Patient experiences and disparities in telehealth HIV care during the COVID-19 pandemic: A mixed methods study from the Southern US

South Carolina (SC) is one of the priority jurisdictions for the Ending the HIV Epidemic (EHE) campaign targeting high HIV transmission areas. During the COVID-19 pandemic, SC experienced care disruptions in more than 80% of HIV clinics. To mitigate these disruptions, almost all HIV care providers offered telehealth. However, participation in and benefits from telehealth were not distributed equally. People with unstable housing, racial and ethnic minorities, older individuals, non-native English speakers, and uninsured individuals engaged in fewer telehealth encounters or experienced more challenges. Organizational, provider-, and patient-side barriers to telehealth use in HIV care included technological, digital literacy, bureaucratic, regulatory, and reimbursement issues. The extent to which COVID-19-related transitions to telehealth for HIV care should be sustained, expanded, or reversed, is not clear. This dissertation seeks to characterize patterns of and disparities in telehealth HIV care during COVID-19 and understand decision processes guiding the selection of HIV visit type. I will address 3 specific aims using a mixed methods exploratory approach: Aim 1. To assess patient and provider experiences with telehealth HIV care and telehealth-related decision processes during COVID-19. I will conduct qualitative in-depth interviews with up to 20 patients and up to 10 HIV care providers. Thematic analysis will be used to explore and synthesize constructs related to barriers, decision making, and other domains of interest. Aim 2. To characterize patterns of telehealth HIV visits during COVID-19. I will analyze electronic health record (EHR) data from approximately 2,400 adult patients cared for at Prisma's Immunology Center (PIC) in Columbia, the largest HIV care provider in SC, to explore whether the distribution of HIV visit types varied over time and the extent to which PWH switched between in-person and telehealth visits. Aim 3. To analyze systematic variation in telehealth use in HIV care during COVID-19 with race, ethnicity, age, and rural vs. urban residence. I will analyze the same EHR data as for Aim 2 using survival and recurrent event analyses to describe systematic variation in the initiation of telehealth, reversion to in-person care, and gaps between visits, with race, ethnicity, age, and rural/urban residence. This dissertation will describe patterns of and disparities in telehealth and in-person HIV care during the COVID- 19 pandemic. Analyses of patient and provider experiences during the pandemic will inform opportunities, barriers, and challenges related to telehealth HIV care and HIV care adjustments needed to meet patient needs and used to contextualize quantitative findings of this dissertation. Equitable access to HIV care is critical for adherence and retention in care. Results of this study therefore hold great potential to inform the optimal use of telehealth, thereby contributing to EHE goals of scaling up key HIV treatment strategies and mitigate disparities in health outcomes for disadvantaged PWH.