A Mixed Methods Study of Perceptions of a Rideshare Intervention to Address Transportation Vulnerability among People Living with HIV in South Carolina

Abstract

Introduction

Transportation vulnerability is a major barrier to HIV care for many people living with HIV (PLHIV)—especially in the rural southern United States (US), given limited public transportation infrastructure and long travel times to HIV care. Rideshare services have proliferated in recent years, and rideshare interventions are now being used in some HIV clinics to overcome transportation barriers. However, little is known about how PLHIV in the southern US perceive rideshare services and whether they are willing to use them to access HIV care—information that is critical for optimizing the implementation of rideshare interventions. The goal of this mixed-methods study was to examine implementation-related factors relevant to uptake of a concierge rideshare intervention among PLHIV in South Carolina.

Methods

A total of 160 PLHIV with self-reported transportation vulnerability were enrolled in a randomized clinical trial to test effectiveness of a concierge rideshare intervention. Prior to intervention implementation, all PLHIV completed brief surveys assessing transportation-related barriers to HIV care and implementation-related factors pertaining to rideshare services. Additional semi-structured individual interviews were also completed by a smaller subset of participants (n = 20) to capture personal experiences and insight into perceptions of rideshare services for accessing HIV care.

Results

Mean scores indicated favorable perceptions of rideshare interventions across the domains of comfort, ease of use, and safety. However, mean scores also indicated participant concerns with costs associated with rideshare, as well as privacy protections. T-tests showed nonsignificant differences in perceptions of rideshare by gender. Qualitative analysis yielded six key themes—"safety/comfort,” “privacy protections”, “appeal/enjoyment,” “convenience/ease”, “issues encountered”, and “cost”—which aligned with three implementation factors (ie, feasibility, acceptability, adoption) that are relevant for successful implementation of rideshare interventions.

Conclusion

While the majority of PLHIV had favorable views of using rideshare services to access HIV treatment and care, several obstacles need to be addressed to ensure the success of rideshare interventions, including HIV-related stigma and technological barriers.

Plain Language Summary

Rideshare services may be helpful for connecting people living with HIV (PLHIV) who have transportation challenges with critical HIV care. PLHIV in South Carolina expressed positive views of rideshare services, perceiving them as comfortable, safe, and easy to use; however, many expressed concerns with privacy and the cost of such services.

Introduction

Residents of the southern United States (US) are disproportionately affected by HIV when compared to residents from other US regions.^1,2 Nearly half of new HIV diagnoses in the US occur in the South despite its much smaller portion of the population, ² and southern residents experience a significantly higher rate of HIV diagnosis (15.4 per 100 000 people) when compared to residents of the West, Midwest, and Northeast (10.0, 7.1, and 8.9 per 100 000, respectively). ² The South has more HIV diagnoses that are made in men who have sex with men (MSM) than any other region, and the majority of MSM who acquire HIV in the southern US are Black and/or African American. ² People living with HIV (PLHIV) in the southern US are also less likely to access care and less likely to achieve viral suppression compared with other regions. ² These disparities are driven by complex and intersecting factors including high rates of poverty, access-related barriers, socio-cultural factors, and policy-related factors. ³ For instance, many southern states such as South Carolina continue to criminalize a variety of HIV-related behaviors despite evidence suggesting that such laws undermine HIV prevention efforts by discouraging HIV testing and disclosure.^4–6 Other policies such as lack of Medicaid expansion in multiple southern states impede progress toward national HIV goals, as Medicaid expansion is linked with increases in the number of individuals who know their HIV status (ie, through expanded coverage for healthcare visits that include HIV testing), and in prescription and use of pre-exposure prophylaxis. ⁷

Other structural barriers, including transportation-related barriers, also impede a strong HIV care continuum. Transportation barriers—such as lack of a personal vehicle or lack of public transportation options—may make it more difficult for an individual to access HIV prevention, treatment, and care. Previous empirical studies have shown that transportation barriers predict poorer adherence to antiretroviral therapy (ART), poorer engagement in HIV care, and poorer retention in care.^8–10 The amount of time PLHIV must travel to reach their HIV care has also been shown to be associated with HIV care disruptions, including being late to appointments, missing HIV care visits, and not being able to see HIV care providers when needed. ¹¹ Despite these nascent studies, approaches to address transportation vulnerability remain largely understudied within the HIV literature.

