"Where It Falls Apart": Barriers to Retention in HIV Care in Latino Immigrants and Migrants.
Julie H Levison, Laura M Bogart, Iman F Khan, Dianna Mejia, Hortensia Amaro, Margarita Alegría, Steven Safren
Author Information
Julie H Levison: 1 Division of General Internal Medicine, Massachusetts General Hospital , Boston, Massachusetts.
Laura M Bogart: 4 Health Unit, RAND Corporation , Santa Monica, California.
Iman F Khan: 1 Division of General Internal Medicine, Massachusetts General Hospital , Boston, Massachusetts.
Dianna Mejia: 1 Division of General Internal Medicine, Massachusetts General Hospital , Boston, Massachusetts.
Hortensia Amaro: 5 Suzanne Dworak-Peck School of Social Work and Department of Preventive Medicine, Keck School of Medicine, University of Southern California , Los Angeles, California.
Margarita Alegría: 2 Department of Medicine, Massachusetts General Hospital , Boston, Massachusetts.
Steven Safren: 7 Department of Psychology, University of Miami , Miami, Florida.
Latino immigrants in the United States are disproportionately affected by HIV. Barriers to consistent attendance (retention) in HIV primary care constrain opportunities for HIV treatment success, but have not been specifically assessed in this population. We conducted semistructured interviews with 37 HIV-infected Latinos (aged ≥18 years and born in Puerto Rico or a Latin American Spanish-speaking country) and 14 HIV providers in metropolitan Boston (total n = 51). The Andersen Model of Healthcare Utilization informed a semistructured interview guide, which bilingual research staff used to explore barriers to HIV care. We used thematic analysis to explore the processes of retention in care. Six ubiquitous themes were perceived to influence HIV clinic attendance: (1) stigma as a barrier to HIV serostatus disclosure; (2) social support as a safety net during negative life circumstances; (3) unaddressed trauma and substance use leading to interruption in care; (4) a trusting relationship between patient and provider motivating HIV clinic attendance; (5) basic unmet needs competing with the perceived value of HIV care; and (6) religion providing a source of hope and optimism. Cultural subthemes were the centrality of family (familismo), masculinity (machismo), and trusting relationships (confianza). The timing of barriers was acute (e.g., eviction) and chronic (e.g., family conflict). These co-occurring and dynamic constellation of factors affected HIV primary care attendance over time. HIV-infected Latino immigrants and migrants experienced significant challenges that led to interruptions in HIV care. Anticipatory guidance to prepare for these setbacks may improve retention in HIV care in this population.
