Health System Features That Enhance Access to Comprehensive Primary Care for Women Living with HIV in High-Income Settings: A Systematic Mixed Studies Review

Abstract

Women living with HIV in high-income settings continue to experience modifiable barriers to care. We sought to determine the features of care that facilitate access to comprehensive primary care, inclusive of HIV, comorbidity, and sexual and reproductive healthcare. Using a systematic mixed studies review design, we reviewed qualitative, mixed methods, and quantitative studies identified in Ovid MEDLINE, EMBASE, and CINAHL databases (January 2000 to August 2017). Eligibility criteria included women living with HIV; high-income countries; primary care; and healthcare accessibility. We performed a thematic synthesis using NVivo. After screening 3466 records, we retained 44 articles and identified 13 themes. Drawing on a social–ecological framework on engagement in HIV care, we situated the themes across three levels of the healthcare system: care providers, clinical care environments, and social and institutional factors. At the care provider level, features enhancing access to comprehensive primary care included positive patient–provider relationships and availability of peer support, case managers, and/or nurse navigators. Within clinical care environments, facilitators to care were appointment reminder systems, nonidentifying clinic signs, women and family spaces, transportation services, and coordination of care to meet women's HIV, comorbidity, and sexual and reproductive healthcare needs. Finally, social and institutional factors included healthcare insurance, patient and physician education, and dispelling HIV-related stigma. This review highlights several features of care that are particularly relevant to the care-seeking experience of women living with HIV. Improving their health through comprehensive care requires a variety of strategies at the provider, clinic, and greater social and institutional levels.

Introduction

In high-income countries, non-AIDS-related causes of death now exceed AIDS-related mortality, and people living with HIV report a higher prevalence of comorbidity and multi-morbidity than the general population, a difference more pronounced in women than men.^1
–3 The healthcare needs of women living with HIV include the management of HIV, reproductive and sexual health, and comorbidities, including the following: mental health;⁴ addictions;⁵ hepatitis-C;⁶ neurocognitive functioning;⁷ contraceptive choice and pregnancy planning services;^8,9 cervical and breast cancer screening;¹⁰ and, health issues related to aging and menopause.¹¹ Further, women living with HIV face gendered social-structural issues that negatively impact health, such as poverty, racism, HIV-related stigma, trauma, and multiple forms of violence.^12

–16

To meet these evolving care needs, researchers and clinicians are increasingly looking to primary care approaches and chronic care models (CCM) as a useful means of conceptualizing and addressing the comprehensive care needs of HIV-affected populations.^2,17

–20 Chu and Selwyn have called this transition in care a “paradigm shift,” and characterized HIV care as having entered a “chronic disease era.”²¹ Similar to that of the general population, a primary care approach for people living with HIV should be person rather than disease focused, providing a point of entry for care, as well as routine screenings, long-term management of chronic disease, health promotion and disease prevention, and responding to social circumstances that impact patient's health.²² In this article, we use the term comprehensive primary care as a summary term for the management of HIV, sexual and reproductive health, and comorbidities. We have also chosen this term as it is person not disease specific, and to make a distinction from the term “HIV primary care,” which often refers only to HIV-specific care (e.g., adherence support and viral load monitoring).²³

Women, who now comprise over half the people living with HIV globally²⁴ and a quarter of those in North America,^25,26 continue to experience avoidable barriers to care. Many of these barriers are attributable to the disadvantaged social and economic position women living with HIV occupy in society, and have been well described in the literature.^27

–32 Further, HIV services are seldom tailored to women's specific needs, leading to alienation from services.^33,34 Barriers to care often intersect, compounding the effect of one another, to further marginalize women and render care services out of reach.^14,35 Access to care can be described as: “the ‘degree of fit’ existing between patients and healthcare systems, with good fit characterized by availability, acceptability, and affordability of health system resources to those needing them.”^22,36,37 In high-income settings, deficiencies in the “degree of fit” are apparent through women's suboptimal use of HIV primary care²⁹ and gaps along the HIV cascade of care.^38

–44 The consequence of poorer access to care is exemplified in the lower life expectancy of women living with HIV compared with men (6 years less), in both the United States and Canada.^45,46 This contrasts with general population trends, and with life expectancy across genders in low-/middle-income settings (e.g., South Africa, Uganda, and Rwanda) where men report a lower life expectancy,^47,48 indicating the importance of regionally specific responses to address the gendered aspect of healthcare accessibility.

Fundamentally redressing barriers to care requires societal and systemic changes to alleviate poverty, racism, gender inequity, and HIV stigma. In parallel to these endeavors and in an effort to promptly respond to a largely disadvantaged population, strategies within the healthcare system may also be adopted to improve the “degree of fit” between patient's realities and existing care services. The aim of our review was to identify features of care (i.e., interventions, providers, care models, and programs) that facilitate access to comprehensive primary care for women living with HIV. We limited this review to high-income countries given important differences in healthcare systems, populations affected, and underlying social determinants of health.⁴⁸

Methods

Research design

The systematic mixed studies review design allowed us to draw from both qualitative and quantitative evidence to identify features of care considered valuable or desirable to the women seeking care (qualitative), and/or shown to be effective in enhancing access to care (quantitative). As such, our review includes both studies where semistructured qualitative interviews allowed women to name facilitators to care, and quantitative studies, such as pilots and quality improvement endeavors, where healthcare features were tested and measured based on existing hypotheses. We adopted a “convergent qualitative synthesis,” as described by Pluye and Hong, meaning we transformed study findings into qualitative themes.⁴⁹ A qualitative synthesis is particularly useful when assembling studies with different markers of care, as is the case here, where we were interested in comprehensive primary care, inclusive of women's health, and HIV-specific care. A meta-analysis was therefore impossible.

Eligibility criteria

We limited the review to full-text, peer-reviewed, empirical research articles, in French or English, using data collected between January 2000, when HIV began being considered a chronic disease,²¹ and August 2017. Eligibility rested on four criteria: (1) adult women with HIV (exclusively women participants [cis and trans] or where results were disaggregated by sex or gender); (2) studies from high-income countries, as operationalized through the Organization for Economic Cooperation and Development (OECD), which comprised 35 counties selected for their commitment to democracy, elevated human development index, and high incomes, such as Japan, Australia, and Canada;⁴⁷ (3) care practices relevant to primary care settings as defined by primary care guidelines for people living with HIV^17,50
–52 and confirmed by two primary care providers [A.D.P. and S.M.; e.g., cervical cancer screening at initiation of care, at 6 months, and annually thereafter; regular monitoring of viral loads (3–6 months); and the screening and management of comorbidities such as cardiovascular disease, hypertension, renal disease]; and (4) studies pertaining to care features that facilitate access to care.

Search strategy

The database search strategy was devised with a McGill University librarian with expertise in knowledge synthesis and health, and included index terms and keywords. We conducted the search using Ovid MEDLINE, EMBASE, and CINAHL. Identified records were imported into EndNote software, and duplicate articles removed.

