HealthAugust 18, 2021

For adults with HIV, lack of viral suppression linked to lower care engagement and increased barriers to care

More than one-third of U.S. adults with HIV are not virally suppressed. People who are not virally suppressed have lower engagement with HIV care and report more barriers to care, reports a study in the September/October issue of The Journal of the Association of Nurses in AIDS Care (JANAC). The official journal of the Association of Nurses in AIDS Care, JANAC is published in the Lippincott portfolio by Wolters Kluwer.

The study highlights the multifaceted barriers to care facing people with HIV – which may contribute to difficulty in keeping their viral load under control, according to the new research by Sharoda Dasgupta, PhD, MPH, and colleagues of the Centers for Disease Control and Prevention (CDC). They write, "These findings underscore the importance of addressing barriers to care, particularly among people who are not virally suppressed."

New findings on barriers to effective care to control HIV viral load

The researchers analyzed measures on engagement with health care in nearly 12,000 U.S. adults with diagnosed HIV from 2015 to 2018, drawn from the CDC's ongoing Medical Monitoring Project. Care engagement was compared for people with and without sustained viral suppression – defined as having all viral load tests being "undetectable" or less than 200 copies per milliliter over the past year. Ensuring people with HIV reach and sustain viral suppression helps people with HIV stay healthy and prevent transmission of HIV, and is a key goal of the national strategy.

Care retention and viral suppression

Overall, nearly 80 percent of adults with diagnosed HIV were retained in HIV care during the study period. People without viral suppression were less likely to be retained in care: about 57 percent, compared with over 90 percent of those with sustained viral suppression. They were more likely to miss healthcare visits, and get professional help to receive more care. Those without sustained viral suppression were also more likely to feel they did not receive enough HIV care: 18 percent, compared to 6 percent of those with recommended viral suppression.

Life circumstances as barriers to care

Nearly all people with HIV reported at least one barrier to receiving HIV care, while most reported multiple barriers. Life circumstances that impeded receipt of care were reported by one-half of people with HIV. About one-third cited problems with money or insurance, not feeling sick enough to take medicine, and health care providers not requesting more appointments. Over one-fourth cited trouble finding transportation as a barrier to receiving care.

People who were not virally suppressed were more likely to report more than one barrier. They were more likely to report life circumstances that impeded receipt of care, problems with money or health insurance, having fear or denial about living with HIV, and not believing antiretroviral therapy as HIV treatment would improve their health as barriers to receiving HIV care. 

"HIV care engagement is an important predictor of viral suppression – a key outcome for ending the US HIV epidemic," Dr. Dasgupta and coauthors write. Their study is the first to provide detailed, nationally representative estimates on barriers to HIV care by viral suppression status among U.S. adults with HIV.

The results suggest that many U.S. adults living with HIV do not have sustained viral suppression, placing them at risk of HIV-related complications and viral transmission. Those who are not virally suppressed are less likely to be engaged in care, more likely to miss visits, and more likely to feel they do not receive enough HIV care.

Addressing barriers to care engagement

The study also provides insights into the complex barriers to HIV care, particularly among people who do not have sustained viral suppression. People who are not virally suppressed may have unique challenges that prevent them from engaging in HIV care, demonstrating the need for approaches to address barriers to care engagement. Wraparound services — which often provide HIV ancillary care services that support retention in care and viral suppression — are essential for people with HIV who may be experiencing life circumstances that impede HIV care engagement, including substance use, mental health issues, poverty, or homelessness. 

Ancillary care services — such as transportation assistance, meal or food services, and shelter or housing assistance — may help address financial barriers to care engagement, which were especially prominent among those who were not virally suppressed. In addition, the CDC's "Stay Connected" care retention program is an intervention that focuses on building relationships between people with HIV and providers — including patient navigators — to address challenges to engaging in care. Building these relationships may be helpful for providing referrals for key support services based on individual patient needs.

Dr. Dasgupta and colleagues conclude that continued efforts to address barriers to care through high-impact programs and leveraging a comprehensive care model in HIV care settings may improve HIV clinical outcomes, particularly among people experiencing multiple barriers to care.  

Read: “Barriers to HIV Care by Viral Suppression Status Among US Adults With HIV: Findings From the Centers for Disease Control and Prevention Medical Monitoring Project”

DOI: 10.1097/JNC.0000000000000249

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