South Carolina is one of seven rural states prioritized by the federal Ending the HIV Epidemic initiative, which aims to reduce the number of new HIV infections in the US by 90% by 2030. ¹² However, structural barriers such as transportation access continue to hinder progress toward this goal. In 2020, the South Carolina Department of Health and Environmental Control identified lack of transportation as the greatest statewide barrier to HIV prevention and testing. ¹³ Limited access to timely testing, treatment, and preventive services exacerbates health disparities, making it crucial to explore transportation interventions to address these challenges.

Existing literature identifies transportation vulnerability as a significant risk factor for poorer adherence to ART and reduced engagement and retention in HIV care. However, few studies have examined the perspectives of PLHIV as related to transportation interventions or programming. To address this gap, the current study employed a mixed-methods approach to explore the feasibility, usability, and acceptability of rideshare services for PLHIV in South Carolina. Smartphone application or “app”-based rideshare services (eg, LYFT, Uber) have proliferated in recent years and are increasingly being used by patients to access medical care. Rideshare services may help overcome existing structural barriers to care for PLHIV; however, more information is needed on user preferences for these novel transportation services.

Methods

Participants and Study Site

Data described here were collected at baseline of a larger parent study to test whether a concierge rideshare intervention improved engagement in care and viral suppression for PLHIV; participant details have been reported elsewhere.^11,14 The parent study included randomization to either treatment as usual or provision of a free concierge rideshare transportation intervention for a 12-month period. Participants were eligible to participate if they were aged ≥18 years, living with HIV, re-engaging with care after being “lost to care” (ie, ≥9 months with no HIV-related medical appointments or viral load tests) and/or were in care but reported transportation challenges, and were a resident of Richland or Lexington counties of South Carolina. Transportation challenges were screened for using a brief questionnaire that assessed personal vehicle ownership, frequency of transportation problems, and whether participants had trouble getting to their HIV care appointments. Participants were excluded from participation if they were aged <18 years, did not reside in either Richland or Lexington counties, and/or did not indicate current transportation difficulties on the participant screening tool.

Participants included 160 PLHIV (61.9% male, 35.6% female, 2.5% transgender), with a mean age of 46.9 years (SD = 11.9) (range = 21-68 years). A majority of participants were Black and/or African American (77.5%), while smaller numbers identified as White (18.8%), or another race (3.8%). A majority of participants described their sexual identity as heterosexual or straight (51.3%). Most were single or never married (76.9%), and 15.6% were widowed, divorced, or separated. Overall, the participant sample had low socio-economic levels and low educational attainment, with a majority (56.3%) reporting a household income of <$10 000 per year.

A subset (n = 20) of participants (N = 160) also took part in individual, semi-structured interviews to share their experiences and perceptions of rideshare services. The qualitative subset of participants largely reflected the racial and ethnic characteristics of the full group; participants were predominantly Black or African American (n = 17, 85.0%), with two identifying as another race and one as White. The qualitative subset of participants had a larger portion of women (55.0%) than the full participant sample. See Table 1 for demographic data for the full sample and the qualitative sub-sample.

Table 1.

Sociodemographic Characteristics of Participants.

	Total Participants (N = 160)	Subset of Participants Completing Qualitative Interviews (n = 20)
	Number (Column %)	Number (Column %)
Age in years, mean (SD)	46.9 (11.9)	50 (10.4)
Marital status
Single	123 (76.9%)	15 (75.0%)
Married	11 (6.9%)	1 (5.0%)
Widowed, divorced, or separated	25 (15.6%)	4 (20.0%)
Sexual identity
Heterosexual or straight	82 (51.3%)	15 (75.0%)
Gay or lesbian	44 (27.5%)	3 (15.0%)
Bisexual	21 (13.1%)	1 (5.0%)
Other	5 (3.1%)	0 (0%)
Did not report	8 (5.0%)	1 (5.0%)
Gender
Male	99 (61.9%)	9 (45.0%)
Female	57 (35.6%)	11 (55.0%)
Transgender	4 (2.5%)	0 (0%)
Race
White	30 (18.8%)	1 (5.0%)
Black/African American	124 (77.5%)	17 (85.0%)
Other	6 (3.8%)	2 (10.0%)
Ethnicity
Hispanic or Latinx	10 (6.3%)	2 (10.0%)
Non-Hispanic or Latinx	150 (93.7%)	18 (90.0%)
Education attainment
Less than high school	43 (26.9%)	10 (50.0%)
High school graduate or GED	53 (33.1%)	7 (35.0%)
Some college or associate	52 (32.5%)	2 (10.0%)
Bachelor's degree or higher	12 (7.5%)	1 (5.0%)
Employment
Employed full time	38 (23.8%)	2 (10.0%)
Employed part time	15 (9.4%)	0 (0%)
Unemployed	65 (40.6%)	9 (45.0%)
Other (student, retired)	6 (3.8%)	1 (5.0%)
Unable to work	33 (20.6%)	7 (35.0%)
Did not report	3 (1.9%)	1 (5.0%)
Annual household income
Less than $10 000	90 (56.3%)	15 (75.0%)
$10 000 to $24 999	40 (25.0%)	2 (10.0%)
$25 000 to $49 999	24 (15.0%)	1 (5.0%)
$50 000 or more	6 (3.8%)	2 (10.0%)