Study selection

We selected studies for inclusion in two stages (Fig. 1). First, we screened only the titles and abstracts, followed by the article's full text. A second reviewer (S.M. or A.D.P.) screened a random selection of records (10%), and the inter-rater reliability (Kappa score) was deemed “good” at both stages; 0.6 for the title and abstract and 0.7 for full text.⁵³ Disagreements were resolved through discussions (N.O. and A.D.P.), which also served to clarify inclusion/exclusion criteria before the first reviewed (N.O.) screened the remaining records. From the included articles, one researcher (N.O.) performed backward citation tracking (references) and forward citation tracking (articles citing records retained). In addition, two authors (N.O. and A.D.P.) read and discussed the articles selected, before confirming the final studies included.

FIG. 1.

PRISMA flow diagram of included studies.

Quality appraisal

We relied on the Mixed Method Appraisal Tool (MMAT) to guide our critical appraisal of included articles.⁵⁴ The MMAT is designed to appraise the methodological quality of studies, based on appropriate criteria for the research design in question. Qualitative research includes four criteria: (1) appropriate data; (2) appropriate analyses; (3) consideration of context; and (4) consideration of researcher's influence. Quantitative studies are evaluated based on the study design; for nonrandomized studies, four criteria include (1) recruitment bias; (2) appropriate measurement; (3) comparison between groups; and (4) acceptable response rates. While mixed methods studies are evaluated on 11 criteria, including an evaluation of the qualitative component, the quantitative component, and the integration of both sources of findings. Each criterion is rated as sufficiently present or not, leading to scores out of 4 for qualitative and quantitative studies, and out of 11 for mixed methods studies. Two researchers (N.O. and Q.N.H.) independently conducted the appraisal and established final ratings through discussion.

Data extraction and synthesis

We extracted data from each study using a standardized form, including population, setting, methods, data collection, intervention (when applicable), and main findings (Table 1). Our convergent qualitative synthesis⁴⁹ was guided by a thematic synthesis process described by Thomas and Harden.⁵⁵ Using NVivo data management software (version 11.41 for Mac), we thematically coded each qualitative and quantitative findings section for multiple themes. Descriptive themes were generated by the lead author (N.O.), codes were built, refined from one article to the next, and then discussed among coauthors (N.O. and A.D.P.) before being finalized. Drawing on Mugavero et al.'s social ecological framework on engagement in HIV medical care,⁵⁶ we similarly chose to situate the themes across different levels of the healthcare system to construct larger analytical categories of our themes. In this way, our analysis followed the process described by Thomas and Harden, through which “descriptive themes remain ‘close’ to the primary studies, the analytical themes represent a stage of interpretation whereby the reviewer ‘go beyond’ the primary studies and generate new interpretive constructs, explanations or hypothesis.”⁵⁵

Table 1.

