The number of people with limited English proficiency (LEP) in the United States is increasing [1]. People with LEP do not speak English as their primary language and have limited ability to read, write, and speak English [2]. According to U.S. Census data, among people who spoke a language other than English at home, 8.2% had LEP [3]. From 2015–2018, adults with LEP accounted for almost 10% of all adults with diagnosed HIV in the United States [4]. People with LEP experience disparities in health care access and outcomes. Compared with people without LEP, people with LEP reported more trouble understanding medication instructions, experienced more adverse medication reactions, experienced greater lengths of stay in hospitals, were more likely to lack a usual health care provider, and were more likely to be overdue for preventive care and screening [5-8]. In a scoping review of the literature, people with LEP often expressed that they were inadequately informed or failed to understand their diagnosis, medication management, potential treatment implications, and the resources accessible to them [9]. In another study, people with LEP described how language barriers negatively affected their confidence in making decisions about their medical care [10].

Safe and effective health care relies on clear communication between health care providers and patients. Professional interpretation services can enable clear verbal communication [11]. Unfortunately, people with LEP often rely on ad hoc or untrained interpreters, such as family members, friends, or other people who are untrained or do not uphold the clinical standards of a professional interpreter [10, 12].

One of the four key strategies of the Ending the HIV Epidemic (EHE) initiative is to “treat people with HIV rapidly and effectively to reach sustained viral suppression” [13]. Treating PWH with LEP requires providing HIV care and treatment in a language they understand, which can be accomplished with language interpretation services. To our knowledge, no study has examined the availability of language assistance in facilities where PWH with LEP receive care. Thus, our objectives were to 1) describe the percentage of PWH with LEP who received HIV care at a health care facility offering language interpretation services, overall and by selected characteristics and 2) describe the percentage of HIV care facilities providing language interpretation services, overall and by selected characteristics.

For this analysis, we used data from the Medical Monitoring Project (MMP)—an annual, cross-sectional survey designed to produce nationally representative estimates of the behavioral and clinical characteristics of adults with diagnosed HIV in the United States—and the MMP Facility Survey (MMPFS)—a survey of HIV medical facilities that collected data on facility characteristics, including provision of clinical and supportive services.

Almost 90% of PWH with LEP received HIV care at a facility that provided language interpretation services (Table 1). People with less than a high school education were more likely than those with more than a high school education to attend a facility that provided language interpretation services (93.1% vs. 87.0%; PR, 1.07; CI, 1.01–1.13). People who were unemployed were less likely than those who were employed to attend a facility with language interpretation services (83.7% vs. 90.6%; PR, 0.92; CI, 0.84–1.02). We found no other differences in the remaining examined variables.

Among facilities providing HIV care to MMP respondents, 83.6% provided language interpretation services either onsite (62.9%) or through established referrals (20.6%) (Table 2). Federally Qualified Health Centers (FQHC) or FQHC look-alikes were more likely than non-FQHC facilities to provide language interpretation services (91.4% vs. 81.4%; PR, 1.12; CI, 1.03–1.22; Table 2). Private practices were less likely than non-private practices to provide language interpretation services (72.3% vs. 90.0%; PR, 0.80; CI, 0.72–0.90). Facilities that received RWHAP funding were more likely than those that did not receive RWHAP funding to provide language interpretation services (93.2% vs. 76.3%; PR, 1.22; CI,1.12–1.33). Facilities that accepted (vs. did not accept) Medicaid were more likely to provide language interpretation services (86.5% vs. 69.1%; PR, 1.25; CI, 1.05–1.49) as were facilities that accepted (vs. did not accept) AIDS Drug Assistance Program (ADAP) or other Ryan White coverage (91.6% vs. 71.7%; PR, 1.28; CI, 1.14–1.43). Facilities in a primary care health professional shortage area were more likely than facilities not located in these areas to provide language interpretation services (88.5% vs. 79.6%; PR, 1.11; CI, 1.02–1.22). No differences were found among facilities located in metropolitan (vs. non-metropolitan) areas and facilities located (vs. not located) in medically underserved areas. Facilities that provided (vs. did not provide) training in other areas of cultural competency (not including HIV stigma and discrimination training) were more likely to provide language interpretation services (90.3% vs. 70.4%; PR, 1.28; CI, 1.13–1.45).

