Background

Home-based care for HIV patients is popular in contexts severely affected by the epidemic and exacts a heavy toll on caregivers. This study aimed at understanding the experiences of caregivers and their survival strategies.

Methods

A total of 18 caregivers (3 males and 15 females) were interviewed using a semi-structured interview guide, and thematic analysis was used to analyse the data.

Results

Analysis suggests that the caregivers are burdened with insecure provisions for food and difficulties in accessing health care. They however survived these strains through managing their relationships, sharing burden with care-recipients, social networks and instrumental spirituality. These findings are discussed under two major themes: 1). Labour of caregiving and 2). Survivalism.

Conclusions

Home-based care presents huge opportunities for community response to the HIV/AIDS epidemic in African settings. It is however burdensome and thus should not be left for families alone to shoulder. There is therefore an urgent need for protecting home-based care for HIV children in Uganda. Implications for improving and strengthening social interventions in home-based care of HIV/AIDS in the Ugandan context are addressed.

Assessing the Impact of Perinatal HIV Case Management on Outcomes Along the HIV Care Continuum for Pregnant and Postpartum Women Living With HIV, Philadelphia 2005-2013

To evaluate the impact of a Perinatal Medical Case Management (PCM) Program for women living with HIV (WLWH). Characteristics of pregnant and postpartum WLWH were compared between those who engaged in PCM and those who did not. Using secondary data collected from routine HIV surveillance, multivariable regression models were used to evaluate the association between PCM and four outcomes adapted from the HIV care continuum. In multivariable models, compared to WLWH not in PCM, participants (n = 448, 52.8%) were almost twice as likely to achieve HIV suppression before delivery (aOR 1.90 [1.33, 2.71], p = 0.0005); were more likely to be retained in HIV care 1 year postpartum (aOR 1.59 [1.17, 2.16], p = 0.0029); and were equally likely to engage in HIV care within 90-days of delivery (aOR 1.21 [0.88, 1.65], p = 0.236) and be virally suppressed 1 year postpartum (aOR 1.26 [0.90, 1.77], p = 0.178). PCM is an important intervention for preventing perinatal HIV transmission and closings gaps in the HIV care continuum for WLWH during pregnancy and postpartum.

Factors Associated with Health Information Seeking, Processing, and Use Among HIV Positive Adults in the Dominican Republic

Effective treatment and management of human immunodeficiency virus (HIV) depend on patients' ability to locate, comprehend, and apply health information. This study's purpose was to identify characteristics associated with these skills among HIV positive adults in the Dominican Republic. An information behavior survey was administered to 107 participants then three logistic regressions were conducted to identify characteristics associated with information seeking, processing, and use. Never having cared for someone who was sick was significantly associated with less information seeking, processing, and use. Males were more likely to be active information seekers and those who had attended the clinic for six or fewer years were less likely to actively seek information. Younger individuals had increased odds of higher information processing and those without comorbidities had increased odds of more information use. Results may inform researchers, organizations, and providers about how patients interact with health information in limited resource settings.

Efficacy of a multilevel intervention on the mental health of people living with HIV and their family members in rural China

OBJECTIVE

HIV has a profound impact on infected individuals and their families. This study evaluated the efficacy of an intervention aimed at improving the mental health of people living with HIV (PLH) and their family members.

METHOD

A randomized controlled trial of 475 PLH and 522 family members was conducted in Anhui, China. The intervention comprised activities at individual, family, and community levels. The study outcomes, which included depressive symptoms and coping with illness for the PLH and depressive symptoms and caregiver burden for the family members, were assessed at baseline and at 6-, 12-, 18-, and 24-month follow-up. We used a mixed-effects regression model with village- and participant-level random effects to assess the intervention effect on the improvement of outcome measures.

RESULTS

Relative to the control condition, the PLH and family members of the intervention group reported a significant reduction in depressive symptoms. The largest difference in depressive symptoms was observed at 6 months for the PLH and at 12 months for family members. Decreases in perceived caregiver burden over time were observed for family members in both conditions; however, the group difference did not reach statistical significance. Significant intervention effect on the coping with illness was reported by the PLH.

CONCLUSIONS

The study highlights the importance of empowering families affected by HIV to confront the challenges together rather than individually. It may be optimal for future programs to include both PLH and their family members to maximize intervention effects through strengthening interactions and support within a family. (PsycINFO Database Record

The Global HIV/AIDS Epidemic and Related Mental Health Issues: The Crisis for Africans and Black Americans

HIV/AIDS is one of the most devastating diseases that humanity has ever faced. Since the first clinical evidence of HIV/AIDS was reported in 1981, more than 60 million people have been infected with the virus and more than 20 million have died of AIDS. This article provides an overview of the global HIV/AIDS epidemic with a focus on its impact on sub-Saharan Africa and people of African descent in the United States.