Characteristics of Included Studies

First author (year), ref. no.	Country/city	Setting/recruitment	Participants—age, ethnicity, income	Design	Data collection/methods	Primary care/issue addressed	Program/intervention	Findings/features that facilitate access to care	MMAT, 1 = yes 0 = no
Qualitative research (n = 14)
Andrasik (2008)⁶¹	United States/Greater Miami area	2 CBOs and 1 HIV clinic	35 WLHIV—mean age 37 years, 100% African American, 77% income <$10,000/year	Qualitative	35 Semistructured interviews	Cervical cancer screening	NA	Improved interactions with providers and staff (e.g., receptionist); transportation supports; ensuring care continuity (same provider—confidentiality); improved insurance coverage (e.g., copays); one provider in the room; a female provider.	1.1 = 1 1.2 = 1 1.3 = 0 1.4 = 0
Boehme (2012)⁶⁵	United States/Rural Alabama	4 ASOs	39 WLHIV—39% older than 50 years, 92% African American, 64% income <$9,999/year	Qualitative descriptive inquiry	4 Focus groups	Retention in care	NA	Women described positive patient–provider relationship as being caring, informative, and competent.	1.1 = 1 1.2 = 1 1.3 = 1 1.4 = 0
Carter (2015)⁸³	Canada/British Columbia	HIV clinics, ASOs	28 WLHIV—50% white, 39% indigenous, 64% 31–50 years of age, 52% income <$20,000	Qualitative	4 Focus groups	HIV care and support	NA	WLHIV required meaningful peer involvement in the design and delivery of HIV/AIDS services to improve access to care.	1.1 = 1 1.2 = 1 1.3 = 0 1.4 = 1
Finocchario-Kessler (2012)⁹	United States/Urban East Coast	HIV clinics	20 WLHIV—28 years mean age, 95% African American	Qualitative	20 Semistructured interviews	Reproductive counseling	NA	Provider relationships (strong rapport, trust), including age (too young) and gender (female) influenced patient willingness to discuss reproductive health and fertility desire. Participants reported easier and more supportive conversations with gynecologist versus their HIV-care providers.	1.1 = 1 1.2 = 0 1.3 = 0 1.4 = 0
Fletcher (2014)⁶²	United States/Houston	Integrated HIV clinic	33 WLHIV—51 years median age, 70% African American, 94% income <$10,000/year	Qualitative	5 Focus groups	Cervical cancer screening	NA	Implementing strategies to lessen pain and discomfort. Improved understanding of cervical cancer prevention for WLHIV. Strong interpersonal relationships with providers. Reliable transportation services. Decreased appointment duration (separate appointment might be preferred). Appointment reminders.	1.1 = 1 1.2 = 1 1.3 = 0 1.4 = 0
Greene (2015)⁶⁷	Canada/Toronto and Hamilton	Numerous HIV outpatient clinics and ASOs	17 WLHIV—47 years median age, diverse ethnicities, 83 cis-gendered, 1 trans women	Qualitative	17 Semistructured interviews	HIV-care	PCM—12 biweekly sessions over 6 months	Advantages of PCM: access to supportive services; provides a model of individualized support that is safe, accessible without fear of disclosure and stigma; mentorship, motivation, and optimism; increased sense of belonging.	1.1 = 1 1.2 = 1 1.3 = 0 1.4 = 1
Guionnet (2014)⁵⁹	Spain/Madrid	Hospital—infectious disease department	26 WLHIV—41 years median age, 10 sub-Saharan Africa, 8 Latin America, 8 Spain, 50% employed	Qualitative grounded theory	26 Semistructured interviews	Retention in care	NA	Good patient–provider relationships are crucial and must include up to date information (e.g., HIV as a chronic disease, not a death sentence); provide emotional support; translate scientific language; zero judgment; open dialogue/ability to ask questions; flexible appointment (outside working hours to allow for inflexible employment); updates of results by phone. Multi-disciplinary teams. Professional interpreters (avoid family members). “Patient-Expert” provides support, encourages trust in the healthcare system.	1.1 = 1 1.2 = 1 1.3 = 1 1.4 = 1
Kempf (2010)⁵⁸	United States/Alabama	4 Rural HIV clinics	40 WLHIV—mean age 46 years, 92% black, 64% income <$9,999	Qualitative descriptive design	4 Focus groups	HIV care	NA	Trustful patient–provider relationships; appointment reminders; transportation support; organizational care structure; comprehensive care, flexible scheduling, extended hours; inconspicuous services (stigma/disclosure management); peer support.	1.1 = 1 1.2 = 1 1.3 = 1 1.4 = 0
Kenya (2015)⁶³	United States/Miami	Flyers in clinics and CBOs	21 WLHIV—aged 30–60 years of age, 100% Haitian, low income	Qualitative CBPR, grounded theory	3 Focus groups	HPV and cervical cancer knowledge	NA	Eliminating health provider stigma; improved patient education regarding HPV and cervical cancer knowledge.	1.1 = 1 1.2 = 1 1.3 = 0 1.4 = 1
McDoom (2015)⁶⁰	United States/Boston	15 HIV-primary care clinic, and five snowball samplings	20 WLHIV—older black women, 57 years mean age, 100% African American	Qualitative	20 Semistructured interviews	Engagement in HIV care	NA	Mitigating inadvertent HIV disclosure from seeking care; eliminating judgmental behavior from care providers.	1.1 = 1 1.2 = 1 1.3 = 0 1.4 = 1
Vyavaharkar (2008)⁶⁴	United States/South Carolina	2 CBOs seven research study from rural care setting	22 WLHIV—44 years mean age, 100% African American, 45% income <$4,999/year	Qualitative	3 Focus groups	Healthcare and social services	NA	Transportation services; reduce bureaucratic steps to access services; enhanced HIV education to general providers (better care, eliminate stigma); improved patient–provider communication; collaboration (networking, communicating) between healthcare providers; improved mental healthcare services; peer support programs.	1.1 = 1 1.2 = 1 1.3 = 0 1.4 = 0
Williams (2015)⁶⁸	United States/Alabama	ASOs and local clinics	20 WLHIV—50 years mean age, 100% African American	Qualitative	20 Semistructured interviews	Cervical cancer screening	NA	Providers of the female gender (for some patients); further information regarding the advantages of screening, frequency of screening, and heightened risk of cervical cancer given HIV status is needed.	1.1 = 1 1.2 = 1 1.3 = 0 1.4 = 0
Wilson (2013)⁷⁹	United States/Metro San Francisco	CBO	10 WLHIV—African American, trans women, age ranged from 28 to 55 years	Qualitative	10 Semistructured interviews	HIV care	NA	Instrumental support: combining hormone therapy and gender- related care, transportation, incentives for basic needs (food). Emotional support: training for staff rapport, patient satisfaction, quality improvements, appointment accompaniment, volunteer job information. Informational support: trans-sensitivity training for staff, patients as partners in their care, information available in waiting and examination rooms.	1.1 = 1 1.2 = 1 1.3 = 1 1.4 = 0
Wood (2005)⁵⁷	United States/Massachusetts	5 Areas outside Boston metropolitan	40 WLHIV—5 care providers; WLHIV—mean age 34	Qualitative grounded theory	40 Semistructured interviews	HIV care	NA	Increased access to mental health services. Good relationships with providers. Improved privacy and confidentiality in care environments. Improved cultural competency. Access to supportive services. Family-oriented models of care.	1.1 = 1 1.2 = 1 1.3 = 1 1.4 = 1
Mixed method research (n = 2)
Boehme (2014)⁸⁴	United States/Alabama	4 Rural HIV clinics	18 WLHIV—83% African American, 55% income $1,000/month	Mixed methods	Qualitative: four focus groups and nominal group ranking; quantitative: survey	Retention in postpartum HIV care (5 years) and ARV adherence	NA	Transportation supports; supportive clinic staff; flexible scheduling; childcare; peer advocates; appointment reminders.	1.1 = 1 1.2 = 1 1.3 = 0 1.4 = 0 3.1 = 0 3.2 = 1 3.3 = 1 3.4 = 1 5.1 = 1 5.2 = 0 5.3 = 0