Procedures

All study procedures were approved by the University of South Carolina Institutional Review Board (IRB) (#Pro00090288). Participant recruitment for the parent trial lasted from March 2020 to June 2021 with PLHIV from a comprehensive immunology center invited to take part in the study in-person by clinic staff. Power analyses were conducted for the parent study based on number of participants needed to detect intervention effects for the randomized control trial, resulting in a total sample size of 160. Participants provided written and oral informed consent prior to enrolling in the parent intervention trial. After enrolling in the study but before any components of the intervention were delivered (ie, at baseline), all participants completed a questionnaire designed by the study team to assess demographic characteristics, transportation barriers, and perceptions of rideshare services. All participants who enrolled in the parent study were eligible for a $25 participant incentive at study enrollment and another $25 incentive at study completion. The reporting of this study conforms to the Consolidated Criteria for Reporting Qualitative Research (CORE-Q) checklist. ¹⁵

A subset of participants from the parent trial were invited to take part in qualitative interviews, with invitations being provided to participants by case managers and/or clinic staff based on interviewer availability at the time of their care appointments. Participants were invited to take part in the qualitative interviews until sufficient data were collected to reach data saturation, which occurred with 20 interviews. All invited participants chose to take part in the interview. Participants were provided with an additional $100 participant incentive for the qualitative interview, and interviews were conducted in a private clinic location. Participants who took part in qualitative interviews provided additional oral consent prior to the interviews, as approved by the University of South Carolina IRB.

Interviews were conducted by a graduate research assistant and an academic researcher (ie, second and sixth author) who had no prior relationships with the participants. Participants were not informed about personal characteristics of the interviewers. Both interviewers were trained in qualitative approaches and research ethics. Both interviewers were cisgender women from the health service psychology field. All interviews were audio recorded. Field notes were kept to assess preliminary themes and interviewers met regularly to discuss interviews. The interviews lasted between 15 and 50 min (M = 26 min). Although there was substantial variability in interview lengths, these reflected differences in engagement and in the amount of information provided by participants in response to semi-structured questions, rather than a difference in the questions asked.

Measures

Sociodemographic variables. Participants provided demographic information including age, race, ethnicity, sexual identity, gender, annual household income, educational attainment, and employment status.

Perceptions of benefits of using a rideshare service. Participants were asked to endorse their agreement with a series of 10 statements (see Appendix A) to assess perceptions of rideshare including: (1) “Using Lyft or Uber would save me money.”; (2) “Using Lyft or Uber would help my household's monthly budget.” ; (3) “Using Lyft or Uber would make it easier to get from place to place.”; (4) “Using Lyft or Uber is something I would enjoy.”; (5) “Using Lyft or Uber appeals to me.”; (6) “Using Lyft or Uber would reduce stress for me.”; (7) “I would feel comfortable giving my personal information to Lyft or Uber.”; (8) “Using Lyft or Uber is safe.”; (9) “I would use Lyft or Uber if it was available to me.”; and (10) “Using Lyft or Uber would be easy for me.” Participants rated these statements on a scale 1 (strongly disagree) to 5 (strongly agree), and scores were summed. This measure has not been used previously. It was created by study team members with expertise in structural public health interventions and implementation science to understand participants’ perspectives of potential benefits of using rideshare services.

Semi-structured interview on transportation-related experiences and perceptions. A semi-structured interview protocol (see Appendix B) was developed by the team of researchers with expertise in fields including social and behavioral science, psychology, public health, and medicine. Participants were asked a series of open-ended questions about their transportation experiences related to HIV care. Questions surveyed transportation vulnerability and transportation-related challenges; attempts to overcome transportation-related barriers to care; and transportation-related experiences and preferences. See Appendix A for the full interview protocol. Qualitative findings related to experiences with transportation vulnerability have been previously published. ¹⁴

For the current study, relevant themes and exemplar quotes were extracted that were specific to rideshare services (eg, Lyft, Uber).

