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One size does not fit all: preferences for HIV care delivery among out-of-care people living with HIV in the United States

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BACKGROUND: Only half of the people living with HIV (PLWH) in the United States are retained in HIV care and 56% have achieved viral suppression, due in part to transportation barriers, stigma, mental health, substance use, and medical mistrust. Alternative community-based HIV care models have potential to address the diverse needs of patients and improve retention in care in the United States, but the success of these models is contingent on acceptance by patients and key community stakeholders.
METHODS: Recognizing that the preferences of PLWH who are out-of-care (PLWH-OOC) likely differ from those retained in care, from June 2019 to May 2021, we conducted a mixed-methods study composed of surveys (n=50) with PLWH-OOC and in-depth interviews (n=41) with key clinic and community stakeholders to examine the relative preference and perceived advantages and disadvantages for 7 different community-based HIV care models. Survey data was analyzed to assess average rank preference for each care model and interview transcripts were thematically coded to examine individual and systems-level factors influencing model acceptance.
RESULTS: Of the 50 participants surveyed, 86% were Black, 52% were sexual minorities, and 64% had annual income<$10,000. Highest preference for care delivery was via a mobile clinic ("µ=2.36), followed by community-based peer navigation ("µ=3.54), primary care clinics ("µ=4.1), telemedicine ("µ=4.46), traditional HIV subspeciality clinic ("µ=4.48), homeless shelters ("µ=4.9), and drug treatment centers ("µ=5.44). Common factors influencing preference included convenience, accessibility, potential to preserve confidentiality, ensure quality of care, and foster rapport with their HIV care provider, access to a smart device, and stigma associated with accessing shelters and drug treatment facilities. Participants discussed the need for integration of care models and for individuals to choose different care models at different times. Providers and patients differed in preference for care model and weighting of relative advantages and disadvantages of each.
CONCLUSIONS: Findings highlight the need to integrate alternative, community-based care models into the national plan to end the HIV epidemic and allow for PLWH-OOC to choose the model most fitting for individual circumstance. Future implementation research should evaluate the relative effectiveness of the models and whether findings apply to other communities globally.