Sanchez Amanda L, Mills Chynna, Coley DeAuj'Zhane, Hoskins Katelin, Momplaisir Florence, Gross Robert, Brady Kathleen A, Beidas Rinad S
Department of Psychology, George Mason University, Fairfax, VA, USA.
Department of Psychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
Int J Equity Health. 2025 May 6;24(1):123. doi: 10.1186/s12939-025-02481-8.
Adherence and retention in care are key targets to achieve favorable health outcomes for people with HIV. Challenges with adherence and retention are pronounced for marginalized communities facing intersectional structural oppression. Community health worker delivery of Managed Problem Solving (MAPS+), an evidence-based behavioral intervention, has the potential to improve adherence and retention, yet understanding structural inequities affecting people with HIV is necessary to increase the likelihood of equitable implementation. The current study explores systemic inequities influencing HIV care adherence and retention, and approaches to address these challenges. We conducted semi-structured interviews with 13 clinics and 4 constituent groups: prescribing clinicians, non-prescribing clinical team members (e.g., medical case managers), clinic administrators, and policymakers. Through reflexive thematic analysis within a constructionist paradigm, we identified two key themes. The first elucidated experiences of systemic inequities such as access to resources, healthcare system navigation difficulties, power differentials, medical mistrust, intersectional stigma and potential patient burden associated with MAPS+. The second theme highlighted the ways in which staff and clinicians shoulder the burden of addressing inequities by approaching people with HIV with dignity and developing trusting relationships and how MAPS + can bolster this approach by partnering with and centering patient needs. While these individual and organizational efforts are valuable, ending the HIV epidemic requires structural changes to address systemic inequities directly. This research underscores the complex interplay between structural oppression and HIV care, calling for comprehensive approaches to achieve health equity.
坚持治疗和持续接受治疗是为艾滋病毒感染者实现良好健康结果的关键目标。对于面临交叉结构性压迫的边缘化社区而言，坚持治疗和持续接受治疗面临着严峻挑战。社区卫生工作者提供的循证行为干预措施——管理式问题解决法（MAPS+），有可能改善治疗的坚持率和持续率，但要提高公平实施的可能性，就必须了解影响艾滋病毒感染者的结构性不平等问题。本研究探讨了影响艾滋病毒治疗坚持率和持续率的系统性不平等问题，以及应对这些挑战的方法。我们对13家诊所和4个组成群体进行了半结构化访谈：开处方的临床医生、非开处方的临床团队成员（如医疗病例管理人员）、诊所管理人员和政策制定者。通过建构主义范式下的反思性主题分析，我们确定了两个关键主题。第一个主题阐述了系统性不平等的经历，如资源获取、医疗系统导航困难、权力差异、医疗不信任、交叉污名以及与MAPS+相关的潜在患者负担。第二个主题强调了工作人员和临床医生通过以尊严对待艾滋病毒感染者并建立信任关系来承担解决不平等问题的负担的方式，以及MAPS+如何通过与患者需求合作并以患者需求为中心来支持这种方法。虽然这些个人和组织的努力很有价值，但要终结艾滋病毒流行，需要进行结构性变革以直接解决系统性不平等问题。这项研究强调了结构性压迫与艾滋病毒治疗之间复杂的相互作用，呼吁采取综合方法来实现健康公平。