Statistical Analysis

Quantitative survey data were analyzed using SPSS version 29.0. The study had no missing data, and a total of 160 participants were included in quantitative analysis. Descriptive statistics were calculated to describe participant perceptions of rideshare services, and bivariate correlations were conducted to examine the associations between variables of interest. Additionally, t-tests were run to examine whether there were any differences in perceptions of the rideshare services by gender. The alpha level was set at 0.05 for all analyses.

The semi-structured interviews were transcribed verbatim, cross-checked for accuracy, and deidentified for qualitative analysis. A team-based, interactive coding approach was used, with data managed in Dedoose (version 8.3.44). ¹⁶ Two coders independently reviewed two interviews to develop initial codes and a codebook. The codebook was tested through blind coding of additional interviews. Coders met to resolve discrepancies, add new codes when necessary, and merge redundant codes. Once adequate agreement was reached (ensuring consistency with the codebook), transcripts were divided equally between the coders for primary coding. Unblinded secondary coding followed, and coders met to reconcile any discrepancies. Due to study constraints, member checking (ie, in which participants provide feedback on findings) was not completed. Data saturation was reached, with consistent and clear themes emerging during analysis. For the current study, all excerpts related to rideshare perceptions, including the parent codes “safety/comfort,” “privacy protections,” “appeal/enjoyment,” “convenience/ease,” “issues encountered,” and “cost” of rideshare services were analyzed.

Results

Participants had positive perceptions of rideshare services in terms of their comfort, ease of use, and safety (see Table 2). Items assessing these domains had mean scores that fell between “neutral” to “agree.” However, mean scores for items assessing cost effectiveness and privacy suggested negative perceptions for these domains, as indicated by mean scores that fell between “neutral” to “disagree.” Independent samples t-tests were run to examine whether there were any differences in perceptions of rideshare items by gender (ie, male, female). There were no significant gender differences in rideshare perceptions, though one item (ie, “Using Lyft would reduce stress for me”) had a significance of P = .05 (ie, M score for male participants = 3.34; M score for female participants = 2.96; see Table 2). Bivariate correlations were also assessed (see Table 3). Results from bivariate correlations indicate that gender was significantly positively associated with age and significantly negatively associated with household income. Household income was significantly positively associated with education level. No significant correlations were found with age, gender, education level, household income, and overall perceptions of rideshare. Integrated mixed-methods findings incorporating both quantitative survey data (N = 160) and qualitative individual, semi-structured interview data (n = 20) follow.

Table 2.

Participant Perceptions of Benefits of Using a Rideshare Service (N = 160).

	Mean/SD (All Participants)	Mean/SD (Male)	Mean/SD (Female)	Test Statistic
	M (SD)	M (SD)	M (SD)	t (df)
Using Lyft or Uber would save me money.	2.96 (1.41)	2.97 (1.43)	2.95 (1.41)	t (155) = .10, P = .924.; d = .016
Using Lyft or Uber would help my household's monthly budget.	2.88 (1.45)	2.93 (1.42)	2.80 (1.51)	t (153) = .52, P = .606.; d = .086
Using Lyft or Uber would make it easier to get from place to place.	3.39 (1.47)	3.55 (1.39)	3.11 (1.59)	t (156) = 1.85, P = .066; d = .307
Using Lyft or Uber is something I would enjoy.	3.24 (1.33)	3.28 (1.30)	3.18 (1.40)	t (155) = .44, P = .658.; d = .074
Using Lyft or Uber appeals to me.	3.18 (1.38)	3.20 (1.37)	3.16 (1.41)	t (154) = .15, P = .882.; d = .025
Using Lyft or Uber would reduce stress for me.	3.20 (1.38)	3.34 (1.35)	2.96 (1.41)	t (154) = 1.62, P = .054; d = .272
I would feel comfortable giving personal information to Lyft or Uber.	2.81 (1.45)	2.93 (1.45)	2.59 (1.44)	t (155) = 1.42, P = .158; d = .236
Using Lyft or Uber is safe.	3.32 (1.19)	3.40 (1.09)	3.18 (1.35)	t (155) = 1.14, P = .258; d = .188
I would use Lyft or Uber if it was available to me.	3.64 (1.28)	3.75 (1.81)	3.46 (1.44)	t (98.30) = 1.34, P = .185; d = .234
Using Lyft or Uber would be easy for me.	3.48 (1.28)	3.55 (1.22)	3.35 (1.41)	t (157) = .93, P = .353; d = .154

Note: Independent samples t-test were conducted to identify differences between men and women on individual items.

