Migrants Living with HIV: Exploring Barriers to HIV Care Engagement and an Approach to Address Challenges Beyond Diagnosis

Background: Migrants living with HIV (MLWH) are a rapidly growing population in countries affiliated with the Organization for Economic Co-Operation and Development (OECD). Across OECD countries, MLWH have poorer health outcomes compared to their non-migrant counterparts. Research on the barriers and facilitators to care for MLWH in OECD countries has centered on HIV testing. Concurrently, to champion an equity-focused response to eliminating HIV and AIDS as public health threats, HIV scholars and organizations have called for developing, evaluating, and scaling targeted clinical interventions specifically for MLWH. To respond to these calls, a new approach to caring for MLWH in Montreal, Canada, has been piloted in a multidisciplinary clinic since 2020. Specifically, “the ASAP study” provides MLWH with free antiretroviral therapy (ART), on-site and rapidly (i.e., within 7 days of being linked to care).Objectives: The specific objectives of this doctoral thesis are to: (1) systematically review the barriers and facilitators MLWH in OECD countries encounter beyond diagnosis; (2) investigate the patient-reported experiences and outcomes of MLWH enrolled in ASAP through qualitative and quantitative methods; and (3) explore HIV-related clinical outcomes and the effect of social determinants of health on these outcomes for MLWH enrolled in ASAP.Methods: To address these objectives, I conducted: a systematic mixed studies review (protocol published in BMJ Open, and results published in AIDS Patient Care & STDs); a longitudinal qualitative analysis of semi-structured interviews with MLWH enrolled in ASAP (manuscript published in the Journal of Personalized Medicine); a quantitative analysis encompassing descriptive statistics and linear mixed modelling for patient-reported outcome and experience measures among MLWH enrolled in ASAP (manuscript under review in AIDS Research and Therapy); and a quantitative analysis involving descriptive statistics and survival analyses on HIV-related clinical outcomes, and the effect of social determinants on these outcomes for MLWH enrolled in ASAP (manuscript published in HIV Medicine).Results: Manuscripts 1 and 2: MLWH experience numerous challenges that impede their initial linkage to and sustained engagement with HIV care and treatment, and ultimately their HIV viral suppression. In particular, not meeting basic needs such as housing and food, or not having stable and secure finances, occupation, or immigration status can lead to disengagement with HIV services among MLWH. However, in this review, providing MLWH with multidisciplinary care was identified as a facilitator to sustained engagement with HIV services. Manuscript 3: Receiving humanizing, holistic, and empowering care from a multidisciplinary team, alongside free ART rapidly, were identified as highly positive elements in the HIV care experience of MLWH, and seemed to motivate their HIV self-management and encourage sustained engagement with care. However, throughout their time in care, MLWH expressed that they continued experiencing complex psycho-social challenges. Manuscript 4: MLWH reported highly positive experiences and outcomes around their HIV care and treatment but continued to report high levels of psychological distress throughout their time engaged in care. Manuscript 5: On median, MLWH enrolled in ASAP were able to initiate ART and reach HIV viral undetectability within 5 (range: 0-50) and 57 days (range: 5-365), respectively. Those who took significantly longer to initiate ART: were less than 35 years old; identified as heterosexual; had less than university-level education; or were unemployed. No social determinant was found to significantly affect time to undetectability.Conclusion: This doctoral thesis contributes timely findings towards understanding the healthcare experiences and outcomes of MLWH. Notably, MLWH experience tremendous multifaceted barriers across each step of the HIV Care Cascade. However, preliminary evidence supports an approach to care grounded in aspects of patient-centred care (e.g., the provision of humanizing and empowering services), with the provision of free ART dispensed on-site and rapidly, to facilitate ART initiation, sustain HIV care engagement, and efficiently reach HIV viral undetectability among MLWH. However, these services appear insufficient for thoroughly addressing the mental health needs of MLWH. Concurrently, ART initiation appears to be influenced by social determinants. This suggests the importance of embedding dedicated, well-funded, and accessible mental health support in HIV clinical settings, and further considering the impact of social determinants of health when designing clinical interventions for more equitable outcomes

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