Healthcare Provider Strategies and Approaches to Supporting People Living With HIV Who Are Experiencing HIV Treatment Disengagement in British Columbia,Canada

Abstract

We conducted a strengths-based, qualitative study to elucidate the approaches and strategies utilized by healthcare providers (HCPs) to support HIV treatment engagement in British Columbia (BC), Canada. Healthcare providers (e.g., nurses, peer navigators, and pharmacists) across the province of BC were recruited through regional HIV programs and by word of mouth through purposive sampling strategies. An academic and community researcher co-conducted semi-structured phone interviews with HCPs providing HIV-specific healthcare. Emergent coding and participatory analysis, guided by interpretive description and the socio-ecological model, were used to uncover themes. Across all provincial health regions, 19 HCPs were interviewed between November 2020 and May 2021. Narratives centered around HIV care as a relational practice and the importance of person-centered care approaches. HCPs underscored the need to foster long-term, trusting relationships with clients, founded on respect, compassion, and non-judgmental approaches, which acknowledged the unique care engagement needs and experiences of people living with HIV (PLWH) experiencing treatment breaks. Successful engagement approaches supported clients’ overall stability, which directly support treatment adherence. This includes strategies tailored to address unique client contexts and priorities related to psychosocial and other intersecting health needs. Collaborative relationships with other providers, both formal multidisciplinary team-based care and partnerships with ancillary service staff, were found to improve care continuity. Our study highlights the importance of relationship-building, person-centered care, and collaborative care to support PLWH experiencing breaks in treatment. HIV HCPs emphasized holistic, community-centered approaches as crucial to successful and long-term engagement of PLWH in care.

Keywords

HIV care engagement treatment interruptions healthcare providers

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References

Amibor

Ogunrotifa

A. B.

(2012). Unravelling barriers to accessing HIV prevention services experienced by African and Caribbean communities in Canada: Lessons from Toronto. Global Journal of Health Science, 4(3), 1–12. https://doi.org/10.5539/gjhs.v4n3p1

BC Centre for Excellence in HIV/AIDS . (2021). Provincial best practice in HIV case management. https://bccfe.ca/wp-content/uploads/2024/04/provincial_best_practices_in_hiv_case_management.pdf

Blashill

A. J.

Bedoya

C. A.

Mayer

K. H.

O’Cleirigh

Pinkston

M. M.

Remmert

J. E.

Mimiaga

M. J.

Safren

S. A.

(2015). Psychosocial syndemics are additively associated with worse ART adherence in HIV-infected individuals. AIDS and Behavior, 19(6), 981–986. https://doi.org/10.1007/s10461-014-0925-6

Bronfenbrenner

(1989). Ecological system theories. In Vasta

(Ed.) Six theories of child development: Revised formulations and current issues. 6, 187–249. JAI Press.

Brown

Perkins

Acuña

Thacker

Bolds

Hawkins

Stewart

Barroso

Sommer

Van der Eerden

Heckman

Osman

Smith

Alexander

Harvick

Link

Crawley

Nabaweesi

Aboubaker

Pettit

(2023). Community-based participatory research to guide adoption of culturally responsive trauma-informed HIV care throughout Nashville, Tennessee. Research Square. https://doi.org/10.21203/rs.3.rs-3739954/v1

Browne

A. J.

Varcoe

Ford-Gilboe

Wathen

C. N.

EQUIP Research Team . (2015). EQUIP Healthcare: An overview of a multi-component intervention to enhance equity-oriented care in primary health care settings. International Journal for Equity in Health, 14(1), Article 152. https://doi.org/10.1186/s12939-015-0271-y

Browne

A. J.

Varcoe

C. M.

Wong

S. T.

Smye

V. L.

Lavoie

Littlejohn

Godwin

Krause

Khan

K. B.

Fridkin

Rodney

O’Neil

Lennox

(2012). Closing the health equity gap: Evidence-based strategies for primary health care organizations. International Journal for Equity in Health, 11(1), Article 59. https://doi.org/10.1186/1475-9276-11-59