Buchberg (2015)⁹⁸	United States/Houston	2 County clinics	35 WLHIV—28 years mean age, 77% black 14% Hispanic, uninsured/underinsured	Mixed methods, descriptive	Qualitative: semistructured interview (n = 22); quantitative: survey (n = 35) electronic medical records	Retention in postpartum care (6 months) with PCP	NA	Transportation supports; nonstigmatizing care environments; knowledge of benefits to adherence to care; strong relationships with healthcare providers.	1.1 = 1 1.2 = 1 1.3 = 1 1.4 = 0 3.1 = 1 3.2 = 1 3.3 = 1 3.4 = 1 5.1 = 1 5.2 = 0 5.3 = 0
Quantitative research (n = 28)
Andersen (2007)⁷⁷	United States/Detroit	HIV-primary care (loosely connected)	112 WLHIV—45 years mean age, 91%African American, income $586/month	3 Groups pre/post	Nurse administered questionnaire and chart review	Retention HIV medical care	12-Month weekly transportation versus 12-month transportation—plus (6-month nursing case management: home visits, appointment accompaniment, referrals to drug and mental health services	When given transportation plus the number of HIV medical visits increased, Friedman analysis of variance: F (2,94) of 5.160, p = 0.007. Providing transportation alone was ineffective.	3.1 = 0 3.2 = 1 3.3 = 1 3.4 = 1
Andersen (2005)⁵	United States/Detroit	HIV Clinic	75 WLHIV—lost to follow-up, Co-occurring mental health and substance abuse	RCT nursing intervention group versus SOC	Interview tool at baseline, 3, 6, 9, 12 months and clinical chart	Linking and retention in care	Nursing intervention (appointment booking, linking to social services, integrating care among providers)	Nurse navigation of healthcare services suggests that appointment accompaniment improved appointment attendance, in the first 3 months, but did not sustain retention over time.	2.1 = 0 2.2 = 0 2.3 = 1 2.4 = 1
Anderson (2017)⁸²	United States/Philadelphia	In care	665 WLHIV—849 mother–infant pairs = 51.5% between 25 and 34 years of age, 79% African American	Retrospective analysis	HIV—population-based surveillance database	Postpartum retention in care (1 year)	Perinatal HIV case management program (PCM): services coordination, mobilize resources, link clients to community-based social and supportive services, client referral, secure food, transportation housing.	PCM improves retention in postpartum care (52.7% vs. 34.2%) aOR: 1.59 (1.17–2.16).	3.1 = 1 3.2 = 1 3.3 = 1 3.4 = 1
Boyd (2005)⁸⁵	United States/rural areas of Georgia, Alabama, and South Carolina	Public health and community-based organizations	13 WLHIV experiences of substance abuse—42 years mean age, 80% African American, 87% income <$10,000/year	One group pre/post	Peer administered questionnaire	Substance abuse	Pilot peer counseling intervention to provide emotional and informational support to assist WLHIV to change their substance use and develop problem-focused coping strategies. Based on motivation enhancement therapy. Four sessions over 8–12 weeks.	Increased readiness to change alcohol and drug use; fewer negative consequences from alcohol and drugs (physical consequences, impulse control, social responsibility, and control over use).	3.1 = 1 3.2 = 0 3.3 = 0 3.4 = 1
Cook (2014)⁹¹	United States/California, Illinois, New York, Washington, DC	HIV-care and testing sites, TB centers, STI-clinics, and CBOs (WIHS cohort)	1,352 WLHIV—43 years median age, 56% African American	Retrospective analysis, multi-site cohort	Interview-based questionnaire and clinical examination	Depressive treatment	NA	PCP continuity supports access to adequate depression treatment for patients with a major depressive disorder diagnosis, OR: 3.79 (1.18–12.14), and with reported depressive symptoms using CESD-12, OR 3.08 (1.69–5.62).	3.1 = 1 3.2 = 1 3.3 = 1 3.4 = 1
Cross (2014)⁷⁰	United States/Washington	Infectious disease clinic	422 WLHIV—40 years median age, 79% African American, 15% white	One group pre/post	Medical chart review	Pap test	Multi-pronged quality improvement intervention included: clinician training, automatic e-mail reminder to providers, examination rooms rearranged, female chaperones made available, medical supplies restocked, prize incentives for providers, patients called before appointment, patient “goody-bag,” and patient education.	Pap tests increased from 53% to 75.3% (p < 0.01), a 43% increase.	3.1 = 1 3.2 = 0 3.3 = 1 3.4 = 1
Dal Maso (2010)⁷²	Northern Italy	10 Infectivology clinics	1002 WLHIV—41 years median age, 80% native Italians	Cross-sectional study	Self-administered questionnaire	Pap test	NA	Receiving pap screening advice from a gynecologist rather than an infectivologist (OR = 0.6, 95% CI: 0.4–0.9) reduced the lack of Pap smear test in the last year.	3.1 = 1 3.2 = 0 3.3 = 1 3.4 = 1
Deering (2009)⁸⁶	Canada/Vancouver Downtown Eastside	HIV clinics and CBO	20 WLHIV—sex workers who use drugs, 42 years mean age	Pilot evaluation	Nurse administered questionnaire	Uptake and adherence to ARVs	Peer-driven interventions included: weekly support meetings, health advocacy (buddy) system, peer outreach services, and on-site nursing care.	Peer-driven interventions improved (n = 11/20) or sustained adherence (n = 4/20). Mean adherence within the study period was 75.8%.	3.1 = 0 3.2 = 1 3.3 = 0 3.4 = 0
Fonquernie (2010)⁸⁸	France/Paris	Teaching hospital	484 WLHIV and 1946 PLHIV—43 years mean age, 65% French origin, 19% sub-Saharan	One group, pre/post	Medical chart review	Pap test and mammography	Computer algorithms, based on current comorbidity management guidelines, provide clinicians with patient care plan suggestions.	Pap testing improved from 44% to 52% (p = 0.04) and mammography from 50% to 83% (p = < 0.001).	3.1 = 1 3.2 = 1 3.3 = 1 3.4 = 1
Ganta (2017)⁸⁹	United States/Southern Nevada	Outpatient HIV clinic	473 WLHIV—(no demographic information)	One group, pre/post	Medical chart review	Pap test	Patients were reminded of their annual Pap test, three sequential text messages, followed by three phone calls.	Reminders increased the rate of completed Pap smear screening from 2.5% at baseline to 11.8%.	3.1 = 1 3.2 = 1 3.3 = 1 3.4 = 1
Gardner (2014)⁸⁰	United States/Boston, New York, Baltimore, Birmingham, Miami, Houston	6 HIV clinical sites	1838 PLHIV. 665 WLHIV—new patients and those at risk of nonretention, 69% African American, 86% Medicaid/Medicare	RCT—two intervention arms, one SOC over 12 months	Audio computer-assisted self-interview and medical records	Attending HIV care	EC (EC = dedicated individual, maintaining personal contact with patients) with basic HIV education versus EC+skills (behavioral skills-IBM model) versus SOC (appointment reminders)	Among women, EC improves HIV visit constancy 1.18 (95% CI: 1.02–1.37) and visit adherence 1.08 (95% CI: 1.03–1.13) compared with SOC. The skill-building component did not improve retention further. Note: data are disaggregated by sex.	2.1 = 1 2.2 = 0 2.3 = 1 2.4 = 1
Gokhale (2017)⁶⁹	United States	Multiple sites	1144 Care providers for WLHIV (physicians, physician assistants, and nurse practitioners)—60%> 50 years of age, 54% male, 63% white	Cross-sectional study	Medical monitoring provider survey	CRHC	NA	Providers who deliver primary care, (52% [CI: 44–60] vs. 33% [CI: 22–44], p = 0.01), who are female (57% [CI: 48–65] vs. 40% [CI: 31–50], p = 0.01), and with 20 or fewer years experience (51% [CI: 44–59] vs. 41% [CI: 32–52], p = 0.03) were associated with providing CRHC.	3.1 = 1 3.2 = 1 3.3 = 1 3.4 = 1