Table 3.

Bivariate Correlations Between Key Study Variables (N = 160).

	M	SD	1	2	3	4	5
1. Age	45.96	11.50	-
2. Gender			.177*	-
3. Education level			−.127	−.015	-
4. Household income			−.086	−.171*	.245**	-
5. Perceptions of rideshare	31.74	11.24	.107	−.092	−.310	−.041	-

Note: Transportation barriers and perceptions of rideshare variables are total scores.

*P < .05, **P < .01.

Rideshare Safety

One quantitative item assessed participants’ perceptions of safety while using rideshare services (ie, “Using Lyft or Uber is safe.”), and mean participant scores showed agreement with this (M = 3.32, SD = 1.19), with the mean score falling between “neutral” and “agree.” The theme of safety was evident in qualitative interview data. For example, one participant expressed appreciation for rideshare services due to safety features the rideshare service provided, including clear demarcation of rideshare cars:

I’m a homebody, so I don’t go nowhere … I’ve been out of the house in the whole year, probably about less than [once] a month. And that may sound funny but it's true … So, I really love [the rideshare]. I really like it because they on time. They tell you, ‘Okay, look out for, you know … a black such and such [car make and model]. It's very safe for me. It's very, very safe … I love it. If they come there, they [tell you] the ride, the license plate number, all this … to make you feel safer’.

Participants also noted feeling more secure riding in a rideshare vehicle than in the vehicle of a known friend or family member:

I feel safer in a Lyft than I would in somebody [else's] car.

I’ll catch a Lyft before I take a ride with somebody. And it's crazy because you don’t know the Lyft drivers. But I never had no bad experience with a Lyft driver. Man or woman. I’ve never had a bad experience versus me getting a ride with somebody I don’t know …. And it's crazy because I don’t know the Lyft driver either, but the atmosphere and the energy I get from these Lyft drivers is enough to make me know, Okay, I’m safe. They’re not going to bother me’

Similarly, another participant highlighted feeling safe using rideshare services because of the identification lights displayed on drivers’ dashboards, ensuring they are affiliated with the company:

But, I’m always feeling comfortable with you know, Uber, or, as long as the right people using, you know what I’m saying. With the lighting so you can know that that's an Uber or a Lyft.

A different participant also noted that rideshare programs have become increasingly safer due to the provision of driver information to riders:

But now, it's more safer. It's more safer now … they send it out the name, and they put everything on it.

Privacy Protections

One item assessed participants’ comfort level in sharing personal information with rideshare companies. Mean scores for this item (ie, “I would feel comfortable giving personal information to Lyft or Uber”) fell in the negative range of the scale (M = 2.81, SD = 1.45). Participants on average reported perceptions of “disagree” to “neutral” for this item. One participant described these privacy concerns, which were exacerbated by being located in a relatively small city where individuals know each other.

I've lived in Columbia all my life. So you're taking that chance of that Lyft [that] come in. And what if I went to school with that person? Or what if I know them personally or they know me?

She described how rideshare drivers are not bound by the Health Insurance Portability and Accountability Act (HIPAA) laws, which caused her privacy concerns. She further explained that she had concerns about her information being shared on an app (ie, Lyft, Uber) due to potential disclosure of her information and HIV status. She described how taking a taxi was a better option related to safety because information was not stored:

You just tell them where to take you. Nothing is tracked, not dealing with an app where your information can be possibly shared, you know, this is verbal communication. Right. If you forget, I can remind you, I don't have no problem. You know, rather than putting them out information into an app, you just don't know how stuff is being used for data and you know, I just don’t know.

Appeal/Enjoyment of Rideshare

Two quantitative items assessed participants’ perceptions of rideshare services as desirable (ie, “Using Lyft or Uber appeals to me”) (M = 3.18, SD = 1.38) and enjoyable (ie, “Using Lyft or Uber is something I would enjoy”) (M = 3.24, SD = 1.33). These scores fall between “neutral” and “agree,” indicating positive perceptions, which were also reflected in qualitative data. Specifically, a participant described feeling joy when seeing the illuminated rideshare sign:

Overall when I see that lighted Lyft sign, I smile.

