Health Care Facility Characteristics Associated With Providing Telehealth HIV Care Services During the COVID-19 Pandemic

Abstract

Objectives. To describe provision of HIV telehealth services during the COVID-19 pandemic using data from the Centers for Disease Control and Prevention (CDC) Medical Monitoring Project Facility Survey for the Ending the HIV Epidemic in the United States initiative, which aims to achieve an at least 90% reduction in new HIV infections by 2030 and highlights telehealth as an important strategy.

Methods. During 2021, we surveyed 1023 facilities providing HIV care to a nationally representative sample of US adults with diagnosed HIV, of which 45% responded. We calculated weighted percentages with 95% confidence intervals comparing the characteristics of facilities providing telehealth services.

Results. Overall, 83.4% of facilities provided HIV care telehealth services by the facility’s own providers (82.0%) or by outside providers through remote conferencing (27.0%). Gaps in coverage were identified in smaller facilities and in facilities in rural and primary care health professional shortage areas.

Conclusions. Although most HIV care facilities provided telehealth services during the COVID-19 pandemic, gaps were identified, which must be addressed to meet Ending the HIV Epidemic in the United States goals and better prepare for future health emergencies. (Am J Public Health. 2025;115(3):349–353. https://doi.org/10.2105/AJPH.2024.307908)

The Department of Health and Human Services’ Ending the HIV Epidemic in the United States (EHE) initiative highlights telehealth as a strategy to achieve an at least 90% reduction in new HIV infections by 2030. Addressing the disproportionate burden of new infections within certain geographic areas and populations is an EHE aim.¹ Telehealth can advance EHE’s aims by improving access to and retention in HIV care, particularly for patients with limited transportation options and other barriers to in-person medical visits, and as a tool to expand HIV preexposure prophylaxis for the prevention of new infections.

During the COVID-19 pandemic, use of telehealth increased dramatically.² Among directly funded Ryan White HIV/AIDS Program (RWHAP) medical provider grantees (i.e., those funded through Part C or Part D), 99% provided telehealth during August‒September 2020, up from 22% before the COVID-19 pandemic.³ However, information about the availability of HIV care telehealth services at a wide range of types and locations of HIV care facilities nationally during the COVID-19 pandemic has not been available.

We used data from the Centers for Disease Control and Prevention’s Medical Monitoring Project (MMP) Facility Survey to describe the availability of telehealth services at facilities where a representative sample of persons with HIV received HIV care.

METHODS

MMP is a 2-stage complex sample survey, including an interview and medical record abstraction, designed to produce nationally representative estimates of US adults with diagnosed HIV.⁴ The MMP facility survey was designed to understand the characteristics of facilities providing HIV care to MMP participants, with the survey’s methods reported elsewhere.⁵ Briefly, MMP participants reported their most frequent source of HIV care during the previous 24 months to determine the location for medical record abstraction. For the MMP facility survey, we surveyed all HIV care facilities where medical record abstractions were performed for 2019 MMP cycle participants (June 2019‒May 2020). Facility data were collected during July– November of 2021; 455 facilities (45%) responded to the survey.

We classified facilities as having provided telehealth services if they provided HIV care by remote conferencing by facility HIV care providers or outside HIV care providers. We used publicly available data to classify facilities by primary care health professional shortage area (HPSA) designation,⁶ medically underserved area or population designation,⁷ and Rural‒Urban Continuum Code.⁸

Data were weighted to reduce nonresponse bias. We calculated weighted percentages with 95% confidence intervals (CIs) to compare characteristics of facilities providing telehealth services and prevalence ratios (PRs) with predicted marginal means to examine associations based on availability of telehealth services. Results with CIs are presented in the tables. The analysis was performed with SAS version 9.4 survey procedures (SAS Institute, Cary, NC) and SAS-callable SUDAAN version 11 (RTI International, Research Triangle Park, NC).

RESULTS

Overall, 83.4% of facilities provided telehealth HIV care services during the COVID-19 pandemic (Table 1). An estimated 82.0% provided telehealth services by the facility’s own providers and 27.0% by an outside HIV provider through remote conferencing (Tables A and B, available as supplements to the online version of this article at https://ajph.org).