Bryant

Bolt

Botfield

J. R.

Martin

Doyle

Murphy

Graham

Newman

C. E.

Bell

Treloar

Browne

A. J.

Aggleton

(2021). Beyond deficit: ‘Strengths‐based approaches’ in Indigenous health research. Sociology of Health & Illness, 43(6), 1405–1421. https://doi.org/10.1111/1467-9566.13311

Burgess

Jongbloed

Vorobyova

Grieve

Lyndon

Wesseling

Salters

Hogg

R. S.

Parashar

Pearce

M. E.

(2021). The “sticky notes” method: Adapting interpretive description methodology for team-based qualitative analysis in community-based participatory research. Qualitative Health Research, 31(7), 1335–1344. https://doi.org/10.1177/10497323211002489

10.

Carter

Min

J. E.

Chau

Lima

V. D.

Kestler

Pick

Money

Montaner

J. S. G.

Hogg

R. S.

Kaida

(2014). Gender inequities in quality of care among HIV-positive individuals initiating antiretroviral treatment in British Columbia, Canada (2000–2010). PLoS One, 9(3), Article e92334. https://doi.org/10.1371/journal.pone.0092334

11.

Carter

A. J.

Bourgeois

O’Brien

Abelsohn

Tharao

Greene

Margolese

Kaida

Sanchez

Palmer

A. K.

Cescon

de Pokomandy

Loutfy

M. R.

CHIWOS Research Team . (2013). Women‐specific HIV/AIDS services: Identifying and defining the components of holistic service delivery for women living with HIV/AIDS. Journal of the International AIDS Society, 16(1), Article 17433. https://doi.org/10.7448/IAS.16.1.17433

12.

Claborn

K. R.

Meier

Miller

M. B.

Leffingwell

T. R.

(2015). A systematic review of treatment fatigue among HIV-infected patients prescribed antiretroviral therapy. Psychology Health & Medicine, 20(3), 255–265. https://doi.org/10.1080/13548506.2014.945601

13.

Closson

McNeil

McDougall

Fernando

Collins

Baltzer Turje

Howard

Parashar

(2016). Meaningful engagement of people living with HIV who use drugs: Methodology for the design of a Peer Research Associate (PRA) hiring model. Harm Reduction Journal, 13(1), Article 26. https://doi.org/10.1186/s12954-016-0116-z

14.

Dawson-Rose

Cuca

Y. P.

Webel

A. R.

Solís Báez

S. S.

Holzemer

W. L.

Rivero-Méndez

Sanzero Eller

Reid

Johnson

M. O.

Kemppainen

Reyes

Nokes

Nicholas

P. K.

Matshediso

Mogobe

K. D.

Sabone

M. B.

Ntsayagae

E. I.

Shaibu

Corless

I. B.

Lindgren

(2016). Building trust and relationships between patients and providers: An essential complement to health literacy in HIV care. Journal of the Association of Nurses in AIDS Care, 27(5), 574–584. https://doi.org/10.1016/j.jana.2016.03.001

15.

Donnelly

L. R.

Bailey

Jessani

Postnikoff

Kerston

Brondani

(2016). Stigma experiences in marginalized people living with HIV seeking health services and resources in Canada. Journal of the Association of Nurses in AIDS Care, 27(6), 768–783. https://doi.org/10.1016/j.jana.2016.07.003

16.

Duffy

Madevu‐Matson

Posner

J. E.

Zwick

Sharer

Powell

A. M.

(2022). Systematic review: Development of a person‐centered care framework within the context of HIV treatment settings in sub‐Saharan Africa. Tropical Medicine & International Health, 27(5), 479–493. https://doi.org/10.1111/tmi.13746

17.