Alcohol Use and HIV Testing in a National Sample of Women

The HIV/AIDS epidemic continues to disproportionately affect racial and ethnic minority groups and women in the United States. Prevention research suggests that reduced alcohol use and increased HIV testing are associated with lower incidence of HIV transmission among high-risk populations. Multivariable logistic regression analyses of the 2009 National Health Interview Survey data were performed for a national sample of 15,470 adult women to examine the relationship between alcohol use and likelihood of HIV testing. There is a significant association between level of alcohol use and HIV testing. Women who identified as heavy drinkers and moderate drinkers were significantly less likely to report ever testing for HIV. Findings add to the limited literature on the association between alcohol use and HIV testing behaviors among women. Given the incidence of HIV among women, this study highlights the importance of HIV testing, especially for alcohol-using women.

The risk of viral rebound in the year after delivery in women remaining on antiretroviral therapy

The objective of this study is to assess the risk of viral rebound in postpartum women on suppressive combination antiretroviral therapy (cART).

How older black women perceive the effects of stigma and social support on engagement in HIV care

As black women over age 50 represent a growing share of women living with HIV, understanding what helps them persist and engage in ongoing HIV care will become increasingly important. Delineating the specific roles of social support and stigma on HIV care experiences among this population remains unclear. We qualitatively examined how experiences with stigma and social support either facilitated or inhibited engagement in HIV care, from the perspective of older black women. Semi-structured interviews were conducted with 20 older black women currently receiving HIV care at primary care clinics in the Metropolitan Boston area. Women expressed that experiences with stigma and seeking support played an important role in evaluating the risks and benefits of engaging in care. Social support facilitated their ability to engage in care, while stigma interfered with their ability to engage in care throughout the course of their illness. Providers in particular, can facilitate engagement by understanding the changes in these women's lives as they struggle with stigma and disclosure while engaging in HIV care. The patient's experiences with social support and stigma and their perceptions about engagement are important considerations for medical teams to tailor efforts to engage older black women in regular HIV care.

Barriers to health-care and psychological distress among mothers living with HIV in Quebec (Canada)

Health-care providers play a major role in providing good quality care and in preventing psychological distress among mothers living with HIV (MLHIV). The objectives of this study are to explore the impact of health-care services and satisfaction with care providers on psychological distress in MLHIV. One hundred MLHIV were recruited from community and clinical settings in the province of Quebec (Canada). Prevalence estimation of clinical psychological distress and univariate and multivariable logistic regression models were performed to predict clinical psychological distress. Forty-five percent of the participants reported clinical psychological distress. In the multivariable regression, the following variables were significantly associated with psychological distress while controlling for sociodemographic variables: resilience, quality of communication with the care providers, resources, and HIV disclosure concerns. The multivariate results support the key role of personal, structural, and medical resources in understanding psychological distress among MLHIV. Interventions that can support the psychological health of MLHIV are discussed.

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.

Measuring food and nutrition security: tools and considerations for use among people living with HIV

As an increasing number of countries implement integrated food and nutrition security (FNS) and HIV programs, global stakeholders need clarity on how to best measure FNS at the individual and household level. This paper reviews prominent FNS measurement tools, and describes considerations for interpretation in the context of HIV. There exist a range of FNS measurement tools and many have been adapted for use in HIV-endemic settings. Considerations in selecting appropriate tools include sub-types (food sufficiency, dietary diversity and food safety); scope/level of application; and available resources. Tools need to reflect both the needs of PLHIV and affected households and FNS program objectives. Generalized food sufficiency and dietary diversity tools may provide adequate measures of FNS in PLHIV for programmatic applications. Food consumption measurement tools provide further data for clinical or research applications. Measurement of food safety is an important, but underdeveloped aspect of assessment, especially for PLHIV.

Gender inequities in quality of care among HIV-positive individuals initiating antiretroviral treatment in British Columbia, Canada (2000-2010)

Objectives

We measured gender differences in “Quality of Care” (QOC) during the first year after initiation of antiretroviral therapy and investigated factors associated with poorer QOC among women.

Design

QOC was estimated using the Programmatic Compliance Score (PCS), a validated metric associated with all-cause mortality, among all patients (≥19 years) who initiated ART in British Columbia, Canada (2000–2010).