A different participant expressed enjoyment in conversing with rideshare drivers, highlighting their friendliness and engagement:

I mean, they are nice. They're really, really nice. And they show concern, so, you know, ‘hi, [how's] everything's going?’ … things like that. I mean, they hold conversation. We laugh, we talk, time goes on to it again … You can communicate.

Rideshare Convenience/Ease

Four survey items assessed participants’ perceptions of the convenience and ease of rideshare services; mean scores for all four items indicated positive attitudes for this domain. Participants agreed that a rideshare service “would make it easier to get from place to place” (M = 3.39, SD = 1.47) and “would be easy for me” (M = 3.48, SD = 1.28). Participants, on average, also endorsed that they would use a rideshare service if it were available to them (M = 3.64, SD = 1.28). Finally, participants agreed that using rideshare “would reduce stress” (M = 3.20, SD = 1.38). Qualitative data also aligned with positive perceptions in terms of convenience and use. One participant highlighted how rideshare services increased their likelihood of attending doctor's appointments and arriving on time:

Cause as long as we got Lyft, a lot of us patients will come to the doctor. If we guaranteed a ride [there] and a ride back, we will come. Cause I know a lot of people with the Medicaid van. It comes and people do come to their appointments [but] you ain’t getting there on time.

Another participant expressed appreciation for the reliability of rideshare services:

They’re on point, they’re on time.

Similarly, a different participant shared the same sentiment:

But the last, since I've been doing the Uber [Lyft] driver, it's been great. It's been awesome. Pick you up on time. Good drivers.

A final participant expressed how using the rideshare service reduced some of their stress:

So whichever it's a big help when I do can get the Uber [Lyft] in [to the HIV clinic], that takes off a lot of strain from me.

While most participants described the use of the rideshare intervention to be convenient and easy, others described challenges encountered. Specifically, two participants discussed times their rideshare was late or did not arrive, forcing them to adjust plans and use alternative transportation.

One time it didn’t come at all. The Lyft didn’t come at all.

Another participant described,

I guess some people [drivers] show up past their appointment [time].

Finally, one participant described how it was challenging for him to originally understand how to manage the rideshare, until a staff member provided guidance.

It was just a little confusing, but then once she told me how to do it, it's been pretty smooth.

Costs Associated with Rideshare

Two quantitative items assessed participants’ perceptions of cost-related aspects of rideshare services. Mean scores for both items skewed negatively. On average, participant responses fell between “neutral” and “disagree” in terms of whether they perceived that using a rideshare service “would save me money” (M = 2.96, SD = 1.41). Similarly, mean ratings for whether using rideshare “would help my household's monthly budget” also fell between “neutral” and “disagree” (M = 2.88, SD = 1.45). One participant discussed how rideshare services could be affordable and a “win-win” situation if healthcare systems or clinics were paying for the service:

So I think that [a concierge rideshare service] is excellent for people like me that don’t have no cars … I think it needs to be implemented in every organization that need it that [have] people [that] have problems with transportation … it's a win-win situation. I get to my appointment, and [the rideshare driver is] getting paid for taking me to my appointment. You don’t have to wait on me, but you come back and get me, you know what I’m saying?

Discussion

The present study explored perceptions of a rideshare intervention among PLHIV in South Carolina—a southern state that bears a high burden of HIV-related morbidity and mortality and where many individuals living with HIV experience significant transportation-related barriers to care.^2,3 Transportation access is a critical but understudied social determinant of health within the HIV field. The small body of prior research shows that transportation barriers significantly impact HIV care engagement, particularly in the US South.^8–10,16 These barriers may be magnified in rural southern states like South Carolina, given the poor public transportation infrastructure, large travel distances to access care, and high number of residents who are of low socio-economic status. ¹ The current study's mixed-methods approach provides valuable insights into perceptions of rideshare interventions among PLHIV, an increasingly proposed means of addressing transportation vulnerability.^17–19 Using both quantitative and qualitative methods, findings can inform development of future transportation interventions designed to overcome transportation barriers and enable more PLHIV to engage in care in order to achieve and maintain viral suppression.