Irvine (2014)⁸¹	United States/New York	In care	1355 WLHIV and 3641 PLHIV—45 years median age, 53% black, 38% Hispanic, 39% income <$9,000/year	One group, pre/post	Population-based HIV surveillance registry	Engagement in care and viral load suppression	Comprehensive HIV Care Coordination Programs (CCP) include: outreach for case finding, case management, multi-disciplinary team, communication patient navigation, accompaniment, antiretroviral therapy adherence support, health promotion	CCP programs demonstrate improved engagement in care from 73.7% to 91.3%, RR = 1.24 (1.21–1.27), and viral load suppression from 32.3% to 50.9%, RR = 1.58 (1.50–1.66).	3.1 = 1 3.2 = 1 3.3 = 1 3.4 = 1
Keiser (2006)⁷¹	Switzerland/Geneva	HIV outpatient clinics, SHCS	2186 WLHIV—36 years median age, 67% white	Prospective cohort study	Questionnaire every 6 months, clinical laboratory tests.	Pap test, gynecological visit	NA	Gynecological visits and Pap test were more likely when receiving care in SHCS clinics versus private practice. No gynecological examination: OR: 1.21, p = 0.01, and no Pap test: 1.15, p = 0.04.	3.1 = 1 3.2 = 0 3.3 = 1 3.4 = 0
Kupprat (2009)⁸⁷	United States/New York City	In care	46 WLHIV—47 years median age, 63% African American, 37% Latina/other, 87% on Medicaid	Retrospective analysis	Medical chart review (4 months)	Support group, substance use, and mental health services	NA	Integrated care (medical model agency) supported access to mental health and substance abuse treatments. While nonmedical model agencies supported attendance in support groups.	4.1 = 1 4.2 = 1 4.3 = 1 4.4 = 0
Leece (2010)⁷⁴	Canada/Ottawa	Immunodeficiency clinic	218 WLHIV—64% 30–50 years of age, 69% from an HIV endemic country	Retrospective cohort	Medical chart review (1 year)	Pap test	NA	Having a PCP (family physicians or nurse practitioners) supports access to Pap tests. 67% versus 41% RR 1.6 (94% CI: 1.06–2.52)	3.1 = 1 3.2 = 1 3.3 = 1 3.4 = 1
Lemly (2007)⁹⁴	France/Paris	4 Hospitals	169 WLHIV—31 years median age, 70% sub-Saharan African origin, 18% European origin	Retrospective analysis, cohort study	Medical records	Postpartum appointment attendance (24 months)	NA	Having numerous care visits during pregnancy to establish a care seeking pattern OR 2.00 (1.24–3.22). The study also recommends: linking child and maternal care (such as family planning clinics) may improve retention; 8 of the 18 women who did not attend postnatal care continued to attend pediatric appointments.	3.1 = 1 3.2 = 1 3.3 = 1 3.4 = 1
Logan (2010)⁷³	United States/Florida	Ryan white funded HIV clinic	200 WLHIV—57% African American, 23% Hispanic, 20% white, $8,180 mean annual income	Retrospective analysis, randomly selected patients	Medical chart review	Pap test	NA	Receipt of Pap test postdiagnosis was associated with type of insurance. No insurance versus private, Medicaid, or Medicare (p = 0.0185). Women receiving Pap test at a gynecology clinic were more likely to receive recommended two Pap test postdiagnosis (p = 0.0185).	3.1 = 1 3.2 = 1 3.3 = 1 3.4 = 1
Ludema (2017)⁹⁵	United States/California, Illinois, New York, Washington DC	HIV-care and testing sites, TB centers, STI-clinics, and CBOs (WIHS cohort)	1,130 WLHIV—46 years median age, 64% African American, 21% Hispanic, 58% income below $12,000/year	Retrospective analysis, multi-site cohort	Interview-based questionnaire and clinical examination	Blood pressure control	NA	Not having medical insurance was associated with suboptimal control of hypertension. Comparing the uninsured to those with Medicaid, risk difference of 0.16 (95% CI: 0.10–0.23).	3.1 = 1 3.2 = 1 3.3 = 1 3.4 = 1
Ludema (2016)⁹⁶	United States/California, Illinois, New York, Washington DC	HIV-care and testing sites, TB centers, STI-clinics, and CBOs (WIHS cohort)	1481 WLHIV—43 years median age, 56% African American, 27% Hispanic, 49% income <$12,000/year	Retrospective analysis, multi-site cohort	Interview-based questionnaire and clinical examination	HIV viral suppression	NA	Insurance coverage, such as ADAP, which covers otherwise uninsured women, supports viral suppression. Those with ADAP had a lower relative hazard of unsuppressed viral load HR 0.49 (0.28–0.85) than those without ADAP HR 1.0 (0.63–1.57).	3.1 = 1 3.2 = 1 3.3 = 1 3.4 = 1
Ogunwale (2016)⁹²	United States/Texas	Integrated HIV clinic for indigent women	209 WLHIV—∼43 years mean age, 65% African American, 25% Hispanic	Cross-sectional study	Self-administered questionnaire	Pap test	NA	Higher number of health visits (aOR 1.34 [95% CI: 1.08–1.75]) and correct knowledge of Pap test (aOR 3.23, [95% CI: 1.02–9.43]), increased odds of Pap test compliance.	3.1 = 1 3.2 = 1 3.3 = 1 3.4 = 1
Oster (2009)⁹³	United States/18 states	Care facilities	2417 WLHIV—39 years median age, 69% African American, 15% Hispanic, 55% income <$10,000/year	Retrospective analysis, multi-site surveillance project	Interview-based questionnaire	Pap test	NA	Odds of missing pap test increased for women whose last pelvic examination was not at most recent site of HIV care, aOR = 2.6 (2.1–3.2).	3.1 = 1 3.2 = 0 3.3 = 1 3.4 = 1
Pillai (2009)⁷⁸	United States/New York	5 ASOs	60 WLHIV—47 years mean age, 66% African American, 28% Latina, mean monthly income $808/month	Retrospective analysis, cross-sectional	Self-reported survey	Access to and satisfaction with healthcare	NA	Integrated care systems, with case management and supportive services, lead to overall satisfaction and reported ease of access to care.	4.1 = 1 4.2 = 1 4.3 = 1 4.4 = 0
Robinson (2016)⁶⁶	United States/Baltimore	University-affiliated HIV clinic	148 WLHIV—46 mean age, 89% African American, over half made under $999/month	Cross-sectional study	Interviewer-administered questionnaire and biomarker data	UVL	NA	Women with frequent doctor–patient communication had 35% higher likelihood of UVL (AIR 1.35 [95% CI: 1.06–1.72]) compared with women with less doctor–patient communication. ^aNote data are disaggregated.	3.1 = 0 3.2 = 1 3.3 = 1 3.4 = 0
Shannon (2005)⁷⁵	Canada/Vancouver (Downtown East Side)	Drop-in center for sex workers	159 WLHIV—sex workers, mean age 39 years, 49% aboriginal ancestry, 43% white, 81% received income assistance	Cross-sectional study	Interview-based questionnaire	HIV treatment (ARVs)	NA	Facilitators suggested: daily home or street ARV delivery; drop in centered delivery; women-only clinics.	4.1 = 1 4.2 = 0 4.3 = 0 4.4 = 0
Shuter (2003)⁹⁰	United States/New York	Outpatient infectious disease clinic	1026 WLHIV—mean age 42 years, 43% black, 52% Latino	1 Group, pre/post	Hospital database	Pap test	29 Providers were supplied with a weekly compute- based Pap smear reminder list. 1 year project.	Improved yearly pap smear from 61.4% to 73.2%, OR (95% CI: 1.53–1.93). Data suggest sustained intervention over time.	3.1 = 1 3.2 = 1 3.3 = 1 3.4 = 1
Visnegarwala (2006)⁷⁶	United States/Houston Texas	HIV clinic	54 WLHIV—39 median years of age, 84% African America, Indigent women	Pilot project evaluation	Social worker	Virologic suppression	SOC versus ACS (case manager, social worker, HIV-peer caseworker, pharmacist) versus DDT (weekly, biweekly ARV delivery by peers/WLHIV).	Peer-based DDT improved virologic suppression across the intervention groups: 86% for DDT, 54% for ACS versus 36%, for SOC.	3.1 = 0 3.2 = 1 3.3 = 1 3.4 = 0
Yi (2011)⁹⁷	United States/California, Illinois, New York, Washington DC	HIV-care and testing sites, TB centers, STI-clinics, and CBOs (WIHS cohort)	1094 WLHIV—70% above 40 mean years of age, 55% African American, 13% white, 12% Hispanic, 50%, income <$12,000/year	Retrospective cross-sectional analysis, existing cohort	Interview-based questionnaire and clinical examination	Use of ARVs and hypertensive medication	NA	Receipt of ADAP was significantly associated with ARV use (OR 2.4; [95% CI: 1.5–3.7]). ADAP also increased, although not significantly, the use of hypertensive medications (OR 2.4; [95% CI: 0.93–6.0]).	3.1 = 1 3.2 = 1 3.3 = 1 3.4 = 1