Methods

PCS includes six indicators of non-compliance with treatment initiation guidelines at baseline (not having drug resistance testing before treatment; starting on a non-recommended regimen; starting therapy at CD4<200 cells/mm³) and during first-year follow-up (receiving <3 CD4 tests; receiving <3 viral load tests; not achieving viral suppression within six months). Summary scores range from 0–6; higher scores indicate poorer QOC. Multivariable ordinal logistic regression was used to measure if female gender was an independent predictor of poorer QOC and factors associated with poorer QOC among women.

Results

QOC was determined for 3,642 patients (20% women). At baseline: 42% of women (34% men) did not have resistance testing before treatment; 17% of women (9% men) started on a non-recommended regimen (all p<0.001). At follow-up: 17% of women (11% men) received <3 CD4; 17% of women (11% men) received <3 VL; 50% of women (41% men) did not achieve viral suppression (all p<0.001). Overall, QOC was better among men (mean PSC = 1.54 (SD = 1.30)) compared with women (mean = 1.89 (SD = 1.37); p<0.001). In the multivariable model, female gender (AOR = 1.16 [95% CI: 0.99–1.35]; p = 0.062) remained associated with poorer QOC after covariate adjustment. Among women, those with injection drug use history, of Aboriginal ancestry, from Vancouver Island, and who initiated ART in earlier years were more likely to have poorer QOC.

Conclusions

Poorer QOC among women, especially from marginalized communities, demands that barriers undermining women's access to high-quality care be addressed to improve treatment and health for women with HIV.

A qualitative study of barriers to enrollment into free HIV care: perspectives of never-in-care HIV-positive patients and providers in Rakai, Uganda

Background. Early entry into HIV care is low in Sub-Saharan Africa. In Rakai, about a third (31.5%) of HIV-positive clients who knew their serostatus did not enroll into free care services. This qualitative study explored barriers to entry into care from HIV-positive clients who had never enrolled in care and HIV care providers. Methods. We conducted 48 in-depth interviews among HIV-infected individuals aged 15–49 years, who had not entered care within six months of result receipt and referral for free care. Key-informant interviews were conducted with 12 providers. Interviews were audio-recorded and transcripts subjected to thematic content analysis based on the health belief model. Results. Barriers to using HIV care included fear of stigma and HIV disclosure, women's lack of support from male partners, demanding work schedules, and high transport costs. Programmatic barriers included fear of antiretroviral drug side effects, long waiting and travel times, and inadequate staff respect for patients. Denial of HIV status, belief in spiritual healing, and absence of AIDS symptoms were also barriers. Conclusion. Targeted interventions to combat stigma, strengthen couple counseling and health education programs, address gender inequalities, and implement patient-friendly and flexible clinic service hours are needed to address barriers to HIV care.

Interventions to promote linkage to and utilization of HIV medical care among HIV-diagnosed persons: a qualitative systematic review, 1996-2011

This qualitative systematic review examined interventions that promote linkage to or utilization of HIV care among HIV-diagnosed persons in the United States. We conducted automated searches of electronic databases (i.e., MEDLINE, EMBASE, PsycINFO, CINAHL) and manual searches of journals, reference lists, and listservs. Fourteen studies from 19 published reports between 1996 and 2011 met our inclusion criteria. We developed a three-tier approach, based on strength of study design, to evaluate 6 findings on linkage to care and 18 findings on HIV care utilization. Our review identified similar strategies for the two outcomes, including active coordinator's role in helping with linking to or utilizing HIV care; offering information and education about HIV care; providing motivational or strengths-based counseling; accompanying clients to medical appointments and helping with appointment coordination. The interventions focused almost exclusively on individual-level factors. More research is recommended to examine interventions that address system and structural barriers.

Linking HIV-positive adolescents to care in 15 different clinics across the United States: creating solutions to address structural barriers for linkage to care