Overall, the results suggest that offering free or subsidized rideshare services may be a promising transportation solution for PLHIV facing transportation challenges. Survey data revealed that participants generally had positive perceptions about the convenience, appeal, and safety of rideshare services. PLHIV also endorsed that rideshare services could help reduce stress. Qualitative findings from semi-structured interviews further supported the feasibility, acceptability, and convenience of rideshare interventions, with PLHIV expressing positive sentiments regarding safety, enjoyment/appeal, and convenience/ease of use. Many participants reported that rideshare services improved their likelihood of attending medical appointments on time, which emphasizes the importance of acceptability and perceived benefits for any future rideshare intervention success. ²⁰ These overall findings are consistent with research examining the use of rideshare interventions for other vulnerable patient populations with chronic healthcare conditions, in which provision of rideshare assistance was associated with increased rates of appointment attendance. ¹⁷

Although participants generally viewed rideshare services positively, two domains were identified that had negative ratings. First, participants expressed concerns about cost-related aspects associated with rideshare, highlighting structural barriers that are important to consider when developing future rideshare programming for PLHIV. Participants were enrolled in a parent study that provided rideshare services to participants randomized to the intervention condition, which allowed some participants to access this service for free. In qualitative interviews, several participants expressed financial constraints that prevented them from independently paying for rideshare services for travel to their HIV care appointments, further underscoring the economic hardships experienced by many PLHIV. With over three-fourths of the sample have an annual household income of less than $10 000, financial strain remains a significant barrier to care, reinforcing the need for strong, affordable public transportation and other programming to address the needs of low-income PLHIV. Given the connection between socio-economic vulnerability and transportation vulnerability, self-paying for rideshares to access HIV care would likely be challenging for many individuals with HIV in South Carolina. Covering the cost of such a service, as was done as a part of the parent study, likely addresses these barriers but raises additional concerns about long-term viability. A pilot study of a rideshare intervention in primary care demonstrated the affordability of such an intervention compared with provision of non-emergency medical transportation with other populations, suggesting potential affordability of scaling up rideshare interventions. ¹⁷ Future research should examine clinic-based costs for implementing such a program in HIV care-providing institutions.

Notably, across all 10 rideshare-related survey items used in the current study, the strongest endorsement from participants was for an item querying about whether they would use rideshare services “if they were available,” underscoring the importance of accessibility in successful implementation of future rideshare interventions. Access—including financial accessibility, geographic coverage of services, and ease of use for individuals with disabilitiesis a key factor that should be studied further to understand expand use of rideshare by PLHIV. Some rural areas, which include those with the greatest travel times to care, may not have ready access to rideshares, requiring other types of transportation services.

Technology-related aspects of rideshare use are also an important consideration. Access to smartphone technology and cell service coverage for booking rideshare services, as well as general digital literacy, are likely to significantly impact use of rideshare services for PLHIV.^18,19 For instance, one participant in the qualitative portion of the current study described preferring to use a medical van over rideshare, due to finding the overall process simpler. Some others described finding the scheduling process confusing and preferred having someone coordinate their rides rather than scheduling them on their own, suggesting potential benefits of employing “concierge” rideshare services for some PLHIV where clinics coordinate the rideshare for patients. Given the rapidly aging HIV population in the US, any efforts to incorporate rideshares must pay keen attention to whether individuals have the technological tools and literacy necessary for booking and payment of rideshare services. Indeed, research with adults ≥65 years old suggests that technological literacy was a barrier to their use of rideshares, though a significant portion (41.2%) reported using rideshares within the past month; thus, these approaches may be useful for older adults living with HIV, provided appropriate support is given in navigating the use of rideshares. ²¹ Policymakers and healthcare providers should consider integrating rideshare services into existing HIV care frameworks, particularly in regions with limited public transportation infrastructure. Adjusting Medicaid policies to cover additional non-emergency medical transportation, including rideshare options, could be a crucial step toward improving healthcare access for PLHIV. ⁷

Additionally, while most participants felt safe while using rideshare services, some expressed concerns about being recognized by drivers in their community—concerns that are driven by high rates of HIV-related stigma and fears about inadvertent disclosure of one's HIV status.^1,22–24 In a qualitative interview, one participant expressed that rideshare drivers are not bound by HIPAA, raising further privacy concerns for that individual. This finding was reflected in survey data, in which participants overall expressed discomfort with sharing personal information with a rideshare service. Concerns about confidentiality and privacy protections from rideshare drivers and companies could deter individuals from using them, particularly in smaller communities where fears of unintended disclosure may be heightened. These findings are consistent with prior work showing privacy and stigma concerns with using rideshares for PLHIV. ²⁵ Despite these challenges, most participants found the rideshare service beneficial. With attention to key participant needs—such as financial assistance, enhanced privacy measures, and streamlined scheduling—rideshare interventions could be an important way to reduce structural barriers to care and support a strong continuum of care for PLHIV.