TABLE 1—

Characteristics of HIV Care Facilities Where Providers Delivered HIV Clinical Care by Remote Conferencing or Patients Received HIV Clinical Care From Outside HIV Providers via Remote Conferencing: Medical Monitoring Project Facility Survey, 2021, United States

	Facilities Utilizing Remote Conferencing for HIV Clinical Care
	No.a	% (95% CI)b	PR (95% CI)
Total	374	83.4 (79.6, 87.2)
Type of facility
Federally qualified health center (FQHC) or FQHC look-alike
Yes	88	82.3 (73.9, 90.6)	1 (Ref)
No	283	83.6 (79.3, 87.9)	1.02 (0.91, 1.14)
Hospital-based infectious disease clinic
Yes	86	88.7 (81.5, 95.8)	1 (Ref)
No	285	81.8 (77.4, 86.3)	0.92 (0.84, 1.02)
Hospital-based primary care clinic
Yes	34	76.1 (62.1, 90.1)	1 (Ref)
No	337	84.1 (80.1, 88.0)	1.11 (0.91, 1.34)
Private practice
Yes	114	86.2 (80.2, 92.2)	1 (Ref)
No	257	81.6 (76.7, 86.5)	0.95 (0.86, 1.04)
Primary care health professional shortage area designation
Yes	166	76.6 (70.2, 82.9)	0.86 (0.78, 0.95)
No	208	89.0 (84.6, 93.4)	1 (Ref)
Medically underserved area/population designation
Yes	187	85.7 (80.5, 90.8)	1 (Ref)
No	187	81.7 (76.2, 87.1)	0.95 (0.87, 1.04)
Rural-Urban Continuum Code
Counties in metro areas of > 1 million population	264	84.8 (80.4, 89.1)	1 (Ref)
Counties in metro areas of 250 000–1 million population	62	80.3 (69.9, 90.7)	0.95 (0.82, 1.09)
Nonmetro counties	23	68.6 (50.3, 86.9)c	0.81 (0.62, 1.06)
Any Ryan White HIV/AIDS Program funding
Yes	224	89.3 (85.1, 93.5)	1 (Ref)
No	150	78.9 (73.1, 84.8)	0.88 (0.81, 0.96)
Types of health coverage accepted
Medicaid
Yes	328	85.9 (82.1, 89.8)	1 (Ref)
No	43	71.3 (59.8, 82.8)	0.83 (0.70, 0.98)
Medicare
Yes	349	84.4 (80.6, 88.3)	1 (Ref)
No	22	71.1 (54.3, 87.9)c	0.84 (0.66, 1.07)
Private insurance
Yes	347	84.3 (80.4, 88.2)	1 (Ref)
No	24	73.0 (56.9, 89.1)c	0.87 (0.69, 1.08)
AIDS Drug Assistance Program or other Ryan White coverage
Yes	264	89.0 (85.1, 92.9)	1 (Ref)
No	107	75.2 (67.9, 82.4)	0.84 (0.76, 0.94)
Veterans Administration
Yes	136	85.8 (79.8, 91.7)	1 (Ref)
No	235	81.9 (77.0, 86.9)	0.96 (0.87, 1.05)
HIV patient load
< 50	18	60.4 (42.6, 78.1)c	0.66 (0.49, 0.89)
50–249	83	76.2 (67.6, 84.8)	0.83 (0.73, 0.95)
250–499	98	89.8 (83.4, 96.2)	0.98 (0.88, 1.08)
500–999	62	85.8 (76.9, 94.7)	0.93 (0.82, 1.06)
≥ 1000	86	91.9 (85.5, 98.3)	1 (Ref)
HIV care provider staffing
Only full-time HIV care providers	151	88.9 (83.9, 93.9)	1.08 (0.99, 1.19)
A mix of full-time and part-time HIV care providers	166	82.1 (76.1, 88.0)	1 (Ref)
Only part-time HIV care provider	49	74.6 (62.8, 86.5)	0.91 (0.76, 1.08)
Provider types
Physicians only	74	82.8 (74.7, 90.8)	1 (Ref)
Combined provider types (physicians and nonphysician providers)	280	84.9 (80.6, 89.2)	1.03 (0.92, 1.14)
Physician specialties
Only infectious disease specialists	77	93.4 (88.3, 98.5)	1 (Ref)
Only primary care specialists	81	75.6 (67.0, 84.2)	0.81 (0.71, 0.92)
Infectious disease and primary care specialists	205	82.9 (77.5, 88.4)	0.89 (0.81, 0.97)
Clinical and supportive services that are currently available onsite or through established outside referral relationships
Any subsistence servicesd
Yes	335	87.7 (84.1, 91.4)	1 (Ref)
No	39	63.2 (51.0, 75.5)	0.72 (0.59, 0.88)
HIV preexposure prophylaxis
Yes	318	87.7 (83.9, 91.4)	1 (Ref)
No	53	62.2 (50.6, 73.8)	0.71 (0.59, 0.86)
HIV postexposure prophylaxis
Yes	306	84.7 (80.7, 88.8)	1 (Ref)
No	67	76.6 (66.4, 86.8)	0.90 (0.78, 1.04)

Note. CI = confidence interval; PR = prevalence ratio.