Linkage to care is a critical corollary to expanded HIV testing, but many adolescents are not successfully linked to care, in part due to fragmented care systems. Through a collaboration of the National Institutes of Health (NIH), Centers for Disease Control and Prevention (CDC) and the Adolescent Trials Network (ATN), a linkage to care outreach worker was provided to ATN clinics. Factors related to linkage were explored to better understand how to improve retention rates and health outcomes for HIV-positive adolescents. We conducted 124 interviews with staff at 15 Adolescent Trials Network clinics to better understand linkage to care processes, barriers, and facilitators. Content analysis was conducted focusing on structural barriers to care and potential solutions, specifically at the macro-, meso-, and micro-levels. Macro-level barriers included navigating health insurance policies, transportation to appointments, and ease of collecting and sharing client-level contact information between testing agencies, local health departments and clinics; meso-level barriers included lack of youth friendliness within clinic space and staff, and duplication of linkage services; micro-level barriers included adolescents' readiness for care and adolescent developmental capacity. Staff initiated solutions included providing transportation for appointments and funding clinic visits and tests with a range of grants and clinic funds while waiting for insurance approval. However, such solutions were often ad hoc and partial, using micro-level solutions to address macro-level barriers. Comprehensive initiatives to improve linkage to care are needed to address barriers to HIV-care for adolescents, whose unique developmental needs make accessing care particularly challenging. Matching the level of structural solution to the level of structural barriers (i.e., macro-level with macro-level), such as creating policy to address needed youth healthcare entitlements versus covering uninsured patients with clinic funds is imperative to achieving the goal of increasing linkage to care rates for newly diagnosed adolescents.

Missed connections: HIV-infected people never in care

OBJECTIVE

Clinical interventions that lengthen life after HIV infection and significantly reduce transmission could have greater impact if more HIV-diagnosed people received HIV care. We tested a surveillance-based approach to investigating reasons for delayed entry to care.

METHODS

Health department staff in three states and two cities contacted eligible adults diagnosed with HIV four to 24 months previously who had no reported CD4+ lymphocyte (CD4) or viral load (VL) tests. The staff conducted interviews, performed CD4 and VL testing, and provided referrals to HIV medical care. Reported CD4 and VL tests were prospectively monitored to determine if respondents had entered care after the interview.

RESULTS

Surveillance-based follow-up uncovered problems with reporting CD4 and VL tests, resulting in surveillance improvements. However, reporting problems led to misspent effort locating people who were already in care. Follow-up proved difficult because contact information in surveillance case records was often outdated or incorrect. Of those reached, 37% were in care and 29% refused participation. Information from 132 people interviewed generated ideas for service improvements, such as emphasizing the benefits of early initiation of HIV care, providing coverage eligibility information soon after diagnosis, and leveraging other medical appointments to provide assistance with linkage to HIV care.

CONCLUSIONS

Surveillance-based follow-up of HIV-diagnosed individuals not linked to care provided information to improve both surveillance and linkage services, but was inefficient because of difficulties identifying, locating, and recruiting eligible people. Inefficiencies attributable to missing, incomplete, or inaccurate surveillance records are likely to diminish as data quality is improved through ongoing use.

Women-specific HIV/AIDS services: identifying and defining the components of holistic service delivery for women living with HIV/AIDS

Introduction

The increasing proportion of women living with HIV has evoked calls for tailored services that respond to women's specific needs. The objective of this investigation was to explore the concept of women-specific HIV/AIDS services to identify and define what key elements underlie this approach to care.

Methods

A comprehensive review was conducted using online databases (CSA Social Service Abstracts, OvidSP, Proquest, Psycinfo, PubMed, CINAHL), augmented with a search for grey literature. In total, 84 articles were retrieved and 30 were included for a full review. Of these 30, 15 were specific to HIV/AIDS, 11 for mental health and addictions and four stemmed from other disciplines.

Results and discussion

The review demonstrated the absence of a consensual definition of women-specific HIV/AIDS services in the literature. We distilled this concept into its defining features and 12 additional dimensions (1) creating an atmosphere of safety, respect and acceptance; (2) facilitating communication and interaction among peers; (3) involving women in the planning, delivery and evaluation of services; (4) providing self-determination opportunities; (5) providing tailored programming for women; (6) facilitating meaningful access to care through the provision of social and supportive services; (7) facilitating access to women-specific and culturally sensitive information; (8) considering family as the unit of intervention; (9) providing multidisciplinary integration and coordination of a comprehensive array of services; (10) meeting women “where they are”; (11) providing gender-, culture- and HIV-sensitive training to health and social care providers; and (12) conducting gendered HIV/AIDS research.

Conclusions

This review highlights that the concept of women-specific HIV/AIDS services is a complex and multidimensional one that has been shaped by diverse theoretical perspectives. Further research is needed to better understand this emerging concept and ultimately assess the effectiveness of women-specific services on HIV-positive women's health outcomes.