MMAT: http://mixedmethodsappraisaltoolpublic.pbworks.com/w/file/fetch/84371689/MMAT%202011%20criteria%20and%20tutorial%202011-06-29updated2014.08.21.pdf

ACS, adherence coordination service; ADAP, AIDS drug assistance program; AIR, adjusted incidence rate ratio; aOR, adjusted odds ratio; ARV, antiretroviral (HIV medication); ASO, AIDS service organization; CBO, community-based organization; CBPR, community-based participatory research; CESD, Center for Epidemiologic Studies–Depression Scale; CI, confidence interval; CRHC, comprehensive reproductive health counseling; DDT, directly delivered therapy; EC, enhanced contact; HPV, human papillomavirus; HR, hazard ratio; MMAT, Mixed Methods Appraisal tool; NA, not applicable; PCM, peer case management; PCP, primary care provider; PLHIV, people living with HIV; RCT, randomized controlled trial; RR, risk ratio; SHCS, Swiss HIV Cohort Study; SOC, standard of care; STI, sexually transmitted infection; TB, tuberculosis; UVL, undetectable viral load; WIHS, the Women's Interagency HIV Study; WLHIV, women living with HIV.

Results

We identified 5514 records, 2048 were duplicates, yielding 3466 titles and abstracts, and 490 full-text articles were screened. Twenty-nine articles met our inclusion criteria. Through citation tracking, we identified 15 additional articles, amounting to 44 studies included in the synthesis (Fig. 1). The majority of studies were conducted in the United States (n = 34), with 10 additional articles from Italy (n = 1), Spain (n = 1), Switzerland (n = 1), France (n = 2), and Canada (n = 5). Women in these studies (n = 17,659) represent diverse populations (i.e., immigrants, racialized communities, low income, sex workers, trans women); some of their care needs may be distinct, but together they share commonalities regarding social status and the resultant elevated barriers to care (Table 1).

Studies consisted of varied research designs and data collection methods. Qualitative methodology was used in 14 studies, using focus groups (n = 6) and in-depth, semistructured interviews (n = 8). Two were mixed methods studies, including focus groups, interviews, closed surveys, and medical records. The remaining 28 studies were quantitative; including randomized controlled trials (n = 2), pilot or pre- and postintervention studies (n = 9), and retrospective or cross-sectional analyses (n = 17). From the 44 articles critically appraised with the MMAT, 3 studies rated 1 out of 4 points, and 10 studies 2 out of 4 points (Table 1). No studies were removed; in comparing themes across the quality of studies, we determined that the omission of lower quality studies would not change the final themes identified.

Across the 44 articles, we generated 13 themes, which we then categorized into 3 domains, from the more immediate relational aspect of care to broader societal level factors: (1) care providers, (2) clinic care environment, and (3) social and institutional factors (Table 2).

Table 2.

Features of Care That Facilitate Access to Comprehensive Primary Care for Women Living with HIV

		Peer support	Case management/nurse management	Positive patient–provider relationships	Physician specialty	Female physician	Integrated and coordinated care	Women and family spaces	Transportation support	Electronic reminder systems	Consistent providers and appointments	Medical insurance and copayments	Education patients and providers	HIV-stigma reduction strategies
		Care providers					Clinic care					Social/institutional
Qualitative
Andrasik	2008			✓		✓			✓		✓	✓	✓	✓
Boehme	2012			✓
Carter	2014	✓												✓
Finocchario-Kessler	2012			✓	✓	✓							✓
Fletcher	2014			✓					✓	✓			✓
Greene	2015	✓	✓			✓								✓
Guionnet	2014	✓		✓			✓						✓	✓
Kempf	2010	✓		✓			✓		✓	✓				✓
Kenya	2015			✓									✓	✓
McDoom	2015			✓										✓
Vyavaharkar	2008	✓		✓			✓		✓				✓	✓
Williams	2015					✓							✓
Wilson	2013	✓	✓				✓		✓				✓
Wood	2005			✓			✓	✓						✓
Mixed methods
Boehme	2014	✓		✓				✓	✓	✓			✓
Buchberg	2015			✓					✓				✓	✓
Quantitative
Andersen	2007		✓						✓
Andersen	2005		✓
Anderson	2017		✓
Boyd	2005	✓
Cook	2014										✓
Cross	2014					✓				✓			✓
Dal Maso	2010				✓
Deering	2009	✓
Fonquernie	2010									✓
Ganta	2017									✓
Gardner	2014		✓
Gokhale	2017				✓	✓
Irvine	2015		✓				✓
Keiser	2006				✓							✓
Kupprat	2009						✓
Leece	2010				✓
Lemly	2007							✓			✓
Logan	2010				✓							✓
Ludema	2017											✓
Ludema	2016											✓
Ogunwale	2016										✓		✓
Oster	2009										✓
Pillai	2009		✓				✓
Robinson	2016			✓							✓
Shannon	2005	✓	✓					✓
Shuter	2003									✓
Visnegarwala	2006	✓	✓
Yi	2011											✓

Themes identified in each article, classified by three levels of the healthcare system: (1) care providers, (2) clinic care environment, and (3) social and institutional factors.