Eklund

J. H.

Holmström

I. K.

Kumlin

Kaminsky

Skoglund

Höglander

Sundler

A. J.

Condén

Summer Meranius

(2019). “Same same or different?” A review of reviews of person-centered and patient-centered care. Patient Education and Counseling, 102(1), 3–11. https://doi.org/10.1016/j.pec.2018.08.029

18.

Flickinger

T. E.

Saha

Moore

R. D.

Beach

M. C.

(2013). Higher quality communication and relationships are associated with improved patient engagement in HIV care. Journal of Acquired Immune Deficiency Syndromes, 63(3), 362–366. https://doi.org/10.1097/QAI.0b013e318295b86a

19.

Giusti

Nkhoma

Petrus

Petersen

Gwyther

Farrant

Venkatapuram

Harding

(2020). The empirical evidence underpinning the concept and practice of person-centred care for serious illness: A systematic review. BMJ Global Health, 5(12), Article e003330. https://doi.org/10.1136/bmjgh-2020-003330

20.

Green

Thorogood

(2014). Qualitative methods for health research (3rd ed.). Sage.

21.

Guba

E. G.

Lincoln

Y. S.

(1982). Epistemological and methodological bases of naturalistic inquiry. ECTJ, 30(4), 233–252. https://doi.org/10.1007/BF02765185

22.

Heath

Samji

Nosyk

Colley

Gilbert

Hogg

R. S.

Montaner

J. S.

STOP HIV/AIDS Study Group . (2014). Cohort profile: Seek and treat for the optimal prevention of HIV/AIDS in British Columbia (STOP HIV/AIDS BC). International Journal of Epidemiology, 43(4), 1073–1081. https://doi.org/10.1093/ije/dyu070

23.

Hendricks

Eshun-Wilson

Rohwer

(2021). A mega-aggregation framework synthesis of the barriers and facilitators to linkage, adherence to ART and retention in care among people living with HIV. Systematic Reviews, 10(1), Article 54. https://doi.org/10.1186/s13643-021-01582-z

24.

Hogg

R. S.

Heath

K. V.

Yip

Craib

K. J.

O’shaughnessy

M. V.

Schechter

M. T.

Montaner

J. S.

(1998). Improved survival among HIV-infected individuals following initiation of antiretroviral therapy. JAMA, 279(6), 450–454. https://doi.org/10.1001/jama.279.6.450

25.

Jackson

S. F.

(2008). A participatory group process to analyze qualitative data. Progress in Community Health Partnerships: Research, Education, and Action, 2(2), 161–170. https://doi.org/10.1353/cpr.0.0010

26.

Jaworsky

Loutfy

Bratu

Sereda

Bayoumi

Richardson

Kuper

Hogg

R. S.

Comparative Outcomes and Service Utilization Trends COAST Study . (2020). Influence of the definition of rurality on geographic differences in HIV outcomes in British Columbia: A retrospective cohort analysis. CMAJ Open, 8(4), E643–E650. https://doi.org/10.9778/cmajo.20200066

27.

Joint United Nations Programme on HIV/AIDS . (2004). From principle to practice: Greater involvement of people living with or affected by HIV/AIDS (GIPA). https://data.unaids.org/publications/irc-pub01/jc252-gipa-i_en.pdf

28.

Kaida

Carter

Nicholson

Lemay

O’Brien

Greene

Tharao

Proulx-Boucher

Gormley

Benoit

Bernier

Thomas-Pavanel

Lewis

de Pokomandy

Loutfy

CHIWOS Research Team . (2019). Hiring, training, and supporting Peer Research Associates: Operationalizing community-based research principles within epidemiological studies by, with, and for women living with HIV. Harm Reduction Journal, 16(1), 47. https://doi.org/10.1186/s12954-019-0309-3

29.

Kerkerian

Kestler

Carter

Wang

Kronfli

Sereda

Roth

Milloy

M. J.

Pick

Money

Webster

Hogg

R. S.

de Pokomandy

Loutfy

Kaida

(2018). Attrition across the HIV cascade of care among a diverse cohort of women living with HIV in Canada. Journal of Acquired Immune Deficiency Syndromes, 79(2), 226–236. https://doi.org/10.1097/QAI.0000000000001775

30.