Interventions to improve retention in HIV primary care: a systematic review of U.S. studies

Retaining HIV-diagnosed persons in care is a national priority, but little is known on what intervention strategies are most effective for promoting retention in care. We conducted a systematic search and qualitatively reviewed 13 published studies and three recent conference presentations to identify evidence-informed retention strategies. We extracted information on study design, methods, and intervention characteristics. Strengths-based case management that encourages clients to recognize and use their own internal abilities to access resources and solve problems offered strong evidence for retention in care. Other evidence-informed strategies included peer navigation, reducing structural- and system-level barriers, including peers as part of a health care team, displaying posters and brochures in waiting rooms, having medical providers present brief messages to patients, and having clinics stay in closer contact with patients across time. Opportunities for additional intervention strategies include using community-based organizations as a setting for engaging HIV-infected persons about the importance of regular care and involving patients' significant others in retention in care interventions.

Socio-economic- and sex-related disparities in rates of hospital admission among patients with HIV infection in Ontario: a population-based study

BACKGROUND

Among people living with HIV infection in the era of combination antiretroviral therapy (cART), admission to hospital may indicate inadequate community-based care. As such, population-based assessments of the utilization of inpatient services represent a necessary component of evaluating the quality of HIV-related care.

METHODS

We used a validated algorithm to search Ontario's administrative health care databases for all persons living with HIV infection aged 18 years or older between 1992/93 and 2008/09. We then conducted a population-based study using time-series and longitudinal analyses to first quantify the immediate effect of cART on hospital admission rates and then analyze recent trends (for 2002/03 to 2008/09) in rates of total and HIV-related admissions.

RESULTS

The introduction of cART in 1996/97 was associated with more pronounced reductions in the rate of hospital admissions among men than among women (for total admissions, -89.9 v. -60.5 per 1000 persons living with HIV infection, p = 0.003; for HIV-related admissions, -56.9 v. -36.3 per 1000 persons living with HIV infection, p < 0.001). Between 2002/03 and 2008/09, higher rates of total hospital admissions were associated with female sex (adjusted relative rate [RR] 1.15, 95% confidence interval [CI] 1.05-1.27) and low socio-economic status (adjusted RR 1.21, 95% CI 1.14-1.29). Higher rates of HIV-related hospital admission were associated with low socio-economic status (adjusted RR 1.30, 95% CI 1.17-1.45). Recent immigrants had lower rates of both total admissions (adjusted RR 0.70, 95% CI 0.61-0.80) and HIV-related admissions (adjusted RR 0.77, 95% CI 0.61-0.96).

INTERPRETATION

We observed important socio-economic- and sex-related disparities in rates of hospital admission among people with HIV living in Ontario, Canada.

Using the HIV surveillance system to monitor the National HIV/AIDS Strategy

OBJECTIVES

To report on indicators of the National HIV/AIDS Strategy, we analyzed data collected through the national HIV surveillance system.

METHODS

We analyzed data from adults and adolescents aged 13 years or older diagnosed with HIV in 13 US jurisdictions that have laboratory reporting of CD4+ T-lymphocyte (CD4) and viral load (VL) test results and enter CD4 and VL test results into the national surveillance system.

RESULTS

Of 4899 people diagnosed in 2009, 81.7% had at least 1 CD4 or VL test performed within 3 months of diagnosis. A higher proportion of Whites (86.2%) than Blacks (78.4%) and Hispanics (82.6%) had a CD4 or VL test. Of 53,642 people diagnosed through 2008 and living with HIV at the end of 2009 who had a VL test, 69.4% had a most recent VL of 200 copies per milliliter or less. The proportion of people with suppressed VLs differed among Blacks (60.2%), Hispanics (70.3%), and Whites (77.4%) and among people aged 13 to 24 years (44.3%) compared with people aged 65 years or older (84.2%). Of men who have sex with men, 74.2% had a suppressed VL.

CONCLUSIONS

The findings highlight disparities in access to and success of care.

Enhanced Collection of Laboratory Data in HIV Surveillance Among 5 States with Confidential Name-based HIV Infection Reporting, 2005-2006

