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

南卡罗来纳州（SC）是终止艾滋病毒流行（EHE）运动的优先管辖区之一， 艾滋病毒高传播地区。在2019冠状病毒病大流行期间，SC经历了超过10年的护理中断， 80%的艾滋病诊所。为了减轻这些干扰，几乎所有艾滋病毒护理提供者都提供远程保健。然而，在这方面， 远程保健的参与和惠益分配不均。住房不稳定的人，种族 和少数民族，老年人，非英语母语的人，以及没有保险的人， 远程保健遇到或经历了更多的挑战。组织、提供者和患者方面的障碍， 远程医疗在艾滋病护理中的应用包括技术、数字扫盲、官僚、监管和报销 问题.应在多大程度上维持与COVID-19相关的艾滋病毒护理向远程医疗的过渡， 扩大或逆转，尚不清楚。本论文旨在描述模式和差距， COVID-19期间的远程医疗艾滋病毒护理，并了解指导选择艾滋病毒访问类型的决策过程。 我将使用混合方法探索性方法解决3个具体目标： 目标1。评估患者和提供者在远程医疗艾滋病毒护理和远程医疗相关决策方面的经验 在COVID-19期间进行。我将对多达20名患者和多达10名艾滋病毒感染者进行定性深入访谈 护理提供者。专题分析将用于探索和综合与障碍、决策、 制作和其他感兴趣的领域。 目标二。描述COVID-19期间远程医疗艾滋病毒访问的模式。我会分析电子健康记录 (EHR)来自哥伦比亚Prisma免疫学中心（PIC）的大约2,400名成年患者的数据， SC最大的艾滋病毒护理提供者，以探讨艾滋病毒就诊类型的分布是否随时间而变化， 威尔斯亲王医院在亲临诊症和遥距诊症之间转换的程度。 目标3：分析COVID-19期间远程医疗在艾滋病毒护理中的使用与种族、民族、年龄、 农村与城市居住。我将使用生存率和复发事件分析与目标2相同的EHR数据 分析描述远程医疗启动、恢复到面对面护理和差距的系统变化 访问之间，种族，民族，年龄和农村/城市居住。 本文将描述COVID-19期间远程医疗和面对面艾滋病毒护理的模式和差异， 19大流行病。对大流行期间患者和提供者经验的分析将为机会提供信息， 与远程保健艾滋病毒护理和艾滋病毒护理调整有关的障碍和挑战，以满足患者需求 并用于将本文的定量研究结果置于情境中。公平地获得艾滋病毒护理对于 坚持和保持护理。因此，这项研究的结果具有很大的潜力，可以为最佳使用 远程保健，从而有助于扩大艾滋病毒治疗战略和减少差距的EHE目标 对弱势威尔斯亲王医院的健康影响。

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.