3.9. Overview of qualitative results
HIV survivors, anxiety, HIV viral suppression, HIV suppression, viral suppression, housing instability
As noted above, the present study was carried out in the early stages of the COVID-19 pandemic in a major COVID-19 epicenter. Overall, participants discussed both ongoing multi-level challenges to HIV management, along with the complexity of managing feelings of anxiety and helplessness related to COVID-19, the general uncertainty of daily living during this time, and the ways in which COVID-19 affected their capacity to manage their HIV treatment. Most participants in the present study had been living with HIV for many years. Although participants did not evidence HIV viral suppression at the time of enrollment, the majority were taking HIV medication at some level prior to enrolling, and most of those who were not on HIV medication at the time of enrollment had taken HIV medication within the last 6 months. Thus, they could be considered long-term HIV survivors, and as such had extensive prior experiences taking HIV medication and engaging in HIV care. Quantitative data highlighted that participants were located in the lower socio-economic strata, and less than half the sample was stably housed. Therefore, we addressed the qualitative research questions in the context of the COVID-19 pandemic, the experience of long-term HIV survivorship, and chronic poverty. In the next section we provide an overview of the qualitative study findings, followed by results for the two qualitative research questions and a joint display (Joint display summarizing the integrated results.Participants discussed a number of significant barriers and interruptions to healthcare access in response to COVID-19, which in turn interfered with their sustained HIV medication use. As we describe throughout this section, some of these barriers pre-dated the COVID-19 pandemic, some were exacerbated by COVID-19, and others were specific to COVID-19. Further, the COVID-19 pandemic certainly served as the backdrop for how the intervention components were experienced with respect to promoting HIV care engagement. In exploring the disconnect between reported high levels of motivation for HIV medication adherence and viral suppression found in the quantitative results, common barriers to HIV management reported by participants included structural impediments such as financial insecurity, housing instability, safety concerns within housing circumstances, and other factors that limited material resources. Importantly, participants underscored the cumulative, synergistic effects of these and other related structural barriers on their mental health and/or substance use patterns, which in turn, frequently diminished HIV treatment as a priority in participants' lives. Some participants expressed complicated perspectives about their individual HIV care, often affected by their state of wellbeing, but also the pressure they felt to attain viral suppression, particularly during periods of elevated stress, which, in turn, exacerbated feelings of stress.Chronic poverty contributed to some participants selling (or diverting) their HIV medication doses to pharmacies operating outside the law, an opportunity to receive financial resources that participants typically found very challenging to decline. Study findings made evident aspects of the intervention components that were experienced as positive, as described below. Findings demonstrated key aspects of the intervention components that were useful in supporting HIV management, as well as ways the intervention components could be improved. One goal of the study was to allow participants to engage in the components even if they could not or did not achieve HIV suppression, and we attended to positive effects of components on behaviors other than HIV management. Names used below are pseudonyms and identifying details have been removed or obscured to protect participants' confidentiality. Participants were queried about their preferred pronouns (e.g., he, she, they, other) at enrollment, and the appropriate pronoun is used below in the description of each participant.