Professional Documents
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Exploring Patient Perception of Barriers and Facilitators to Postpartum HIV Care Retention and
Adherence
Rosemary Kinuthia
Academic Support
Committee Chair
Name Dr. John Cranmer
Expertise for Project Dr. Cranmer is an Assistant Professor at Emory University, Nell Hodgson
Woodruff School of Nursing. He is well versed on how to link
implementation science research in current practice to improve the future
state of healthcare. Dr. Cranmer has extensive experience with clinical care
cascades and has been adopting the HIV care cascade to a different context
in developing countries.
Credentials DNP, MPH, MSN, ANP-BC
Project Faculty #1
Name Dr. Marcia Holstad
Expertise for Project Please see above
Credentials PhD, FNP-BC, FAANP, FAAN
Project Faculty #2
Name Dr. Anandi Sheth
Expertise for Project Dr. Sheth is an Assistant Professor at Emory School of Medicine,
Department of Medicine, Division of Infectious Diseases. Her clinical and
research interests focus on the treatment and prevention of HIV among
women. She is also a provider at my clinical partner site.
Credentials MD
Expansion - Dissemination
1st Journal AIDS Patient Care and STDs http://www.liebertpub.com/forauthors/aids-
patient-care-and-stds/1/
Type of Manuscript Research article
Format Requirement (i.e. Order-of-citation format for references. Cite references within the text by a
APA) superscripted Arabic number.
For journal citations: (1) surname of author(s) and initials; (2) title of
article; (3) journal; (4) year of publication: (5) volume number; (6)
inclusive page range of citation.
Despite a high level of care engagement during pregnancy, in 2016, approximately 30%
of HIV-infected pregnant women that delivered at Grady Hospital had VL>200 copies/mL within
6 months postpartum, increasing their risk for morbidity and perinatal transmission of HIV
during subsequent pregnancies. Identifying patient perceived barriers and facilitators specific to
the population at the Grady Infectious (IDP) would facilitate development and application of
evidence-based interventions that will address the identified gaps. This project will play an
integral role in facilitating continuity of HIV care by transforming how health services are
delivered to and improving the health outcomes of HIV-infected postpartum women in Atlanta,
GA.
This project aims to improve postpartum HIV care for pregnant HIV-infected women
delivering at Grady Hospital by investigating barriers and facilitators to postpartum HIV care
retention and adherence. The specific objectives of this project are: 1) To examine and describe
patients perception of barriers to postpartum HIV care follow-up, and 2) To examine and
describe patients perception of elements that support and enhance continuity of care.
A grounded theory method will applied for this project. A qualitative approach using
semi-structured interviews of HIV-infected women whose most recent viral load (VL) during the
first 6 months post delivery is not <200 copies/mL, and women whose VL was consistently
>200 copies/mL during the first 6 months post delivery. The data to be analyzed for this project
will include transcripts from the interviews. NVivo will be used for analysis to identify key
concept and common themes.
Exploring Patient Perception of Barriers and Facilitators to Postpartum HIV Care Retention and
Adherence
Introduction-Background
public health problem. Data from the Centers of Disease Control and Prevention (CDC) reports
that in the United States, only about 50% of persons diagnosed with HIV receive regular HIV
care1. This global health issue greatly impacts HIV treatment outcomes of patients receiving
care at the Grady Infectious Disease Program (IDP) at Ponce De Leon Center; one of the largest,
most comprehensive facilities dedicated to the treatment of advanced HIV/AIDS in the United
States2. The most recent unpublished raw data from the clinic showed that despite addressing and
controlling for the typical known barriers to HIV care retention and adherence such as cost of
treatment and access, approximately 30% of HIV-infected pregnant women that deliver at Grady
Poor HIV care retention increases the risk for morbidity 4and perinatal transmission of
HIV during subsequent pregnancies 5. For best outcomes HIV infected individuals should adhere
A review of literature reporting findings from a similar problem was conducted to inform
potential causes of poor adherence and retention to HIV care among postpartum women at Grady
IDP. Buchberg et al 7 examined barriers to HIV postpartum care in underserved HIV positive
women in Southern United States. This research study identified lack of time, lack of social
support, transportation issues, and HIV related stigma as barriers to postpartum HIV care
retention. A qualitative study by Boehme et al examining factors impacting HIV care adherence
that was conducted in Alabama uncovered similar themes. Additional barriers to clinic visit
adherence identified in this study include clinic/copay expenses and duration of appointments 8
Potential moderating factors supporting postpartum HIV care retention may be attributed
to knowledge about the importance of adherence to HIV care and having strong relationships
with providers 7. Boehme 8 also found that intrinsic motivation ranked highly as a facilitator for
adherence to postpartum HIV care. Patients expressed their desire to stay healthy and live long,
Addressing individual level as well as system level factors in order to reduce the barriers
