Telehealth Use for HIV Care: Patients' and Healthcare Providers' Perceptions and Predictors of Intention to Use Among Adults Living with HIV in Kampala, Uganda

Abstract

Background and Purpose Human Immunodeficiency Virus (HIV) remains an enormous public health challenge globally. People living with HIV face considerable challenges in accessing HIV services. Telehealth has the potential to address some of the obstacles to HIV care. However, little is known about telehealth's feasibility, acceptability, and efficacy in caring for people living with HIV. In low-resource settings specifically, there is a limited understanding of the determinants of telehealth use, and little is known about patients' and health providers' perceptions of the use of virtual care for people living with HIV. Overall aims. This dissertation had three broad aims: 1) to describe the feasibility, acceptability, and efficacy of telehealth for HIV testing and care, 2) to determine predictors of intention to use telehealth among adults living with HIV, and 3) explore patients' and health providers' perceptions about the use of telehealth to provide follow-up HIV care. Methods Aim 1. This aim was accomplished by conducting a literature review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework. The literature search was conducted across Ovid Medline, PsycINFO, and CINAHL databases for articles published through July 2021. The search yielded 1394 titles and abstracts, and after the screening, 17 full-text articles were included in the review. Aims 2 and 3. The second and third manuscripts involved a mixed methods study conducted among people living with HIV and focus group discussions conducted with nurses and counselors engaged in caring for people living with HIV. The second paper was a sequential explanatory study that examined predictors of intention to use telehealth and perceptions of patients living with HIV. A survey was conducted among 266 patients, and one-on-one interviews were conducted with 12 participants. The third manuscript reports findings from a qualitative study that explored perceptions of health providers (nurses and counselors) about the use of telehealth to provide follow-up HIV care. Results Aim 1. Findings from the literature review showed that videoconferencing and video-based interventions are generally feasible and acceptable. Videoconferencing is effective in improving adherence to HIV treatment and in promoting HIV testing. In addition, video-based interventions were effective in promoting HIV testing, treatment initiation, and adherence to medication. Both modalities enhanced linkage and retention in treatment for HIV-positive patients. Aim 2. Results from the survey part of the study showed that for a unit increase in effort expectancy scores, the odds of a participant scoring high in intention to use telehealth were 1.26 (95% CI, 1.13-1.41) times the odds of obtaining a low score. Likewise, for a unit increase in facilitating conditions scores, the odds of a participant scoring high in intention to use telehealth were 1.44 (95% CI, 1.17-1.73) times the odds of recording a low score. Furthermore, compared to participants who earned 10,000 UGX monthly (about $2.70), patients who earned an estimated monthly income of 100,001-500,000 UGX (approximately $27-135) had increased odds of obtaining a high score on intention to use telehealth. Likewise, compared to participants who earned 10,000 UGX (about $2.70), patients who earned an estimated monthly income of 500,000 UGX or more (≥ $135) had excess odds of obtaining a high score on intention to use telehealth. Also, compared to patients with poor medication adherence, participants with good adherence had increased odds of getting a higher score of intention to use score. Aim 3. From one-on-one interviews conducted with people living with HIV and focus group discussions held with health providers, we found similarities in perceptions about the benefits of telehealth and possible barriers to the adoption of virtual care. Some of the benefits cited by the participants include reducing the cost of care, enhancing the quality of care, promoting patient-health provider relationships, reducing loss to follow-up, and improving medication adherence. Barriers to telehealth adoption include a lack of smartphones, low digital literacy, fears about the security of personal health information, and challenges in accessing the internet. Both patients and health providers believed that telehealth would be suitable for counseling services, monitoring medication adherence, providing health education, and triaging patients. While patients and nurses felt that telehealth would help address stigma, counselors thought the implementation of telehealth would promote stigma among people living with HIV. Additionally, nurses thought the implementation of telehealth would compromise the delivery of other health services, including early diagnosis of non-communicable diseases. Finally, the nurses and counselors provided suggestions about issues that need to be addressed before the implementation of telehealth, including issues related to cost and access to reliable internet, establishing measures to protect patient health information, improving infrastructure, and training health professionals. Conclusions Telehealth interventions are beneficial in HIV testing and treatment. However, the scarcity of primary studies employing these telehealth modalities means that there is a need for more research in these areas, particularly in resource-limited settings that bear a high burden of HIV and AIDS. In addition, telehealth has the potential to enhance patient-centered care, particularly for patients adhering well to their medication. However, its implementation should not exacerbate existing health disparities, particularly among individuals with low socioeconomic and literacy levels. More research is needed to examine ways of integrating telehealth into existing HIV care models and how this will influence health outcomes in people living with HIV as well as the delivery of other health services.