Care provider features

Across the 44 studies, the quality and types of relationships with care providers was the most dominant theme present in 75% of articles (n = 33). Most studies focused on relationships with physicians (n = 22), attributing three specific aspects to improved care. First, the quality of relationship (i.e., trust, confidentiality, ease of communication, caring, competence, and nonjudgmental or stigmatizing) was considered crucial to women's access to HIV-specific care;^57

–60 cervical cancer screening;^61
–63 reproductive counseling;⁹ and overall health and social services,^64,65 while in the quantitative literature, one study demonstrated that women with more frequent doctor–patient communication had a higher likelihood of having an undetectable viral load.⁶⁶ Second, for some, but not all women, the female gender of their provider was said to increase their sense of safety,⁶¹ of feeling understood,⁶⁷ and their willingness to discuss, and undergo gynecological and reproductive care.^9,68 Provider female gender was also associated with an increase in providing reproductive health counseling,⁶⁹ and female chaperones, as part of a multi-pronged quality improvement intervention, contributed to increases in Pap tests performed.⁷⁰ Third, certain provider specialties, such as gynecologist and primary care providers, facilitated receiving comprehensive primary care. Women reported having more comfortable and informative reproductive health discussions with their gynecologists, compared with their usual HIV care provider.⁹ Receiving care from a gynecologist,^71
–73 or from a primary care provider (family physicians or nurse practitioners), was also found to significantly increase receipt of Pap tests,⁷⁴ as well as reproductive health counseling.⁶⁹

Ten articles also emphasized the importance of case managers and nurse navigators, whose roles in supporting women and in addressing socio-structural barriers to care (e.g., transportation services, linking to social services and community organizations, appointment confirmation and accompaniment, and care coordination) were particularly helpful toward maintaining retention in HIV care.^{5,67,75

–82}

Finally, peer advocates, peer support, and peer engagement in the planning and delivery of care were frequently desired by women and considered an enabling aspect of care according to most qualitative literature^{58,59,64,67,79,83} and one mixed methods study.⁸⁴ However, models of peer support and outreach were assessed in only four quantitative studies, all showing improved outcomes for the management of substance abuse,⁸⁵ access and adherence to antiretroviral therapy (ART),^75,86 and viral suppression through peer directly delivered therapy.⁷⁶

Clinic care environment

Aspects of the clinical care environment, such as the organization of care, transportation to clinics, and appointment scheduling, were discussed in 52% (n = 23) of the articles. In the qualitative literature, women indicated that access to care was facilitated when multiple services were integrated into the same clinic,^57,58,79 or when care was coordinated among providers.^59,64 Integrated and coordinated care was assessed in the quantitative literature: the former demonstrated improved engagement in HIV care and viral load suppression;⁸¹ while the latter supported access to mental health and substance abuse treatments,⁸⁷ as well as improved overall satisfaction with and ease of access to care.⁷⁸ Both integrated care and coordinated care helped to mitigate the necessity for repeated HIV disclosures, exposing women to potentially stigmatizing behavior from healthcare providers.^{60,61,64,68,84} Concern for HIV confidentiality was paramount: clinics that did not display signs with “HIV” or “infectious disease” facilitated access to care by avoiding inadvertent HIV disclosure.^60,83

Clinics that incorporated transportation support services such as hospital shuttles, bus tickets, paid parking, or gas vouchers were also described in articles as key facilitators to accessing care. This was an often-cited priority in interviews and focus groups,^{58,61,62,64,79} yet only one quantitative pre/post study⁷⁷ examined the impact of transportation support on women's access to care. This study identified that transportation, when combined with case management, was effective in improving retention in HIV care, although not transportation alone,⁷⁷ suggesting the need for further research.

Regarding appointment scheduling, clinic-based reminder systems, used to indicate when patients are due for specific screenings, improved receipt of Pap tests or mammography in multiple studies.^70,88
–90 Women also valued appointment flexibility, such as the ability to reschedule appointments easily, shorter appointments (vs. full-day commitments), and receiving results by phone,^59,79 especially given precarious employment and childcare considerations. Continuity of care (i.e., seeing the same provider, routine appointments) was also perceived as enhancing women's care experience,⁶¹ improved the receipt of adequate depression treatment,⁹¹ and Pap test screenings,^92,93 while more frequent appointments during pregnancy lead to improved postpartum retention in HIV care 24 months postdelivery.⁹⁴

Social and institutional features

We identified broader institutional and societal factors impacting access to care (i.e., health insurance, education, and societal stigma) in 50% (n = 22) of studies. In the first regard, women in the qualitative literature spoke of copayments and inadequate health insurance as barriers to care.⁶¹ Quantitative studies also demonstrated the importance of insurance coverage and publically funded care systems in the following five studies. In Switzerland, receiving care in a public (vs. private) practice improved gynecological care,⁷¹ and in the United States, having sufficient health insurance coverage was associated with timely Pap test screening,⁷³ optimal blood pressure control,⁹⁵ HIV viral load suppression,⁹⁶ and increased ART use.⁹⁷

Among patients, misinformation or lack of health information introduced additional barriers to care. Misinformation about cervical cancer,^61,62,68 the purpose of Pap tests,^62,63 and safer conception strategies⁹ were common. Women accessing care reported desiring additional HIV and women's health information,^63,64,79 and those with additional knowledge received more regular Pap tests^70,92 and had improved retention in postpartum care.⁹⁴ The clinical competence of providers was also a central component of the quality improvement intervention that increased cervical cancer screening.⁷⁰ Providers' clinical competence was highly valued by patients; lack of provider knowledge on HIV and women's health limited women's ease in accessing care, and in addressing particular healthcare concerns.^9,59,61,65

Lack of HIV knowledge among providers also led to stigmatizing encounters within the healthcare system.^60,64,68 Institutionalized stigma was seen as “critically impacting adherence to care.”⁹⁸ Persistent HIV stigma was another reason why women preferred a one-on-one model of peer support,⁶⁷ and clinic or transportation signage that could not inadvertently disclose their HIV status.^58,60,79,83 Of note, although mitigating HIV-related stigma was considered essential to ensure the accessibility of care, and was named in over half of qualitative studies, no quantitative studies were found that addressed stigma elimination strategies within care settings.

Discussion

The primary aim of this systematic review was to identify features of care that facilitate access to primary care for women living with HIV, especially considering the persistent barriers to care experienced by this population despite living in high-income countries. Drawing on qualitative, mixed methods, and quantitative research, our review synthesized strategies that may be implemented within the healthcare system and may be put into action at multiple levels, including care providers (i.e., peers, case managers, physicians), clinic care environments (i.e., reminders, nonidentifying clinic signs, coordination of care), and wider societal strategies (i.e., health insurance, patient and provider education, dispelling stigma).

In synthesizing the evidence, we also identified features of care that were consistently put forward by women as key to healthcare accessibility in the qualitative literature (e.g., patient–physician relationship, transportation support, eliminating HIV-related stigma), but were seldom investigated in pre/post studies, pilot interventions, or randomized controlled trials. Similarly, when considering the various aspects of care defined in primary care guidelines for women living with HIV, we found the available evidence to be focused predominantly on retention across the HIV cascade of care, Pap test screening, and reproductive health (Table 3). This indicates gaps in women's health research for women living with HIV and highlights specific avenues for future work aimed at improving women's comprehensive health.

Table 3.

