Table 3.

Implications drawn from the present study

Implications for the larger context in which AABL-PLWH are located

It will be necessary to address structural inequality to end the HIV epidemic. Structural racism and structural inequality are fundamental causes of poor engagement along the HIV care continuum, and it is possible to address structural factors. For example, poverty is a fundamental cause of poor engagement and could be eliminated through poverty-reduction measures such as universal basic income or increasing federal financial benefit levels

In addition to addressing structural inequality, it will be necessary to tailor HIV care delivery models to the needs of AABL-PLWH to end the HIV epidemic. To bring this subpopulation of AABL-PLWH onto the HIV care continuum consistently, it will be necessary to simultaneously address structural barriers to engagement, and enhance or modify HIV care delivery models

High-quality housing is a foundation of HIV management. In some geographical locations, housing support for PLWH is needed, but lacking. In other more service-rich settings, such as New York City, housing support is provided, but poor-quality housing such as single-room occupancy residences interferes with HIV care continuum engagement and wellbeing generally

Data science has a role to play in ending the HIV epidemic. AABL-PLWH tend to discontinue HIV medication when life circumstances change. Data science may play a role in efforts to predict and prevent HIV medication discontinuation along with resources (adequate financial benefits, high-quality housing) to buffer the effects of life changes

Corrupt pharmacies undermine efforts to end the HIV epidemic. Ongoing efforts to stop pharmacies from illegally buying HIV medication from patients are needed

Implications for HIV care delivery settings

Structural competence may be lacking in many care settings. HIV care settings can be designed or re-designed in a comprehensive, top-to-bottom approach guided by models such as the IIT-ICM and by involving AABL-PLWH in the design process

Collaborative care approaches may be lacking in many settings. Health care providers can be trained in motivational interviewing, harm reduction, and other collaborative approaches as part of a comprehensive approach to addressing the problem of poor engagement along the HIV care continuum

Health care encounters are short but barriers to engagement are serious. Since health care encounters tend to be short, health care providers can better partner with social service providers and behavioral interventionists to meet the needs to those with the greatest barriers to engagement along the HIV care continuum

PLWH not taking HIV medication often feel unwelcome in HIV care. Not all AABL-PLWH are ready to take HIV medication at any given time and those not taking medication often leave or are even pushed out of HIV primary care. Enhanced efforts to locate and engage AABL-PLWH not taking HIV medication in HIV primary care and other services are warranted

Substance use and mental health treatment in HIV care settings may not be sufficiently available and/or may benefit from the IIT-ICM. Substance use and substance use challenges and mental health concerns are very common among AABL-PLWH who are poorly engaged along the HIV care continuum, but harm reduction and dignity-enhancing services are lacking. Co-locating HIV care, substance use (including harm reduction approaches), mental health, navigation, and other needed services will boost engagement in these services

Care settings may not address emotions inherent in HIV management sufficiently. Many programs and interventions for AABL-PLWH do not sufficiently attend to the emotions inherent in HIV management, but the IIT-ICM and the present study underscore the important role of emotion in engagement along the HIV care continuum,

Patients and providers often have fraught relationships. Patients’ relationships with providers are often complicated by fear and medical distrust, the tendency to give socially desirable responses, and experiences of stigma, in the context of short health care encounter times. Approaches grounded in the IIT-ICM can foster more constructive and open communication and relationships

Power imbalances are common between AABL-PLWH from socioeconomically disadvantaged backgrounds and providers, which may impede open and honest communication. Counseling and treatment approaches grounded in the IIT-ICM can potentially play a role in fostering open communication and trust across these imbalances

Individualized and flexible approaches are needed. Meeting AABL-PLWH “where they are” by addressing the health needs patients prioritize first can generate trust and foster the needed constructive provider/participant relationship, which has the potential to generate additional health goals

Disengagement from the care continuum can be prevented. Retention clinics within HIV care settings can provide targeted services to AABL-PLWH at risk for disengagement