Disparities in healthcare access and utilization among people living with HIV in China: a scoping review and meta-analysis

Abstract

Background Healthcare disparities hinder the goal of ending the HIV pandemic by 2030. This review aimed to understand the status of healthcare disparities among people living with HIV (PLWH) in China and summarize driving factors. Methods We searched six databases: PubMed, Web of Science, Cochrane Library, Scopus, China National Knowledge Infrastructure (CNKI), and China Wanfang. English or Chinese articles published between January 2000 and July 2022 were included if they focused on any disparities in access to and utilization of healthcare among PLWH in China. Grey literature, reviews, conferences, and commentaries were excluded. A random effects model was used to calculate the pooled estimates of data on healthcare access/utilization and identified the driving factors of healthcare disparities based on a socio-ecological framework. Results A total of 8728 articles were identified in the initial search. Fifty-one articles met the inclusion criteria. Of these studies, 37 studies reported HIV-focused care, and 14 focused on non-HIV-focused care. PLWH aged ≥ 45 years, female, ethnic minority, and infected with HIV through sexual transmission had a higher rate of receiving antiretroviral therapy (ART). Females living with HIV have higher adherence to ART than males. Notably, 20% (95% CI, 9-43%, I ² = 96%) of PLWH with illness in two weeks did not seek treatment, and 30% (95% CI, 12-74%, I ² = 90%) refused hospitalization when needed. Barriers to HIV-focused care included the lack of knowledge of HIV/ART and treatment side effects at the individual level, and social discrimination and physician-patient relationships at the community/social level. Structural barriers included out-of-pocket medical costs, and distance and transportation issues. The most frequently reported barriers to non-HIV-focused care were financial constraints and the perceived need for medical services at individual-level factors; and discrimination from healthcare providers, distrust of healthcare services at the community/social level. Conclusion This review suggests disparities in ART access, adherence, and utilization of non-HIV-focused care among PLWH. Financial issues and social discrimination were prominent reasons for healthcare disparities in PLWH care. Creating a supportive social environment and expanding insurance policies, like covering more medical services and increasing reimbursement rates could be considered to promote healthcare equity.

Flgure 1

PRISMA flow diagram for included/excluded studies

Figure 2

The distribution of study regions

Figure 3

Forest plot of PLWH receiving ART by age and gender. A1 shows a forest plot of receiving ART among people aged <45 years living with HIV. A2 shows a forest plot of receiving ART among people aged≥45 years living with HIV. B1 shows a forest plot of receiving ART among men living with HIV. B2 shows a forest plot of receiving ART among women living with HIV.

Figure 4

Forest plot of PLWH receiving ART by ethnicity and transmission route. A1 presents a forest plot of receiving ART among PLHIV of Han ethnicity. A2 presents a forest plot of receiving ART among PLHIV of ethnic minorities. B1 shows a forest plot of receiving ART among people infected with HIV through heterosexual transmission. B2 shows a forest plot of receiving ART among people infected with HIV through homosexual transmission. B3 shows a forest plot of receiving ART among people infected with HIV through injecting drug use.

Figure 5

Forest plot of ART adherence among PLWH.

Figure 6

Forest plot of ART adherence among PLWH by gender. A1 shows a forest plot of full ART adherence among men living with HIV. A2 shows a forest plot of full ART adherence among women living with HIV. B1 shows a forest plot of 2:95% ART adherence among men living with HIV. B2 shows a forest plot of ≥95% ART adherence for women living with HIV. C1 shows a forest plot of >90% ART adherence among men living with HIV. C2 shows a forest plot of >90% ART adherence among women living with HIV.

Flgure 7

Forest plot of outpatient and inpatient service utilization among PLWH. A presents a forest plot of the two-week morbidity among PLWH. B presents a forest plot of the two-week visit among PLWH. C presents a forest plot of the non-visit rate of PLWH with illnesses in two weeks. D presents a forest plot of the annual inpatient among PLWH. E presents a forest plot of the non-hospitalization among PLWH who required hospitalization.

Figures 8

Factors of healthcare access and utilization for PLWH in China.