No abstract

Global and national HIV/AIDS policies utilize the care cascade to emphasize the importance of continued engagement in HIV services from diagnosis to viral suppression. Several studies have documented barriers that men experience in accessing services at specific stages of care, but few have analyzed how these barriers operate along the care cascade. Brazil offers a unique setting for analyzing barriers to HIV care because it is a middle-income country with a large HIV epidemic and free, universal access to HIV/AIDS services. Semi-structured interviews were conducted in 2011 with HIV-infected men (n=25) receiving care at the only HIV/AIDS state reference center in Salvador, Brazil, the third largest city in the country. Interviews were transcribed and coded for analysis. Researchers identified barriers to services along the care cascade: health service-related obstacles (poor quality care, lengthy wait times, and drug supply problems); psychosocial and emotional challenges (fear of disclosure and difficulty accepting HIV diagnosis); indirect costs (transportation and absenteeism at work or school); low perceived risk of HIV; and toxicity and complexity of ARV regimens. The stages of the care cascade interrupted by each barrier were also identified. Most barriers affected multiple, and often all, stages of care, while toxicity and complexity of ARV regimens was only present at a single care stage. Efforts to eliminate more prevalent barriers have the potential to improve care continuity at multiple stages. Going forward, assessing the relative impact of barriers along one's entire care trajectory can help tailor improvements in service provision, facilitate achievement of viral suppression, and improve access to life-saving testing, treatment, and care.

Research on pregnancy termination (PT) largely assumes HIV status is the only reason why HIV-positive women contemplate abortion. As antiretroviral treatment (ART) becomes increasingly available and women are living longer, healthier lives, the time has come to consider the influence of other factors on HIV-positive women’s reproductive decision-making. Because ART has been free and universally available to Brazilians for more than two decades, Brazil provides a unique context in which to explore these issues. Twenty-five semi-structured interviews exploring women’s PT decision-making were conducted with women receiving care at the Reference Centre for HIV/AIDS in Salvador, Brazil. Interviews were transcribed, translated into English, and coded for analysis. HIV played different roles in women’s decision-making. 13 HIV-positive women did not consider PT. Influential factors described by those who did consider PT included fear of HIV transmission, fear of HIV-related stigma, family size, economic constraints, partner and provider influence, as well as lack of access to such services as PT and abortifacients. For some HIV-positive women in Brazil, HIV can be the only reason to consider PT, but other factors are significant. A thorough understanding of all variables affecting reproductive decision-making is necessary for enhancing services and policies and better meeting the needs and rights of HIV-positive women.