outcomes among HIV infected women after delivery 7. In an effort to moderate the problem,
Grady IDP utilizes a multidisciplinary approach to care, and the various departments at Grady
IDP work collaboratively. The center provides access to HIV health education, social workers,
and case managers who assist the clients served by connecting them to essential services such as
housing and transportation. The IDP center also houses several other agencies such as AID
Atlanta and ADAP, which assist clients by providing a broad range of HIV and AIDS services,
and free medications for the treatment of HIV/AIDS. Providing access to these resources in-
Current evidence has shown that a mediating factor for poor retention and adherence
includes identifying context-specific barriers and facilitators to HIV care. Exploring patients
perception of barriers to postpartum HIV care follow-up and elements that support and enhance
retention, thus improving health outcomes 7. For a summary of the literature review see Figure
Hospital had VL>200 copies/mL within 6 months postpartum. Therefore, global aim of the DNP
project is to improve postpartum HIV care for the pregnant HIV-infected women delivering at
Grady Hospital by aiming for VL<200 copies/mL in 100% of the women that deliver at Grady
This project specifically aims to investigate barriers and facilitators to postpartum HIV
care retention and adherence through a qualitative study using semi-structured interviews of up
to 15 HIV infected women by November 2016. The objectives of this project are: 1) To examine
and describe patients perception of barriers to postpartum HIV care follow-up, 2) To examine
and describe patients perception of elements that support and enhance continuity of care, and 3)
Methods
The social-ecological model will be used as the framework for understanding the factors
that influence retention and adherence to HIV care at the IDP. Selection of the social-ecological
model as the framework for this project was influenced by findings suggesting that multilevel
Proposed intervention
Target population
We will recruit up to 7 women whose most recent VL during the first 6 months post
delivery is not <200 copies/mL, and up to 15 whose VL was consistently <200 copies/mL during
excluded if they are less than 18 years old, non-English speaking, or are unwilling to provide
Sampling strategy
Purposive sampling will be applied for this study. Participants will be recruited
exclusively from Grady HIV/OB clinic via provider (clinician, nursing, or social work) referral
after they have attended their postpartum obstetrical visit (or been contacted regarding a missed
visit). Once a provider recommends a patient as a potential participant, the study team will
Variables
A grounded theory qualitative approach will be used for this project. Barriers explored
will include at least the following domains: time constraints, transportation access limitations,
financial barriers, stigma, lack of knowledge/education, social support, childcare, and system
navigation/clinic process. Facilitators considered will include but not limited to: a
multidisciplinary approach for clinical care, Ryan White funding, resources such as AIDS Drug
Assistance Program (ADAP), housing, and AID Atlanta, and positive relationships with
Measurement strategy
During the project implementation phase; September 1, 2016 to November 15, 2016, the
DNP student investigator will conduct either semi-structured phone or in-person interviews after
verbal consent is obtained. Participants will receive a $25 VISA gift card for participation in the
study.
Data analysis
anonymity, names will be omitted from the written transcripts, and recordings will be destroyed
following review of the data. Data will be analyzed using appropriate qualitative analytic
Ethical Inquiry
This project falls under an already approved protocol titled Improving HIV care during
pregnancy and postpartum for HIV-infected women receiving prenatal care at Grady Memorial.
Emory Universitys Institutional Review Board (IRB) reviewed the protocol through the
expedited review procedure because it poses minimal risk. The current protocol will be amended
to reflect most recent data and project aims. See Figure 2 for the current Emory IRB decision
letter.
References
1. Centers for Disease Control and Prevention. Linkage to and Retention in HIV Medical
Care 2013.
2. Grady Health System. Ponce De Leon Center. 2105.
3. Sheth. In: Kinuthia R, editor. 2016.
4. Ulett KB, Willig JH, Lin HY, Routman JS, Abroms S, Allison J, et al. The therapeutic
implications of timely linkage and early retention in HIV care. AIDS Patient Care STDS.
2009;23(1):41-9.
5. Camacho-Gonzalez AF, Kingbo, M. H., Boylan, A., Eckard, A. R., Chahroudi, A., &
Chakraborty, R. Missed opportunities for prevention of mother-to-child transmission in the
United States. AIDS (London, England). 2015;29(12):1511.
6. Mountain E, Pickles M, Mishra S, Vickerman P, Alary M, Boily MC. The HIV care
cascade and antiretroviral therapy in female sex workers: implications for HIV prevention.
Expert Rev Anti Infect Ther. 2014;12(10):1203-19.
7. Buchberg MK, Fletcher FE, Vidrine DJ, Levison J, Peters MY, Hardwicke R, et al. A
mixed-methods approach to understanding barriers to postpartum retention in care among low-
income, HIV-infected women. AIDS Patient Care STDS. 2015;29(3):126-32.
8. Boehme AK, Davies SL, Moneyham L, Shrestha S, Schumacher J, Kempf MC. A
qualitative study on factors impacting HIV care adherence among postpartum HIV-infected
women in the rural southeastern USA. AIDS Care. 2014;26(5):574-81.