Primary Care Services Addressed in the Systematic Review

Primary care guidelines ^a –d for women living with HIV ^50 –52	Articles in review	Article ref. no.
HIV-specific primary care
Cascade of care
Linkage to HIV care	1	⁵
Antiretroviral initiation	2	^75,86
Antiretroviral adherence	3	^75,86,97
Viral load suppression	4	^66,76,81,96
Retention/engagement in care	12	^{5,57 –60,64,65,77,79 –81,83}
Primary care screenings
Cancer screening
Pap test	14	^{61 –63,68,70 –74,88 –90,92,93}
Colorectal cancer	0
Mammography	1	⁸⁸
Coinfection screening
Sexually transmitted infections	0
Tuberculosis	0
Hepatitis	0
Comorbidity
Hematology	0
Body composition: body mass index	0
Cardiovascular	0
Lipids	0
Glucose	0
Pulmonary disease	0
Liver disease	0
Renal disease	0
Bone disease	0
Neurocognitive impairment	0
Hypertension/blood pressure	2	^95,97
Diabetes	0
Menopause	0
Mental health	2	^87,91
Addictions	2	^85,87
Immunizations	0	t
Reproductive and sexual health
Contraceptive counseling	2	^9,69
Disclosure management	1	⁶⁷
Pregnancy planning	2	^9,69
Postpartum retention in care	4	^82,84,94,98
Psychosocial
Lifestyle (diet, exercise)	0
Intimate partner violence	0
Social determinants of health	9	^{57,64,67,77 –79,83,84,98}

Infectious Disease Society of America (IDSA) Primary Care Guidelines for the Management of Persons Infected with HIV: 2013.¹⁷

Guidelines 4.0 European AIDS Clinical Society (EACS).⁶⁰

Primary Care Guidelines for the Management of HIV/AIDS in British Columbia.⁵¹

Periodic medical examination for adults living with HIV. Guide to health professionals in Quebec.⁵²

Our findings are consistent with previous literature reviews pertaining to the care of people living with HIV. Focused on the HIV care cascade (i.e., linkage to care, adherence, suppressed viral load), multiple reviews have also identified the benefits of patient navigation approaches, case management services, patient health education, integration of services, patient appointment reminders, provider screening reminders, directly administered ART, and peers as part of the healthcare team to improve patient engagement in care.^{2,23,99,100,101} Specific to women, Carter et al. also highlighted the need for peer involvement in the planning and delivery of care, family-focused services, and supportive services as key features of care for women living with HIV.¹⁰² In line with Mugavero's social–ecological engagement in HIV care framework, qualitative systematic reviews have similarly emphasized the need to address socio–ecological factors versus individual-level factors in facilitating access to HIV care.^103,104 Indeed, healthcare systems are a particularly malleable social determinant of health,¹⁰⁵ where practical changes may be instituted to respond most rapidly to the barriers to care that impact women's health.

The review adds to this rich body of literature while providing a distinct contribution by identifying features of care that are particularly valuable and effective for women. This is especially important as few studies disaggregate findings by sex or gender (as exemplified in the studies screened for this review), rendering it impossible to ascertain whether an intervention improved care for all, or for a particular subpopulation. Identifying care strategies that also work for specific populations, such as women living with HIV who continue to be a minority of people living with HIV within high-income countries, is essential to ensuring that health advances do not inadvertently exacerbate health inequities by rendering care services out of reach for the most vulnerable.¹⁰⁶

Our review is also distinct as it moves beyond a focus on HIV-specific care outcomes to encompass sexual and reproductive health counseling, routine screenings, and comorbidity management, providing a comprehensive view of care services as HIV progressively becomes managed as a chronic disease. As the CCM describes,¹⁰⁷ our findings also underscore the importance of a multi-faceted approach rather than single interventions to improve the quality of care for those living with long-term chronic disease.^2,23,103 This was demonstrated in quality improvement efforts,⁷⁰ and through women's stated care needs in the qualitative studies. It is worth noting that certain features of care may be particularly beneficial in addressing specific gaps in care, for instance, provider reminders to improve timely screenings, female care providers for increasing patients ease in addressing gynecological and reproductive healthcare needs, or peer support for enabling retention in HIV care.

The findings also reaffirm the growing recognition in the value of patient-oriented research and patient-centered outcomes in evaluating and improving care.^108
–110 Women in the qualitative literature emphasized relational aspects of care, such as interactions with physicians, peers, or case managers. This finding builds on previous evidence that indicates that aspects of care most highly valued by patients may differ from what health providers and managers believe is a priority for action.^111,112 Improving care for women living with HIV may therefore be most effectively accomplished by engaging patients in research and quality improvement efforts.

In sum, of the 13 features of care identified in this review, we emphasize a few below to provide direction for policy and practice. The careful coordination of care between HIV-specific providers and other clinicians, such as the gynecologist and family doctors, is key to ensuring physician knowledge and expertise, easing patient comfort in addressing non-HIV health issues, and in mitigating potentially stigmatizing clinical encounters. Although several features of care identified in this review may be pertinent to other women navigating a fragmented healthcare system with a chronic disease, the particular history of specialized HIV care, and persistence of HIV stigma, presents a particular need for care coordination to eliminate stigmatizing or ill-informed healthcare encounters.^21,33 The coordination of care may be facilitated through the integration of care within a single facility, or through case management, nurse navigation, or peer support, all highly valued in the literature. Additional strategies that may be implemented include the use of electronic reminder systems to prompt physicians to screen according to care guidelines; transportation supports, especially given an increasingly geographically dispersed HIV-positive population; and maintaining and improving health insurance programs and publically funded healthcare.

Limitations

A few limitations of this research should be noted. First, multi-faceted improvement studies present challenges for isolating the specific feature or intervention most effective in improving access to care. In addition, as most participants frequented clinical sites or community organizations, our findings may not speak to the experience of women living with HIV who do not access care and may be most marginalized. Due to resource considerations, two authors were not available to screen all records or code themes independently. However, as detailed in our Methods section, we countered this limitation with a second reviewer screening a percentage of abstract and full texts, and reflexive discussions among coauthors before final articles were selected and themes confirmed. It was also beyond the scope of this review to consult experts (inclusive of women living with HIV) or explore the gray literature (e.g., conference abstracts, government reports, theses and dissertations). This may have limited the identification of relevant studies¹¹³ and the potential contribution of real-world insights from those working in this field or accessing care. Future research might consider including their perspectives, as well as examples of innovative care models or interventions not published in the peer-reviewed literature.

This systematic review, based on 44 studies conducted in 6 high-income countries, identified 13 features of care that facilitate women's access to comprehensive primary care. Our review reaffirms the importance of multi-pronged strategies to meet the care needs of this population and offers examples of valued and effective strategies for care providers, clinics, and greater society to consider in improving the “degree of fit” between women's lives and the care services they seek.

Footnotes

Acknowledgments

The authors would like to thank McGill librarian Genevieve Gore for her valuable assistance in conducting the search strategy.

Author Disclosure Statement

No competing financial interests exist.

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