Kitwood

Brooker

(2019). Dementia reconsidered revisited: The person still comes first. McGraw-Hill Education.

31.

Koehn

McLinden

Collins

A. B.

McDougall

Baltzer-Turje

Miewald

Wang

Salters

K. A.

Hogg

R. S.

Parashar

(2020). Assessing the impact of food insecurity on HIV medication adherence in the context of an integrated care programme for people living with HIV in Vancouver, Canada. Public Health Nutrition, 23(4), 683–690. https://doi.org/10.1017/S1368980019002532

32.

Kranzer

Ford

(2011). Unstructured treatment interruption of antiretroviral therapy in clinical practice: A systematic review. Tropical Medicine & International Health, 16(10), 1297–1313. https://doi.org/10.1111/j.1365-3156.2011.02828.x

33.

Krüsi

Samnani

Deering

D. K.

King

Magagula

Braschel

Shannon

D. K.

(2023). Stigma trajectories, disclosure, access to care, and peer-based supports among African, Caribbean, and Black im/migrant women living with HIV in Canada. SSRN. https://doi.org/10.2139/ssrn.4492324

34.

Lima

V. D.

Brumme

Z. L.

Brumme

Sereda

Krajden

Wong

Guillemi

S. A.

Henry

Hogg

R. S.

Barrios

Montaner

J. S. G.

STOP HIV/AIDS Study Group . (2020). The impact of treatment as prevention on the HIV epidemic in British Columbia, Canada. Current HIV, 17(2), 77–87. https://doi.org/10.1007/s11904-020-00482-6

35.

Lima

V. D.

St‐Jean

Rozada

Shoveller

J. A.

Nosyk

Hogg

R. S.

Sereda

Barrios

Montaner

J. S.

(2017). Progress towards the United Nations 90‐90‐90 and 95‐95‐95 targets: The experience in British Columbia, Canada. Journal of the International AIDS Society, 20(3), Article e25011. https://doi.org/10.1002/jia2.25011

36.

Lourenço

Colley

Nosyk

Shopin

Montaner

J. S.

Lima

V. D.

STOP HIV/AIDS Study Group . (2014). High levels of heterogeneity in the HIV cascade of care across different population subgroups in British Columbia, Canada. PLoS One, 9(12), Article e115277. https://doi.org/10.1371/journal.pone.0115277

37.

MacKenzie

L. J.

Hull

M. W.

Samji

Lima

V. D.

Yip

Zhang

Lourenço

Colley

Hogg

R. S.

Montaner

J. S.

(2017). Is there a rural/urban gap in the quality of HIV care for treatment-naïve HIV-positive individuals initiating antiretroviral therapy in British Columbia? AIDS Care, 29(10), 1218–1226. https://doi.org/10.1080/09540121.2017.1322678

38.

Milloy

M. J.

King

Kerr

Adams

Samji

Guillemi

Wood

Montaner

(2016). Improvements in HIV treatment outcomes among indigenous and non‐indigenous people who use illicit drugs in a Canadian setting. Journal of the International AIDS Society, 19(1), Article 20617. https://doi.org/10.7448/IAS.19.1.20617

39.

Moore

Zhang

Yip

Genebat

Lima

Montaner

Hogg

(2010). Non‐medically supervised treatment interruptions among participants in a universally accessible antiretroviral therapy programme. HIV Medicine, 11(5), 299–307. https://doi.org/10.1111/j.1468-1293.2009.00779.x

40.

Moore

D. M.

Kremer

Wang

Lepik

K. J.

Salters

Montaner

J. S.

Tam

Kling

Bharmal

Goodison

Pakhomova

Barrios

(2022). Evaluation of a public health referral system to re-engage individuals living with HIV who have interrupted antiretroviral therapy in British Columbia, Canada. Journal of Acquired Immune Deficiency Syndromes, 90(1), 33–40. https://doi.org/10.1097/QAI.0000000000002914

41.