Limitations and Future Directions

While the current study provided valuable insights, several limitations should be acknowledged. The small sample limits generalizability, and future studies should replicate the study on a larger scale to better understand how sociodemographic factors influence perceptions of rideshare services. Additionally, this study did not use a validated survey measure to assess perceptions of rideshare services, due to the lack of established tools in this area. Rather, the study team developed a new measure to assess participants’ perceptions of rideshare benefits. Although the measure holds face validity, future research should focus on developing validated measures to evaluate the acceptability and feasibility of rideshare services in healthcare settings. Furthermore, the survey queried participants about specific rideshare services (ie, Lyft, Uber); thus, they may not be representative of participants’ perspectives or experiences with other rideshare services. To strengthen the evidence base, future studies should also explore the cost effectiveness of integrating reliable rideshare services into existing healthcare frameworks to inform policy decisions. Finally, interviews ranged in length substantially. While all participants were asked questions according to the semi-structured qualitative interview guide, variation existed in response patterns from participants, with some participants providing more lengthy responses than others. This may have resulted in some participants not sharing their full perspectives during the interview.

Conclusion

This study contributes to the growing body of literature on transportation interventions in HIV care, demonstrating the rideshare services are perceived by PLHIV to be a feasible and acceptable option for addressing transportation barriers among PLHIV. While affordability and privacy concerns remain, strategic policy changes and targeted implementation efforts could enhance the effectiveness of rideshare interventions. Expanding access to reliable transportation is a critical step toward reducing health disparities and improving outcomes for PLHIV in the southern US.

Appendix A. Items Assessing Perceptions of Rideshare Services

Please indicate your agreement with the following statements.

	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
1. Using Lyft or Uber would save me money.	1	2	3	4	5
2. Using Lyft or Uber would help my household's monthly budget.	1	2	3	4	5
3. Using Lyft or Uber would make it easier to get from place to place.	1	2	3	4	5
4. Using Lyft or Uber is something I would enjoy.	1	2	3	4	5
5. Using Lyft or Uber appeals to me.	1	2	3	4	5
6. Using Lyft or Uber would reduce stress for me.	1	2	3	4	5
7. I would feel comfortable giving my personal information to Lyft or Uber.	1	2	3	4	5
8. Using Lyft or Uber is safe.	1	2	3	4	5
9. I would use Lyft or Uber if it was available to me.	1	2	3	4	5
10. Using Lyft or Uber would be easy for me.	1	2	3	4	5

Appendix B. Semi-Structured Interview Guide

First, I’d like to hear about any challenges or struggles you have experienced in the past with transportation.

1. Can you tell me about any times in the past when you have had difficulty with transportation to your HIV appointments?

2. Have your transportation difficulties ever affected your ability to engage in your HIV care? This could include attending clinic visits, attending lab visits, or refilling your medications.

3. How have your transportation challenges affected your physical health?

4. How have your transportation challenges affected your mental health?

5. Have you ever experienced of the following issues related to transportation: unsafe situations, problems paying for transportation, problems ordering or arranging transportation?

6. What has been most challenging for you in terms of transportation? (eg, reliability, cost, safety, distance, etc)

7. Sometimes people experience stigma because of the type of transportation that they use. This can include feeling bad about yourself and/or having others treat you differently or think differently about you because of the type of transportation you use. Have you ever experienced transportation-related stigma?

Next, I’d like to hear about how you have tried to overcome transportation issues that you may have experienced in the past.

• 8 When you’ve had problems with transportation, what have you tried? (eg, public transportation, relying on friends or family?)

• 9. Have these approaches been successful? Why or why not?

Now, I’d like to hear about your experiences over the past few months while you have been enrolled in the transportation research study at the University of South Carolina.

• 10. While you have been enrolled in the study, have you received Lyft rides or traditional transportation services, such as vouchers or access to the Medicaid van?

• 11. Can you tell me about the transportation that you’ve been using since being enrolled in the study?

• 12. Was the transportation that you’ve been using safe? Was it convenient? Was it easy to use?

• 13. Would you recommend the transportation services that you’ve been using to other people? Why or why not?

• 14. (IF using Lyft) Did you have any issues with the process of ordering and receiving Lyft rides?

Finally, I’d like to ask about your recommendations and your insight into how we can help other people living with HIV overcome transportation challenges.

• 15. How do you think we can improve transportation services for other people living with HIV? (programs, services, reimbursements?)