Running Head: DNP PROJECT

Exploring Patient Perception of Barriers and Facilitators to Postpartum HIV Care Retention and

Adherence

Rosemary Kinuthia

Emory University Nell Hodgson Woodruff School of Nursing

DNP PROJECT

DNP Project Prospectus

August, 2016

Project Summary Matrix

Item Brief Summary
DNP Student - Transformer
DNP Student Name Rosemary Kinuthia, MPH, RN
Professional Passion & Issue My professional passion is to improve population health outcomes,
especially in HIV/AIDS populations in underserved areas. I am interested
in improving health outcomes in these populations by exploring how to
improve linkage and retention to care and promote antiretroviral
medication adherence.
Practice - Learning Context
Site
Practice Site(s) My practice site is the Grady Infectious Diseases Program (IDP) at Ponce
De Leon Center.
341 Ponce De Leon Avenue Atlanta, GA 30308 Phone: (404) 616-2440
Sites Link to Passion-Interest The Ponce De Leon Center is one of the largest, most comprehensive
facilities dedicated to the treatment of advanced HIV/AIDS in the United
States. The Ponce Center and its onsite affiliates provide various medical
and support services to approximately 5000 eligible men, women,
adolescents, and children living with HIV/AIDS (Grady Health System,
2015)
Project
Title TBD (title requires change after recent revisions in problem)
Specific Topic Area My goal is to explore patient perceived barriers and facilities to retention
and adherence to are HIV infected women that deliver at Grady Memorial
Hospital
Conceptual Model(s)
Health Belief Model (HBM)
Mentor
Name Dr. Marcia Holstad
Expertise for Project Dr. Holstad is an Assistant Professor at Emory University, Nell Hodgson
Woodruff School of Nursing. She has extensive experience working with
and conducting research in HIV. Currently she is the Principal Investigator
of two NIH funded HIV projects. She is also an APRN provider at the
potential clinical partner site.
Title Assistant Professor, Emory University, Nell Hodgson Woodruff School of
Nursing
Marcia Stanhope Professor in Public Health
Assistant Director for Clinical & Social Science Integration, Center for
AIDS Research
Credentials PhD, FNP-BC, FAANP, FAAN
Contact Email: nurmmcd@emory.edu
Phone: (404) 727-1307
DNP PROJECT

Academic Support
Committee Chair
Name Dr. John Cranmer
Expertise for Project Dr. Cranmer is an Assistant Professor at Emory University, Nell Hodgson
Woodruff School of Nursing. He is well versed on how to link
implementation science research in current practice to improve the future
state of healthcare. Dr. Cranmer has extensive experience with clinical care
cascades and has been adopting the HIV care cascade to a different context
in developing countries.
Credentials DNP, MPH, MSN, ANP-BC
Project Faculty #1
Name Dr. Marcia Holstad
Expertise for Project Please see above
Credentials PhD, FNP-BC, FAANP, FAAN
Project Faculty #2
Name Dr. Anandi Sheth
Expertise for Project Dr. Sheth is an Assistant Professor at Emory School of Medicine,
Department of Medicine, Division of Infectious Diseases. Her clinical and
research interests focus on the treatment and prevention of HIV among
women. She is also a provider at my clinical partner site.

Credentials MD
Expansion - Dissemination
1st Journal AIDS Patient Care and STDs http://www.liebertpub.com/forauthors/aids-
patient-care-and-stds/1/
Type of Manuscript Research article
Format Requirement (i.e. Order-of-citation format for references. Cite references within the text by a
APA) superscripted Arabic number.
For journal citations: (1) surname of author(s) and initials; (2) title of
article; (3) journal; (4) year of publication: (5) volume number; (6)
inclusive page range of citation.

Weblink to author guidelines http://www.liebertpub.com/forauthors/aids-patient-care-and-stds/1/

Article Word Abstract Format & Impact

# Journal Type Limit Format Figure Guidelines Citation Style Factor
1 AIDS Research Abstract ABSTRACT Each table should Order-of-citation 3.578
PATIENT paper <250 should be be prepared in a format for
CARE and words. capitalized and separate file. Tables references. Cite
STDs No word centered on the should be cited in references within
limit for page and have the text (see Table the text by a
rest of one space 1). Tables should be superscripted
paper. below. The text submitted in Arabic number.
is single Microsoft Word. For journal
spaced and Each figure should citations: (1)
DNP PROJECT

should be be prepared in a surname of

limited to 250 separate file with author(s) and
words. This the figure initials; (2) title of
should appear number visible. article; (3)
on a separate Each figure should journal; (4) year
page. be cited in text (Fig. of publication: (5)
1). Legends should volume number;
be on a separate (6) inclusive page
page from the range of citation.
figures.
 ABSTRACT