Nanditha

N. G. A.

St-Jean

Tafessu

Guillemi

S. A.

Hull

M. W.

Henry

Barrios

Montaner

J. S.

Lima

V. D.

(2019). Missed opportunities for earlier diagnosis of HIV in British Columbia, Canada: A retrospective cohort study. PLoS One, 14(3), Article e0214012. https://doi.org/10.1371/journal.pone.0214012

42.

Orchard

Salters

Michelow

Lepik

Palmer

Hogg

(2016). “My job is to deal with what I can”: HIV care providers’ perspectives on adherence to HAART, addictions, and comprehensive care delivery in Vancouver, British Columbia. Critical Public Health, 26(5), 542–553. https://doi.org/10.1080/09581596.2015.1088641

43.

Poteat

T. C.

Logie

C. H.

(2022). A case for strengths-based approaches to addressing intersectional stigma in HIV research. American Journal of Public Health, 112(S4), S347–S349. https://doi.org/10.2105/AJPH.2021.306659

44.

Public Health Agency of Canada . (2023). Canada-British Columbia agreement to work together to improve health care for Canadians (2023-24 to 2025-26). https://www.canada.ca/en/health-canada/corporate/transparency/health-agreements/shared-health-priorities/working-together-bilateral-agreements/british-columbia-improve-care.html

45.

Puskas

C. M.

Kaida

Miller

C. L.

Zhang

Yip

Pick

Montaner

J. S.

Hogg

R. S.

(2017). The adherence gap: A longitudinal examination of men’s and women’s antiretroviral therapy adherence in British Columbia, 2000–2014. AIDS, 31(6), 827–833. https://doi.org/10.1097/QAD.0000000000001408

46.

Rachlis

Burchell

A. N.

Gardner

Light

Raboud

Antoniou

Bacon

Benoit

Cooper

Kendall

Loutfy

Wobeser

McGee

Rachlis

Rourke

S. B.

Ontario HIV Treatment Network Cohort Study . (2017). Social determinants of health and retention in HIV care in a clinical cohort in Ontario, Canada. AIDS Care, 29(7), 828–837. https://doi.org/10.1080/09540121.2016.1271389

47.

Reeves

(2015). A synthesis of the literature on trauma-informed care. Issues in Mental Health Nursing, 36(9), 698–709. https://doi.org/10.3109/01612840.2015.1025319

48.

Samji

Taha

T. E.

Moore

Burchell

A. N.

Cescon

Cooper

Raboud

J. M.

Klein

Loutfy

M. R.

Machouf

Tsoukas

C. M.

Montaner

J. S. G.

Hogg

R. S.

Canadian Observational Cohort CANOC Collaboration . (2015). Predictors of unstructured antiretroviral treatment interruption and resumption among HIV‐positive individuals in Canada. HIV Medicine, 16(2), 76–87. https://doi.org/10.1111/hiv.12173

49.

Singer

A. W.

Weiser

S. D.

McCoy

S. I.

(2015). Does food insecurity undermine adherence to antiretroviral therapy? A systematic review. AIDS and Behavior, 19(8), 1510–1526. https://doi.org/10.1007/s10461-014-0873-1

50.

Stahl

N. A.

King

J. R.

(2020). Expanding approaches for research: Understanding and using trustworthiness in qualitative research. Journal of Developmental Education, 44(1), 26–28. https://www.jstor.org/stable/45381095

51.

Tattersall

Tam

Moore

Wesseling

Grieve

Wang

Bacani

Montaner

J. S.

Hogg

R. S.

Barrios

Salters

(2022). Healthcare and treatment experiences among people diagnosed with HIV before and after a province-wide treatment as prevention initiative in British Columbia, Canada. BMC Public Health, 22(1), Article 1022. https://doi.org/10.1186/s12889-022-13415-2

52.