^a Numbers may not add up to the total (374) because of missing data.

^b Note that these percentages correspond to the percentage of facilities in a given row of the table that utilized remote conferencing.

^c Estimates have an absolute CI width ≥ 30 or an absolute CI width between 5 and 30 and a relative CI width > 130% and should be interpreted with caution.

^d Any subsistence services include Supplemental Nutrition Assistance Program or Special Supplemental Nutrition Program for Women, Infants, and Children; transportation assistance; meal or food services; and shelter or housing services.

Facilities located in an HPSA were less likely to offer telehealth HIV care services than facilities not in an HPSA (76.6% vs 89.0%), as were facilities located in nonmetro counties compared with counties with at least 1 million people (68.6% vs 84.8%). Facilities that did not receive RWHAP funding were less likely than those that did to offer telehealth HIV care services (78.9% vs 89.3%). Facilities that did not accept Medicaid compared with those that did were less likely to offer telehealth HIV care services (71.3% vs 85.9%), as were facilities that did not accept AIDS Drug Assistance Program or RWHAP coverage compared with those that did (75.2% vs 89.0%). Compared with facilities with more than 1000 patients, those with fewer than 50 patients (60.4% vs 91.9%) and 50 to 249 patients (76.2% vs 91.9%) were less likely to offer telehealth HIV care services, as were facilities with only primary care physicians (75.6% vs 93.4%) or a combination of infectious disease physicians and primary care physicians (82.9% vs 93.4%), compared with facilities where physicians were only infectious disease specialists. Facilities that did not provide subsistence services were less likely to offer telehealth HIV care services than facilities that did (63.2% vs 87.7%), as were facilities that did not versus did offer preexposure prophylaxis (62.2% vs 87.7%).

DISCUSSION

An estimated 17% of HIV clinical care facilities serving a representative sample of US persons with HIV did not provide telehealth HIV services during a pandemic that required immunocompromised persons to reduce public exposure to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) while remaining engaged in HIV care. Patients who received care at facilities caring for fewer than 250 HIV patients, not receiving RWHAP funding, and located in nonmetro counties or HPSAs had particularly low access.

Financial barriers are a potential reason why some HIV care facilities did not provide telehealth services during this critical time. RWHAP-funded facilities received emergency supplemental funding to expand telehealth capacity at the beginning of the pandemic through the Coronavirus Aid, Relief, and Economic Security Act in March of 2020.⁹ However, even among directly funded Ryan White providers, a large proportion faced increased operating costs during the pandemic, forcing them to shut down all or most of their HIV prevention services and, to a lesser extent, HIV care services.³ Non‒RWHAP-funded facilities, which account for more than half of HIV care facilities, serving more than one third of HIV patients,⁵ might have faced even greater financial challenges.

Staffing resources may also have been a barrier in smaller, nonmetro, and HPSAs, and non‒RWHAP-funded facilities. The Extension for Community Healthcare Outcomes project (Project ECHO) may be 1 potential solution to this challenge. Project ECHO is a collaborative model for increasing access to expert specialty care in rural and underserved areas for a variety of conditions, including HIV, by using video conferencing to deliver provider mentoring remotely.¹⁰ HIV care organizations could consider expanding funding for programs like Project ECHO to ensure that smaller, more isolated HIV care facilities can be linked to larger HIV care facilities to strengthen the HIV clinical network.

Limited access to telehealth infrastructure is another barrier to expanding telehealth HIV services. A recent review of successes and unresolved challenges related to telehealth HIV care services identified high-speed Internet access as a challenge particularly affecting poorer, rural, and non-White communities.¹¹ The review recommended investment in broadband access (particularly in rural regions), equipping health departments with necessary equipment, and training staff to deliver telehealth services.

Limitations

To address the low facility response rate, we minimized potential bias by weighting the data based on information known for all facilities. Also, the survey did not measure use of telehealth services, nor was the quality of those services assessed. A strength of this analysis was the use of data from facilities serving a diverse probability sample of persons with HIV.

Public Health Implications

While most HIV care facilities provided telehealth HIV services during the COVID-19 pandemic, gaps in coverage were identified in smaller facilities and in facilities in rural areas and primary care HPSAs. The reasons for these gaps must be better understood to inform resource allocation to address gaps in the availability of HIV care telehealth services to meet EHE goals and be better prepared for future public health emergencies.