As a national organization made up of women living with HIV, the Positive Women's Network-USA (PWN-USA) advocates for better services for women and promotes woman-centered care. Across the treatment cascade HIV care continuum, women experience many barriers that can play a role in their engagemenet in care.  PWN-USA works to draw attention to these barriers and address them by promoting effective models of care.
 

Barriers to access HIV care generally fall into two categories--structural barriers and challenges related to trauma. Structural barriers include financial and logistical challenges that can make accessing care difficult (e.g., transportation, child care, co pays, etc.). Integrating the range of services that women require in addition to HIV care-mental health, substance abuse, sexual and reproduction health care, transportation, housing, child care-can serve to reduce the structural barriers faced by women.
 

Trauma-related barriers include a range of complex issues related to how a patient interacts with both the health care setting and the providers. It is critical that HIV providers address the issue of trauma. An estimated 30 percent of women living with HIV suffer from Post-Traumatic Stress Disorder (PTSD) as a result of past experience with rape, sexual abuse, domestic violence, or other traumatic events. PTSD is often accompanied by co-occurring disorders such as mental illness and substance abuse.  Trauma-informed care is an approach to engaging people with histories of trauma that recognizes the presence of trauma symptoms and acknowledges the role that trauma has played in patients' lives. It seeks to address the unequal power dynamic that can occur between provider and patient and allow the patient to communicate with the provider about her history and build a relationships so that patient and provider can work together to make informed treatment decisions.
 

What can make a significant difference for women trying to negotiate barriers to care is to hear from others who have successfully negotiated similar challenges and can serve as guides. Integrating peer navigators as equal members of the care team can send a powerful message to women living with HIV.
 

"Seeing a peer navigator as a valued member of the care team provides a role model," says Naina Khanna, executive director of PWN-USA. "They see someone like themselves being successful-not just in their own care but in their life."
 

Peer navigators have the time to build relationships with patients and common experiences can help to build trust. Women may share information with the navigator that they do not disclose to other members of the care team. The navigator can serve as bridge between the patient and the team.
 

As she works with women across the country, Ms. Khanna has also observed the importance of helping women develop the skills necessary to take an active role in their own care. Providing women training on how to use computers, research skills, and leadership helps build self esteem and can support greater participation in care-related decisions. PWN-USA members report that skills that provide the ability to be actively involved in their care result in better health outcomes. Providing women this type of training and access to resources like computer labs can be an effective strategy for retention.

"The old models of treatment advocacy need to be updated for the digital age," says Ms. Khanna.

Click this link for more information on Positive Women's Network of the United States of America.

Christie's Place, a community-based organization in San Diego, provides comprehensive HIV/AIDS education, support, and advocacy to women, children, and families.  All services are available in English and Spanish.  It serves 1,100 clients; 450 of whom are living with HIV.

Inb 2010, San Diego County estimated that almost 70% of women who knew their HIV status were not accessing medical care. In response to this, Christie's Place initiated the Coordinated HIV Assistance and Navigation for Growth and Empowerment (CHANGE) for Women program. CHANGE for Women is a gender-responsive network of care designed to address the multi-level barriers to care faced by women. Specific programmatic impact includes:

• Increased awareness via a social marketing campaign, "I am More Than My Status";
• Increased self-efficacy;
• Electronic health literacy and improved adherence through the utilization of technology (My Chart and text messaging);
• Increased engagement in care through Southern California's first Center of Excellence for Women's HIV Care Clinic;
• A gender-responsive, patient-centered medical home;
• More effective responses to barriers to care through a home-based services model; Empowerment of women living with HIV by engaging them as peer navigators; and
• Increased transportation, food and child care services.

In addition, given its proximity to the border with Mexico, the program has formalized partnerships with immigration rights and social justice organizations to provide education/legal advocacy to support access to medical care.

In 2012, Christie's Place expanded the program beyond access and linkage strategies to a focus on retention via trauma-informed care.

"Through the CHANGE for Women program, we have learned that our network of care must address trauma-related barriers that are at the forefront of HIV-infected women's lives in order to improve health outcomes, reduce health disparities, and improve the quality of women's lives. Our new retention in care initiative has allowed us to strengthen and expand lifesaving services and comprehensively address the consequences of trauma on the lives of our clients," said Dr. Erin Falvey, Clinical Manager of Christie's Place.

Intensive staff training for all staff, including management, was necessary to implement the model. The HHS Office of Women's Health provided some of the training as well as technical assistance to fully operationalize and institutionalize the trauma-informed service provision model at Christie's Place.

In addition to the training, the CHANGE for Women Retention in Care team was expanded to better meet the needs of patients. The team includes:

• Bilingual peer navigators;
• Retention specialist;
• MSW-level medical case manager;
• Mental health clinicians; and
• Primary care provider, psychiatrist, and other service providers working with client

The peer navigators play an important role. While they are trained to work within HIV health care and social services settings, they also share their personal experiences and serve as role models for clients.

Other elements of the program that are designed to keep clients engaged include:

• Trauma-informed client orientation (to ensure client understanding of her role as an active collaborator in the treatment process);
• Barrier assessment (assesses the client's current level of functioning and barriers to engagement);
• Behavioral health counseling services (individual, family, and group); and
• Treatment adherence activities.

Since its implementation, the program has seen enhanced engagement and retention of women clients. Engagement of women in HIV care has increased by 12 percent. The peer navigators have brought 233 out-of-care and sub-optimally engaged women living with HIV back into care.

Clients have also responded positively to the program.

"They tell us how important it is to focus on these issues," says Dr. Falvey. "We are helping them take control of their health and well-being through self empowerment."  

Click here for more information on Christie's Place.