Thorne

Kirkham

S. R.

MacDonald‐Emes

(1997). Interpretive description: A noncategorical qualitative alternative for developing nursing knowledge. Research in Nursing & Health, 20(2), 169–177. https://doi.org/10.1002/(sici)1098-240x(199704)20:2<169::aid-nur9>3.0.co;2-i

53.

Turpel-Lafond

M. E.

Johnson

(2021). In plain sight: Addressing Indigenous-specific racism and discrimination in BC health care. (BC Studies: The British Columbian Quarterly, Issue). https://engage.gov.bc.ca/app/uploads/sites/613/2020/11/In-Plain-Sight-Summary-Report.pdf

54.

Ulloa

A. C.

Puskas

Yip

Zhang

Stanley

Stone

Pedromingo

Lima

V. D.

Montaner

J. S.

Guillemi

Barrios

(2019). Retention in care and mortality trends among patients receiving comprehensive care for HIV infection: A retrospective cohort study. CMAJ Open, 7(2), E236–E245. https://doi.org/10.9778/cmajo.20180136

55.

Vancouver Coastal Health . (2020). Improving primary care in Vancouver. https://www.vch.ca/en/news/improving-primary-care-vancouver

56.

Wai

Vasarhelyi

Rutherford

A. R.

Buchner

Gustafson

Compton

Hull

Williams

Barrios

(2022). A qualitative model of the HIV care continuum in Vancouver, Canada. Health Systems, 11(2), 84–97. https://doi.org/10.1080/20476965.2021.1906762

57.

Walcott

Kempf

M.-C.

Merlin

J. S.

Turan

J. M.

(2016). Structural community factors and sub-optimal engagement in HIV care among low-income women in the Deep South of the USA. Culture, Health & Sexuality, 18(6), 682–694. https://doi.org/10.1080/13691058.2015.1110255

58.

Wang

Min

J. E.

Zang

Sereda

Harrigan

R. P.

Montaner

J. S.

Nosyk

(2017). Characterizing human immunodeficiency virus antiretroviral therapy interruption and resulting disease progression using population-level data in British Columbia, 1996–2015. Clinical Infectious Diseases, 65(9), 1496–1503. https://doi.org/10.1093/cid/cix570

59.

Williams

J. R.

Gonzalez-Guarda

R. M.

Ilias

(2017). Trauma-informed decision-making among providers and victims of intimate partner violence during HIV testing: A qualitative study. Journal of the Association of Nurses in AIDS Care, 28(5), 819–831. https://doi.org/10.1016/j.jana.2017.04.010

60.

Wood

T. J.

Koester

K. A.

Christopoulos

K. A.

Sauceda

J. A.

Neilands

T. B.

Johnson

M. O.

(2018). If someone cares about you, you are more apt to come around: Improving HIV care engagement by strengthening the patient–provider relationship. Patient Preference and Adherence, 12, 919–927. https://doi.org/10.2147/PPA.S157003

61.

Zeitouny

Cheung

D. C.

Bremner

K. E.

Pataky

R. E.

Pequeno

Matelski

Peacock

Del Giudice

M. E.

Lapointe-Shaw

Tomlinson

Mendlowitz

A. B.

Mulder

Tsui

T. C. O.

Perlis

Walker

J. D.

Sander

Wong

W. W. L.

Krahn

M. D.

Kulkarni

G. S.

(2023). The impact of the early COVID-19 pandemic on healthcare system resource use and costs in two provinces in Canada: An interrupted time series analysis. PLoS One, 18(9), Article e0290646. https://doi.org/10.1371/journal.pone.0290646

62.

Zhao

Gao

Wang

Liu

Hao

(2016). Differentiation between two healthcare concepts: Person-centered and patient-centered care. International Journal of Nursing Sciences, 3(4), 398–402. https://doi.org/10.1016/j.ijnss.2016.08.009