13 May 2014
British Columbia researchers propose ways of improving care for HIV-positive women
Taking potent combination anti-HIV therapy (commonly called ART or HAART) every day, exactly as directed, is a cornerstone of improving health for HIV-positive people. Many other factors can affect health, well-being and survival of patients, and one of those factors is the quality of care that patients receive.
Researchers at the BC Centre for Excellence in HIV/AIDS in Vancouver have developed a tool to assess the quality of care received by patients. This tool, called the Programmatic Compliance Score (PCS), compares certain aspects of care that patients receive against recommendations within leading HIV treatment guidelines.
In previous research, the BC team that developed the PCS found that patients who are not receiving guideline-recommended care in the first year of using ART are likely to have poor health and an increased risk of death.
In its latest report, the BC team focused on analysing the care received by nearly 3,600 HIV-positive participants (80% men, 20% women). The researchers found that, overall, women appeared to receive “poorer quality of care” than men. Furthermore, the researchers found that women with the following factors were more likely to be recipients of poorer quality of care:
- a history of injecting street drugs
- being of Aboriginal ancestry
- residing on Vancouver island
- initiating ART shortly after it became available in the mid-to-late 1990s
The research team provided ideas of how care for HIV-positive women could be improved. These are discussed later in this CATIE News bulletin.
Researchers reviewed medical information collected from HIV-positive participants who initiated ART between January 2000 and October 2010.
The assessment tool developed by the BC researchers relies on a series of steps outlined in leading treatment guidelines, such as those produced by the BC Centre for Excellence and the International Antiviral Society in the U.S. (IAS-USA). The BC team focused on the following issues:
- prior to initiating ART, having a test to assess if the patient’s HIV is resistant to any anti-HIV drugs
- initiating ART using a combination of drugs preferred by the guidelines
- initiating ART shortly after HIV diagnosis
- during the first year of therapy, receiving at least three CD4+ cell count and viral load tests
- achieving a viral load less than 50 copies/ml after the first six months of therapy
The average profile of participants at the start of the study was as follows:
- 80% men, 20% women
- age – 42 years
- CD4+ count – 200 cells/mm3
- viral load – 79,000 copies/ml
The researchers stated that “women were 58% more likely than men to receive poorer quality of care.”
Women with the following factors were generally less likely to receive guideline-recommended care:
- a history of injecting street drugs
- being of Aboriginal ancestry
- living on Vancouver island
Other findings by the BC team included the following:
- 42% of women compared to 34% of men did not receive testing for drug-resistant HIV prior to starting therapy
- 17% of women compared to 9% of men started ART with a regimen not recommended by guidelines
- roughly similar proportions of women (47%) and men (49%) delayed initiating ART until their immune systems were seriously degraded—when their CD4+ count was less than 200 cells/mm3
During the first year of ART, researchers found the following:
- 17% of women compared to 11% of men received less than three CD4+ cell count tests and less than three viral load assessments
- 50% of women and 41% of men did not have their viral load fall below the 50-copy/ml mark within the first six months of therapy
Bear in mind
The researchers stated that their findings “suggest that women still face several barriers to high-quality care.”
There are many factors that could have had an impact on the quality of care that some women received in BC that were not explored in the present study, including the following:
- stigmas related to gender and HIV
- the presence of psychological issues, including past trauma and depression
- social isolation
- competing responsibilities: women often have to do the work of managing a household, preparing meals and looking after children in addition to working outside the home. These tasks limit the time available for their own needs. Some women, in their role as parent and care-giver, may prioritize the health of other family members before their own health
- negative experiences with the medical-healthcare system
The BC researchers stated that there should be “more tailored, gender-focused strategies that are responsive to women’s needs,” including some of the following ideas:
- the option of “seeing a female care provider”
- prioritize “a safe, nonjudgmental atmosphere for care”
- provide “transportation reimbursement, free childcare, food and other specialized supports to address women’s social and ancillary needs”
- “is supportive of women’s…empowerment, and active participation in their care”
- “is attentive to women’s diversity and lived experience”
- takes an evidence-based approach to helping women cope with, and eventually overcome, addiction
A possible model for care
The researchers stated that one model for women-centred care is Vancouver’s Oak Tree Clinic for HIV-positive women and children. The researchers did a sub-analysis of 233 women who attended this clinic and 509 other women who did not. They found that women who received care at the Oak Tree Clinic were more likely to have higher quality-of-care scores.
There are at least two limitations to the present analysis, as follows:
- It was not able to capture the quality of care that transgender women received.
- There was no data on pregnancy status. So in the cases where some women seek care late in the course of pregnancy and are subsequently diagnosed with HIV, ART may need to be started very quickly to reduce the risk of the fetus becoming infected. In such circumstances, drug resistance testing may not be prioritized or be possible in a timely manner.
Expanding access to care
Public health authorities in BC are expanding opportunities for the offer of HIV testing, counselling and swift referral to subsequent care and treatment. However, it is important that research be undertaken to assess the barriers that stand in the way of optimal care and treatment. The results of the BC analysis show that even in a region that has no financial barriers to treatment for citizens, women experience difficult access to such care. The BC research team calls for new studies to explore and evaluate women-centered care for HIV-positive women.
—Sean R. Hosein
- Lima VD, Le A, Nosyk B, et al. Development and validation of a composite programmatic assessment tool for HIV therapy. PLoS One. 2012;7(11):e47859.
- Carter A, Eun Min J, Chau W, et al. Gender inequities in quality of care among HIV-positive individuals initiating antiretroviral treatment in British Columbia, Canada (2000-2010). PLoS One. 2014 Mar 18;9(3):e92334.