Geographies of HIV Care: Imagining Virtual Care before, during, and after the COVID-19 Pandemic

Background: Since the initial outbreak of the COVID-19 pandemic in the United States, scholarship on the efficacy, implementation, and outcomes of virtual modes of care for people living with HIV have proliferated. This scholarship has examined the scale-up of telehealth (Wood et al. 2020), age and racial disparities in telehealth usage (Friedman et al. 2022), and how telehealth affects patient satisfaction (Rogers et al. 2020) and the patient-provider relationship (Mgbako et al. 2020). Still, relatively little attention has been paid to examining how virtual spaces are shaped and experienced across geographic, organizational, and therapeutic contexts. For example, how are virtual modes of clinical engagement experienced differently across various urban and rural settings and in care tailored to particular patient populations? These questions are particularly relevant to the provision of LBGTQ+ affirming care, where the production of “safe space” holds particular political and clinical salience (Hanhardt 2013; Chang et al. 2018). This study draws on qualitative interview data collected across a variety of geographic locations in Michigan immediately prior to the emergence of the COVID-19 pandemic to examine HIV care providers’ perspectives on geographic barriers to care and telehealth, and in particular, what these perspectives might illustrate about the limits and possibilities of distanced care across geo-spatial contexts.

Methods: In this community-based exploratory qualitative study, HIV health and social service providers (n=8) were recruited using purposive sampling, with attention to recruiting participants from diverse geographic settings (e.g., urban, rural, suburban) and holding diverse roles (e.g., social work, medicine). Participants practiced in seven distinct counties of Michigan, including those both densely (e.g., Wayne County, 2974.4 persons per square mile) and sparsely populated (e.g., Marquette County, 37.1 persons per square mile 2019). Interviews were analyzed using a reflexive thematic approach informed by the principles of grounded theory.

Results: Providers across geographic locations and disciplinary positions expressed quite varied attitudes about the efficacy and potential of virtual approaches to care, including both telehealth and virtual modes of social and peer support. These attitudes varied widely across geographic locations, suggesting that virtual modes of care – far from being a monolithic solution to geographic barriers to care (like lack of transportation and physical distance) – are in fact highly specific to local contexts and environments. While telehealth and other modes of virtual care may be presented as eliminating geographic barriers to care, they are in fact shaped by their relative geographic locations.

Conclusions: These interviews reveal wide variation in how providers understand and navigate virtual modes of care in response to geospatial factors -- particularly in relationship to patients’ social identities and geographic locations. Far from erasing geographic differences and geospatial barriers, these providers demonstrate how virtual responses to geospatial barriers to care may be experienced in quite particular ways across contexts. This study suggests the need for further research in HIV care and related fields to examine the nuances of how virtual spaces are shaped and experienced across geographic, organizational, and therapeutic contexts, particularly in the wake of the COVID-19 pandemic.