Laboratory data reported through HIV surveillance can provide information about disease severity and linkage to care; however these measures are only as accurate as the quality and completeness of data reported. Using data from five states that implemented enhanced collection of laboratory data in HIV surveillance from 2005-2006, we determined completeness of reporting, stage of disease at diagnosis, the most common opportunistic illnesses (OI) at diagnosis, and linkage to medical care. Methods to enhance laboratory reporting included increasing active surveillance efforts, identifying laboratories not reporting to HIV surveillance, increasing electronic reporting, and using laboratory results from auxiliary databases. Of 3,065 persons ≥13 years of age diagnosed with HIV, 35.5% were diagnosed with stage 3 (AIDS) and 37.7% progressed to stage 3 within 12-months after diagnosis. Overall, 78.5% were linked to care within 3 months; however, a higher proportion of persons with ≥1 CD4 or viral load test was found among whites compared with blacks/African Americans (82.1% vs 73.6%, p<0.001). Few (12.3%) had an OI within 3 months of diagnosis. The completeness of laboratory data collected through surveillance was improved with enhanced reporting and provided a more accurate picture of stage of disease and gaps in linkage to care. Additional interventions are needed to meet the goals of the National HIV/AIDS Strategy on linkage to care and the reduction of HIV-related disparities.

'Dying from' to 'living with': framing institutions and the coping processes of African American women living with HIV/AIDS

How do HIV-positive individuals transition from believing and behaving as though they have a 'death sentence' to interpreting and coping with HIV as a chronic but manageable illness? Using interview data collected from 30 HIV-positive African American women beginning in 2005, we reveal how and why interactions with non-profit and government institutions help to explain variation between those who thrive and those who do not following an HIV diagnosis. We argue that 'framing institutions' shape the form and tenor of coping trajectories by offering initial information about one's HIV status, a conceptual framework for understanding what it means to have HIV, language to talk about one's condition, and resources to begin restructuring one's life in the wake of a diagnosis. Ultimately, we highlight how a diverse array of non-profit and government institutions not only play a critical part in helping women cope with HIV but also renegotiate their self-conceptions as black women in the wake of receiving another stigmatizing social marker. In short, organizational ties shape women's movement from beliefs and behaviors that suggest that they are 'dying from' this disease to attitudes and actions consistent with the notion that they can 'live with' HIV.

A community-based study of barriers to HIV care initiation

Timely treatment of HIV infection is a public health priority, yet many HIV-positive persons delay treatment initiation. We conducted a community-based study comparing HIV-positive persons who received an HIV diagnosis at least 3 months ago but had not initiated care (n=100) with a reference population of HIV-positive persons currently in care (n=115) to identify potential barriers to treatment initiation. Study participants were mostly male (78.0%), and persons of color (54.9% Latino, 26.3% black), with median age 37.8 years. Median time since HIV diagnosis was 3.7 years. Univariate analysis revealed that those never in care differed substantially from those currently in care with regard to sociodemographics; HIV testing and counseling experiences; perceived barriers to care; and knowledge, attitudes, and beliefs regarding HIV. Factors independently associated with never initiating HIV care were younger age (adjusted odds ratio [AOR]=0.93; 95% confidence interval [CI]: 0.88, 0.99), shorter time since diagnosis (AOR=0.87; 95% CI: 0.77, 0.98), lacking insurance (AOR=0.11; 95% CI: 0.03, 0.35), not knowing someone with HIV/AIDS (AOR=0.09; 95% CI: 0.03, 0.30) not disclosing HIV status (AOR=0.13; 95% CI: 0.02, 0.70), not receiving help making an HIV care appointment after diagnosis (AOR=0.04; 95% CI: 0.01, 0.14), and not wanting to think about being HIV positive (AOR=3.57; 95% CI: 1.22, 10.46). Our findings suggest that isolation and stigma remain significant barriers to initiating HIV care in populations consisting primarily of persons of color, and that direct linkages to HIV care at the time of diagnosis are critical to promoting timely care initiation in these populations.

Risk factors for delayed access to specialized care in French Guiana

The variables influencing the interval between diagnosis and effective access to specialized care were studied in a cohort of 2,661 human immunodeficiency virus (HIV)-positive patients in French Guiana between 1992 and 2008. Patients with a subsequent follow-up interruption were significantly more likely to have a delayed first consultation after the HIV diagnosis. Ordinal logistic regression showed that younger persons, women, and French citizens were independently associated with greater delays between the HIV diagnosis and the first specialized consultation. However, persons with acquired immunodeficiency syndrome (AIDS) were less likely to have a delay between the HIV diagnosis and the first specialized consultation. Focusing on the link between the private sector and specialized health care may shorten delays and improve care and follow-up.

