AIDSImpact.com:: - Santa Fe, USA 2011

Abstract #375 - Understanding the behavioral determinants of retention in HIV care: a qualitative evaluation of a situated information, motivation, behavioral skills model of care initiation and maintenance
Authors: Presenting Author: Ms. Laramie Smith - University of Connecticut
Additional Authors: Dr. K. Rivet Amico, Dr. Jeffrey Fisher, Dr. Chinazo Cunningham,
Aim: Presently, there are few behavioral models and little in-depth research available to guide our understanding of critical factors that influence HIV-care use once individuals have initiated HIV clinical care that extend beyond patient demography or simple correlates. Retention in HIV care is a critical health behavior in terms of promoting individual health and controlling community level viral burden, a key component in test-and-treat strategies. After initiating HIV care, an estimated 30% to 41% of people living with HIV (PLWH) are poorly retained in HIV care in the US, which is associated with increased odds of mortality and poor viral suppression. The current study aimed to qualitatively evaluate the applicability and validity of a recently proposed theoretical model of retention in HIV care, the situated information, motivation, behavioral skills model of care initiation and maintenance (sIMB-CIM).
Method / Issue: In-depth semi-structured interviews were conducted with a sample of inner-city PLWH accessing traditional clinic-based (N = 10) and non-traditional mobile medical outreach (N = 10) HIV care services in the Bronx, NY. Interviews were transcribed verbatim, segmented and iteratively coded for type of HIV care, HIV-care facilitators/barriers, and sIMB content; yielding an overall Kappa of 0.81, indicating good reliability between coders. Deductive and inductive analyses were used to identify the content and context of critical informational, motivational, and behavioral skills related facilitators and barriers to retention in HIV care and evaluate the relative fit of the model to the qualitative data collected.
Results / Comments: Through content coding, all but 7.1% of participant discourse related to facilitators or barriers to retention in HIV care were characterized by the sIMB theoretical constructs. Irrespective of sIMB content, emergent theme identification elicited a number of important themes influencing HIV care utilization that later demonstrated considerable convergence between the inductively identified thematic content and the a-priori assumptions of the model. These analyses identified unique sIMB content not previously characterized by the model and important contextual considerations. For example, the use of faulty heuristics (misinformation) revealed ways in which patientsâ€™ perceive HIV-care as an â€śall or nothing processâ€ť where any experience of sub-optimal self-care behaviors (e.g., medication non-adherence, acute mental illness, active substance use) delegitimize oneâ€™s perceived ability to engage in any positive self-care behaviors such as routine HIV care. Additionally, anticipated negative reactions from providers, shame or internalized stigma related to these sub-optimal self-care behaviors often fueled patientsâ€™ motivation to withdrawal from routine HIV care. Behavioral skills to identify appropriate sources of social support (e.g., friends, family, providers), for remaining in care in the presence of these contextual factors, should address patientsâ€™ perceived consequences of disclosing their HIV, mental health, or substance use status.
Discussion: Participantsâ€™ experiences map well onto the sIMB theoretical constructs, and formal model evaluations are warranted. These qualitative results provide nuanced identification of important retention-relevant sIMB content and contextual factors. Intervention development efforts informed by the current study indicate a need to attend to multiple determinants of self-directed care attendance (i.e., information, motivation, and behavioral skills) to enhance retention in care over time.
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