Despite a high level of care engagement during pregnancy, in 2016, approximately 30%
of HIV-infected pregnant women that delivered at Grady Hospital had VL>200 copies/mL within
6 months postpartum, increasing their risk for morbidity and perinatal transmission of HIV
during subsequent pregnancies. Identifying patient perceived barriers and facilitators specific to
the population at the Grady Infectious (IDP) would facilitate development and application of
evidence-based interventions that will address the identified gaps. This project will play an
integral role in facilitating continuity of HIV care by transforming how health services are
delivered to and improving the health outcomes of HIV-infected postpartum women in Atlanta,
GA.
This project aims to improve postpartum HIV care for pregnant HIV-infected women
delivering at Grady Hospital by investigating barriers and facilitators to postpartum HIV care
retention and adherence. The specific objectives of this project are: 1) To examine and describe
patients perception of barriers to postpartum HIV care follow-up, and 2) To examine and
describe patients perception of elements that support and enhance continuity of care.
A grounded theory method will applied for this project. A qualitative approach using
semi-structured interviews of HIV-infected women whose most recent viral load (VL) during the
first 6 months post delivery is not <200 copies/mL, and women whose VL was consistently
>200 copies/mL during the first 6 months post delivery. The data to be analyzed for this project
will include transcripts from the interviews. NVivo will be used for analysis to identify key
concept and common themes.
Exploring Patient Perception of Barriers and Facilitators to Postpartum HIV Care Retention and
Adherence

Introduction-Background

Human Immunodeficiency Virus (HIV) medical care follow-up remains a significant

public health problem. Data from the Centers of Disease Control and Prevention (CDC) reports

that in the United States, only about 50% of persons diagnosed with HIV receive regular HIV

care1. This global health issue greatly impacts HIV treatment outcomes of patients receiving

care at the Grady Infectious Disease Program (IDP) at Ponce De Leon Center; one of the largest,

most comprehensive facilities dedicated to the treatment of advanced HIV/AIDS in the United

States2. The most recent unpublished raw data from the clinic showed that despite addressing and

controlling for the typical known barriers to HIV care retention and adherence such as cost of

treatment and access, approximately 30% of HIV-infected pregnant women that deliver at Grady

Hospital had VL>200 copies/mL within 6 months postpartum 3

Poor HIV care retention increases the risk for morbidity 4and perinatal transmission of

HIV during subsequent pregnancies 5. For best outcomes HIV infected individuals should adhere

to treatment and remain in care 6

A review of literature reporting findings from a similar problem was conducted to inform

potential causes of poor adherence and retention to HIV care among postpartum women at Grady

IDP. Buchberg et al 7 examined barriers to HIV postpartum care in underserved HIV positive

women in Southern United States. This research study identified lack of time, lack of social

support, transportation issues, and HIV related stigma as barriers to postpartum HIV care

retention. A qualitative study by Boehme et al examining factors impacting HIV care adherence
that was conducted in Alabama uncovered similar themes. Additional barriers to clinic visit

adherence identified in this study include clinic/copay expenses and duration of appointments 8

Potential moderating factors supporting postpartum HIV care retention may be attributed

to knowledge about the importance of adherence to HIV care and having strong relationships

with providers 7. Boehme 8 also found that intrinsic motivation ranked highly as a facilitator for

adherence to postpartum HIV care. Patients expressed their desire to stay healthy and live long,

as well as being present for their children.

Addressing individual level as well as system level factors in order to reduce the barriers

to postpartum care engagement is significant in improving adherence to treatment and clinical

outcomes among HIV infected women after delivery 7. In an effort to moderate the problem,

Grady IDP utilizes a multidisciplinary approach to care, and the various departments at Grady

IDP work collaboratively. The center provides access to HIV health education, social workers,

and case managers who assist the clients served by connecting them to essential services such as

housing and transportation. The IDP center also houses several other agencies such as AID

Atlanta and ADAP, which assist clients by providing a broad range of HIV and AIDS services,

and free medications for the treatment of HIV/AIDS. Providing access to these resources in-

house strengthens the capacity of the IDP.

Current evidence has shown that a mediating factor for poor retention and adherence

includes identifying context-specific barriers and facilitators to HIV care. Exploring patients

perception of barriers to postpartum HIV care follow-up and elements that support and enhance

continuity of care informs development of customized interventions to support HIV care

retention, thus improving health outcomes 7. For a summary of the literature review see Figure

for literature review study flow diagram.

 Aim-Objectives

In 2016, approximately 30% of HIV-infected pregnant women that delivered at Grady

Hospital had VL>200 copies/mL within 6 months postpartum. Therefore, global aim of the DNP

project is to improve postpartum HIV care for the pregnant HIV-infected women delivering at

Grady Hospital by aiming for VL<200 copies/mL in 100% of the women that deliver at Grady

Hospital, through improved retention and adherence to HIV care.