Main partner factors associated with worse adherence to HAART among women in Baltimore, Maryland: a preliminary study

Compared to US men, US women have worse HAART and HIV health outcomes. The study examined main partner factors associated with women's HAART adherence. The community sample comprised 85% African-Americans; 63% had a main partner and 32% relied on their partner for emotional support. Adherence was highest (92%) among those without a main partner and lowest (57%) among those with an HIV seropositive main partner. In adjusted analysis, adherence was 75% less likely among women with an HIV seropositive main partner and 78% less likely among those relying on their partner for emotional support. Furthermore, HIV seropositive versus other serostatus main partners were most likely to provide medication taking assistance and to be preferred in helping participants deal with HIV, yet were no more likely to be nominated as the most helpful to them. Findings reveal women's perceived unmet support needs from HIV seropositive main partners in this population and the need for interventions to promote their HAART adherence. Seroconcordant couples-focused intervention that enhances mutual support of HAART adherence may be an effective approach to improving women's HAART adherence and reducing US gender disparities in HIV health outcomes.

Challenges and successes in linking HIV-infected women to care in the United States

Women currently account for 27% of new human immunodeficiency virus (HIV) infections in the United States, the majority of which are acquired through heterosexual transmission. In the United States, black and Latino persons are disproportionately affected by the HIV epidemic, a disparity that is most dramatically present among HIV-infected women. Many of these women face significant discrimination as a result of race or ethnicity and sex, and they suffer disproportionately from poverty, low health literacy, and lack of access to high-quality HIV care. As a consequence, despite the availability of highly active antiretroviral therapy (HAART), women with HIV often have delayed entry into care and experience poor outcomes. This article reviews risk factors for HIV infection in women, barriers to engagement in care, and strategies to improve linkage to HIV-related medical and social care.

An evidence-based group coping intervention for women living with HIV and history of childhood sexual abuse

Women living with HIV/AIDS and a history of childhood sexual abuse often exhibit sexual trauma symptoms and elevated rates of HIV-risk behaviors. In this paper, we describe a coping skills group intervention that reduced traumatic stress and sexual-risk behavior in a recent randomized clinical trial. We focused on clinical issues that emerged among female participants receiving the intervention. Clinical observations showed that recognizing connections between trauma, psychological distress, and high risk behaviors was a new and powerful experience for many participants. Participants successfully applied psychoeducational material, expressing an increased sense of power and control over their relationships and behaviors as they developed more adaptive cognitive and behavioral skills. Women expressed high levels of satisfaction with the intervention. Recommendations for clinical practice are provided.

Costs of care for people living with combined HIV/AIDS, chronic mental illness, and substance abuse disorders

To determine healthcare access and costs for triply diagnosed adults, we examined baseline data from the HIV/AIDS Treatment Adherence, Health Outcomes and Cost Study, a multi-site cohort study of HIV+ adults with co-occurring mental and substance abuse disorders conducted between 2000 and 2004. Baseline interviews were conducted with 1138 triply diagnosed adults in eight predominantly urban sites nationwide. A modified version of Structured Interview for DSM-IV Axis I Disorders (SCID) was used to assign Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) diagnoses for the preceding year. Utilization of a broad range of inpatient and outpatient services and medications over the preceding three months was patient-reported in face-to-face interviews. We then applied nationally representative unit costs to impute average monthly expenditures. We measured (poor) access to care during the three-month period by whether the patient had: (a) no outpatient medical visits; (b) at least one emergency room visit without an associated hospitalization; and (c) at least one hospitalization. At baseline, mean expenditures were $3880 per patient per month. This is nearly twice as high as expenditures for HIV/AIDS patients in general. Inpatient care (36%), medications (33%), and outpatient services (31%) each accounted for roughly one-third of expenditures. Expenditures varied by a factor of 2:1 among subgroups of patients, with those on Medicare or Medicaid, not in stable residences, or with poor physical health or high viral loads exhibiting the highest costs. Access to care was worse for women and those with low incomes, unstable residences, same-sex exposure, poor physical or mental health, and high viral loads. We conclude that HIV triply diagnosed adults account for roughly one-fifth of medical spending on HIV patients and that there are large variations in utilization/costs across patient subgroups. Realized access is good for many triply diagnosed patients, but remains suboptimal overall. Deficiencies in HIV care are unevenly distributed, tending to concentrate on already disadvantaged populations.

