CE / CME
Nurses: 1.00 Nursing contact hour
Pharmacists: 1.00 contact hour (0.1 CEUs)
Physicians: maximum of 1.00 AMA PRA Category 1 Credit™
Released: September 12, 2024
Expiration: September 11, 2025
Transportation and Physical Barriers to Care
Transportation is a major socioeconomic barrier to care for many people.4-6 In particular, I am in a region of the country where we have a lot of transportation challenges. Many people living with HIV do not have access to local clinics. Many have to drive an hour or longer to get to appointments 2 or 4 times per year.
The stigma of HIV can also affect transportation. For example, even if you may have a fabulous building with great services, if it is known by the community as the HIV clinic, some patients may choose to drive an hour, “just so I’m in a city where people don’t know me.”
To hear another example of how transportation challenges can lead to other barriers, listen to Vincent Crisostomo, Director of Aging Services at the San Francisco AIDS Foundation.
Strategies to Minimize Physical Barriers to Care
Any way that we can work with federal agencies, grant agencies, community agencies, or businesses to partner with for gas cards, food cards, rideshare money, or private transportation is going to be key. If people can come to clinic for their appointment, but also get a gas or rideshare card and a food card, and then go get their food on the way home, that tackles transportation and the need to make sure that they are well fed.4-6
Peer navigators can also do amazing things to overcome transportation barriers. I used to work with a peer navigator who would pick up people for their visits, bring them to clinic, accompany them in the waiting room and the exam room if they wished, and then drive them back home. This one navigator was overcoming a lot of barriers, including transportation.4-6
One of my favorite ways to address transportation challenges is to think about colocated care. For me, as someone who has been trained in pediatrics, adolescent medicine, and HIV, I love that I can offer almost everything for my patients. I can do their Pap smear if they need it. I can do their primary care if they need it. Even if mental health therapy is not part of my skill set, I can refill their mental health medications.4-6
Colocation of services can be particularly important for the aging or geriatric population. It helps if this population can get all of their different services in one particular space, including having a pharmacist available to check for drugs interactions.4-6
Telehealth is another way to reduce barriers, particularly for individuals who have undetectable viral loads. Do people who are undetectable need to physically come into clinic every 3 or 6 months, or can they alternate between in-person and telehealth visits, or can they come in once per year and have all their other visits as telehealth visits?4-6
Poor Retention in HIV Care Postpartum
I want to turn our attention to a population that often does not receive enough attention, which is people of reproductive potential, particularly those who are postpartum with HIV.
For people living with HIV, the postpartum period can be particularly challenging, because they may have given birth to a baby who has either been exposed to or already has a diagnosis of HIV. With limited time and resources, the question becomes whether they can go to both their own appointments and to their baby’s appointments. If there is not a combined mother–baby clinic, how will that affect their access to care?7[
Personally, I make sure that mothers and their babies can schedule appointments in tandem. Even if there are no appointments available on the schedule, I make time. I have the luxury of being able to do that because of my training and my background. For those who do not have the required experience in pediatrics to provide care for both the mother and infant, I recommend seeing whether there are other HCPs in the clinic who can.
Failing to retain people living with HIV in care during the postpartum period can have serious repercussions. Up to two-thirds of women are unable to achieve or maintain viral suppression postpartum or are lost to follow-up after delivery.7
The strongest predictor of long-term retention in care for individuals who are postpartum is early engagement within 90 days of being postpartum. Therefore, it is critical to work with social workers or case managers to make sure that we follow up during that initial 3-month period. If patients are not responding, we must try to figure out what the barriers to care are for this family. Is it postpartum depression? Are they sick? Did they or the baby have to be hospitalized? Or are they disillusioned, or worried about exposing the baby to HIV? Once we have identified and addressed those barriers, we can work on reengaging these people in care.7
For people with multiple children, finding childcare can also be a barrier to HIV care and postpartum care. In addition to their regular appointments, they have to attend multiple newborn appointments and either find childcare or figure out a way to bring these children along.
A specific example is a patient of mine who was very sick, with a very low CD4+ cell count. They understood the importance of making their appointments, but they could not find childcare. So, it was up to us to decide: Do we figure out how to accommodate this person, or do we send them home? HCPs are not supposed to be childcare workers, but we need to be compassionate and understand that we work with people who have other responsibilities and concerns beyond their HIV. I believe the clinic must find a way to accommodate this parent who has shown up with their other children—that is how we can retain the parent in care.
Strategies to Improve Retention in HIV Care Postpartum
What we can do to improve retention and persistence in care for people who are postpartum? First, we need to be supportive and nonjudgmental, especially regarding rescheduling and tardiness. The postpartum period can be overwhelming, so HCPs should try to accommodate patients’ schedules whenever we can.7,8
It is also important to practice trauma-informed care. Rather than focusing on everything that a patient is not doing, we should determine the reasons. Other components of trauma-informed care include creating safe spaces, practicing shared decision-making and collaborative communication with your patient, and building trust and rapport.7,8
HCPs should also anticipate and reduce the barriers to care during pregnancy. For a patient with a challenging pregnancy, you can coordinate with their pregnancy care provider to create a plan that involves you, the patient, and their obstetrician. This plan should ensure a supportive and effective transition from pregnancy to being postpartum, and may also involve community-based organizations or someone on their medical team who is easily accessible to assist with identifying resources for support.7,8
Improvements to care coordination are also key to helping improve persistence for postpartum individuals in HIV care. Rather than reinvent the wheel, I think we need to refine our existing resources. For example, in addition to handing out a sheet of mental health resources, we should include handouts with postpartum and pregnancy resources as well. Colocation of obstetrician, HIV, and pediatric care is also ideal whenever possible. Patients may still lose a day of work to attend multiple appointments, but most people would rather lose 1 day of work instead of 3 days. Colocation also addresses transportation barriers.7,8
Improving and optimizing how our electronic medical record systems talk to each other across settings would also address an administrative barrier to care.7,8
Case management can also be a great help to understand and address the specific needs of each individual. Case management can take on a more active role in assisting with housing, transportation, food, and mental health resources, in addition to scheduling appointments.7,8
Similarly, having peer support systems of any type is very helpful for postpartum people. Peer navigators are able to perceive and understand nuanced barriers for this population that we may not be aware of.7,8
Finally, leveraging advances in technology can also circumvent barriers to care. For example, if a patient needs help with chest feeding, consider a telehealth consultation. Clinical quick links between your electronic medical record system and a community-based organization can even help people get into housing intake same day.7,8
Financial Pressures
Finances are another key barrier. I think of it in terms of Maslow’s hierarchy of needs. If an individual’s focus is on their more basic needs, such as feeding themselves, having safe housing, taking care of their family, or keeping their job, they will not be able to focus on their HIV care. If their HIV care makes it more challenging to obtain those basic needs, patients will forego that care. Similar to the solutions we discussed for retaining postpartum people in care, we should provide resources to address these financial pressures.9
Brothers Building Brothers by Breaking Barriers
Building up social capital is key to overcoming financial barriers to care. There are some very simple, practical solutions that focus on helping people living with HIV build social capital, such as linking people to job fairs or food assistance programs, and providing clothing and transportation. A paid community or youth advisory board can also be an effective way to increase social capital.9
On a larger scale, Brothers Building Brothers by Breaking Barriers is an example of a group-level intervention to augment social capital and improve engagement in HIV care. This intervention is focused on building social capital and helping individuals develop resilience from a social-ecological framework, at their own individual level, within their communities.9
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