This project specifically aims to investigate barriers and facilitators to postpartum HIV

care retention and adherence through a qualitative study using semi-structured interviews of up

to 15 HIV infected women by November 2016. The objectives of this project are: 1) To examine

and describe patients perception of barriers to postpartum HIV care follow-up, 2) To examine

and describe patients perception of elements that support and enhance continuity of care, and 3)

To recommend potential interventions that may be effective in overcoming the barriers.

Methods

The social-ecological model will be used as the framework for understanding the factors

that influence retention and adherence to HIV care at the IDP. Selection of the social-ecological

model as the framework for this project was influenced by findings suggesting that multilevel

factors influence HIV care retention and adherence. 7

Proposed intervention

This is a qualitative study using semi-structured interviews of up to 20 HIV-infected

women who have delivered at Grady Memorial Hospital.

Target population
 We will recruit up to 7 women whose most recent VL during the first 6 months post

delivery is not <200 copies/mL, and up to 15 whose VL was consistently <200 copies/mL during

the first 6 months post delivery) despite standard clinic follow-up.

Participants will be recruited until thematic saturation is achieved. Patients will be

excluded if they are less than 18 years old, non-English speaking, or are unwilling to provide

verbal informed consent.

Sampling strategy

Purposive sampling will be applied for this study. Participants will be recruited

exclusively from Grady HIV/OB clinic via provider (clinician, nursing, or social work) referral

after they have attended their postpartum obstetrical visit (or been contacted regarding a missed

visit). Once a provider recommends a patient as a potential participant, the study team will

contact them to assess eligibility and interest in participation.

Variables

A grounded theory qualitative approach will be used for this project. Barriers explored

will include at least the following domains: time constraints, transportation access limitations,

financial barriers, stigma, lack of knowledge/education, social support, childcare, and system

navigation/clinic process. Facilitators considered will include but not limited to: a

multidisciplinary approach for clinical care, Ryan White funding, resources such as AIDS Drug

Assistance Program (ADAP), housing, and AID Atlanta, and positive relationships with

providers and staff.

Measurement strategy

During the project implementation phase; September 1, 2016 to November 15, 2016, the

DNP student investigator will conduct either semi-structured phone or in-person interviews after
verbal consent is obtained. Participants will receive a $25 VISA gift card for participation in the

study.

Data analysis

All interviews will be digitally recorded and transcribed. To preserve participant

anonymity, names will be omitted from the written transcripts, and recordings will be destroyed

following review of the data. Data will be analyzed using appropriate qualitative analytic

software such as NVivo.

Ethical Inquiry

This project falls under an already approved protocol titled Improving HIV care during

pregnancy and postpartum for HIV-infected women receiving prenatal care at Grady Memorial.

Emory Universitys Institutional Review Board (IRB) reviewed the protocol through the

expedited review procedure because it poses minimal risk. The current protocol will be amended

to reflect most recent data and project aims. See Figure 2 for the current Emory IRB decision

letter.
 References

1. Centers for Disease Control and Prevention. Linkage to and Retention in HIV Medical
Care 2013.
2. Grady Health System. Ponce De Leon Center. 2105.
3. Sheth. In: Kinuthia R, editor. 2016.
4. Ulett KB, Willig JH, Lin HY, Routman JS, Abroms S, Allison J, et al. The therapeutic
implications of timely linkage and early retention in HIV care. AIDS Patient Care STDS.
2009;23(1):41-9.
5. Camacho-Gonzalez AF, Kingbo, M. H., Boylan, A., Eckard, A. R., Chahroudi, A., &
Chakraborty, R. Missed opportunities for prevention of mother-to-child transmission in the
United States. AIDS (London, England). 2015;29(12):1511.
6. Mountain E, Pickles M, Mishra S, Vickerman P, Alary M, Boily MC. The HIV care
cascade and antiretroviral therapy in female sex workers: implications for HIV prevention.
Expert Rev Anti Infect Ther. 2014;12(10):1203-19.
7. Buchberg MK, Fletcher FE, Vidrine DJ, Levison J, Peters MY, Hardwicke R, et al. A
mixed-methods approach to understanding barriers to postpartum retention in care among low-
income, HIV-infected women. AIDS Patient Care STDS. 2015;29(3):126-32.
8. Boehme AK, Davies SL, Moneyham L, Shrestha S, Schumacher J, Kempf MC. A
qualitative study on factors impacting HIV care adherence among postpartum HIV-infected
women in the rural southeastern USA. AIDS Care. 2014;26(5):574-81.