Factors associated with the failure to seek HIV care and treatment among HIV-positive women in a northern province of Vietnam

This cross-sectional survey examines the utilization of HIV care and treatment services after HIV diagnosis among women in Vietnam and describes factors that may be associated with failure in seeking services. From May 2007 to November 2007, we conducted structured interviews with 353 HIV-positive women living a Haiphong, a northern province of Vietnam. The women were recruited through a network of people living with HIV/AIDS (HPN+) by means of snowball sampling and through the local, governmental HIV registration system (Provincial AIDS Centre [PAC]). Approximately 26.3% of the study participants had never attended HIV care and treatment services. Failure in seeking the services was associated with not being registered in the PAC (odds ratio [OR]: 3.0; 95% confidence interval [CI]: 1.4-6.4), not having a known HIV-positive family member (OR: 3.2; 95% CI: 1.2-8.3), not having disclosed HIV status (OR: 4.0; 95% CI: 2.0-8.1), and factors associated with the testing situation, whereby women who were tested by chance had a 4.0 times increased OR (95% CI: 1.4-11.7) and women who were tested in relation to antenatal care or delivery had 3.0 times increased OR (95% CI: 1.1-8.5) for failure to seek HIV care compared to women who had been tested because their husbands/partners were sick or had died. We suggest that the posttest counseling and referral system for HIV care and treatment need to be improved. An alternative system for picking up those not wishing to attend the official system might help to approach these needy women.

HIV/AIDS disparities: the mounting epidemic plaguing US blacks

The human immunodeficiency virus (HIV)/AIDS epidemic presents a formidable challenge for the black community. Blacks, although a small proportion of the US population, are overrepresented, not only in the number of people living with HIV, but also in the categories of new diagnoses and AIDS-related deaths. Fortunately, national initiatives are in place to slow and ultimately reverse these racial inequities. While these disparities may be widely recognized, their causes are not clearly understood. A variety of underlying issues exist for blacks in the United States that may also contribute to these growing disparities. These include transmission risk factors, socioeconomic factors, underrecognition, delayed presentation, and other comorbid conditions. We present a review of the literature regarding the potential causes of racial disparities and how they may contribute to health outcomes for blacks with HIV/AIDS in the United States. We also identify possible gaps in knowledge and offer future directions for research of HIV/AIDS racial disparities.

Assessing the role of individual and neighbourhood characteristics in HIV testing: evidence from a population based survey

OBJECTIVES

Individuals living in deprived neighbourhoods have poor health outcomes, including human immunodeficiency virus (HIV) infection mortality. We assessed the association between individual and neighbourhood characteristics, and HIV testing across Canada.

METHODS

We used logistic regression modelling to evaluate this association in 2219 men and 2815 women, aged 18-54 years, in Canada, using data from the National Population Health Survey (1996/7),. Socio-economic characteristics and presence of a sexually transmitted infection (STI) were the individual level characteristics. Small area of residence was classified according to categories of material and social deprivation; these were the 'neighbourhood' variables in the model.

RESULTS

Ethnic minority women were less likely to report an HIV test than white women (OR 0.44, 95% CI: 0.23 to 0.86). Women without a regular doctor were significantly less likely to report ever having had an HIV test (OR 0.57, 95% CI: 0.35 to 0.93). Adjusting for individual level characteristics, we found that men and women living in the most materially deprived neighbourhoods were slightly less likely to report HIV testing than those living in the least deprived neighbourhoods (Men - OR 0.61, 95% CI: 0.34 to 1.08; Women - OR 0.62, 95% CI: 0.38 to 1.00).

DISCUSSION

Thus, living in poor neighbourhoods was associated with poor uptake of an HIV test. These economic disparities should be taken in account while designing future prevention strategies. Ethnic minority women were less likely to go for HIV testing and culturally appropriate messages may be required for prevention in ethnic minorities.

Health-related beliefs and decisions about accessing HIV medical care among HIV-infected persons who are not receiving care

In the United States, the publically supported national HIV medical care system is designed to provide HIV medical care to those who would otherwise not receive such care. Nevertheless, many HIV-infected persons are not receiving medical care. Limited information is available from HIV-infected persons not currently in care about the reasons they are not receiving care. From November 2006 to February 2007, we conducted five focus groups at community-based organizations and health departments in five U.S. cities to elicit qualitative information about barriers to entering HIV care. The 37 participants were mostly male (n = 29), over the age of 30 (n = 34), and all but one had not received HIV medical care in the previous 6 months. The focus group discussions revealed health belief-related barriers that have often been overlooked by studies of access to care. Three key themes emerged: avoidance and disbelief of HIV serostatus, conceptions of illness and appropriate health care, and negative experiences with, and distrust of, health care. Our findings point to the potentially important influence of these health-related beliefs on individual decisions about whether to access HIV medical care. We also discuss the implications of these beliefs for provider-patient communication, and suggest that providers frame their communications with patients such that they are attentive to the issues identified by our respondents, to better engage patients as partners in the treatment process.