Facilities that provided (vs. did not provide) other clinical (e.g., clinical case management, pharmacy) and support services (e.g., peer support, transportation, housing, and food assistance) onsite or by referral were more likely to provide language interpretation services (Table 2). For example, facilities that provided clinical case management, other case management, or patient navigation onsite (89.6% vs. 69.9%; PR, 1.28; CI, 1.12–1.46) or by referral (90.6% vs. 79.5%; PR, 1.14; CI, 1.05–1.24) were more likely than those that did not to provide language interpretation services. Facilities that helped with subsistence needs (e.g., housing, transportation, food) onsite (92.3% vs. 75.3%; PR, 1.23; CI, 1.12–1.34) or by referrals (91.1% vs. 64.3%; PR, 1.42; CI, 1.22–1.65) were more likely than those that did not to provide language interpretation services. Facilities that provided none of these clinical and supportive services onsite (67.1% vs. 88%; PR, 0.76; CI, 0.64–0.90) or by referral (42.3% vs. 89.7%; PR, 0.47; CI, 0.34–0.66) were less likely than facilities that provided at least one of these services onsite or by referral to provide language interpretation services.

We found that 89.9% of PWH with LEP received care at facilities that provided language interpretation services. This is a positive finding since language is one of the most common barriers to accessing and using health care among people with LEP and patients with LEP prefer having an interpreter or a health care provider who speaks their language [9, 19]. For people with LEP, professional interpreters are preferable to ad hoc interpreters (e.g., family, friends, and untrained professionals) who are more likely to make mistakes, misinterpret information, provide low-quality communication, and ignore sensitive topics [12]. Furthermore, using a professional interpreter has been associated with clinical care that approaches or is equal to the care patients without language barriers receive [20]. Using a professional interpreter lowers communication mistakes, improves patient understanding, and increases patient satisfaction [20]. We found access to language interpretation services among those with LEP to be relatively equitable, with no differences in most of the demographics and Social Determinants of Health (SDOH) characteristics assessed.

People with LEP with less than a high school education (a SDOH often associated with suboptimal health outcomes) were more likely than those with more education to attend a facility with language interpretation services. This is a promising finding, as having less education and limited proficiency in the dominant language of the country someone resides in is a predictor of low health literacy, which has been associated with difficulties understanding medical instructions, difficulties communicating with a provider, poor patient satisfaction, and suboptimal health outcomes [19, 21]. Language interpretation services may reduce communication barriers that people with LEP and less than a high school education face when accessing and using health care.

People with LEP who were unemployed were less likely than people with LEP who were employed to receive care at a facility with language interpretation services. Although we did not collect information on immigration status, it is possible that a proportion of PWH with LEP who are unemployed may be undocumented immigrants. Undocumented immigrants face employment challenges in the United States, as they have no work authorization and are faced with work eligibility restrictions [22]. Alternatively, some undocumented immigrants might be working without a work authorization and might be afraid to report their employment. With some specific exceptions, undocumented immigrants are prohibited from enrolling in most federal benefit programs and are ineligible for public health insurance like Medicare or Medicaid [23]. Undocumented immigrants might not seek assistance when accessing health care for fear it would expose their unlawful status in the United States. Furthermore, undocumented immigrants might seek care at facilities without robust safety net programs, since they might assume they are ineligible for any assistance or might fear attempting to access programs that might reveal their undocumented status. Future studies should explore this finding further.

Most HIV care facilities provided language interpretation services onsite or through referrals. A key strategy of the EHE initiative is to treat PWH “rapidly and effectively to reach sustained viral suppression” [13]. For people with LEP, HIV care and treatment must be provided in linguistically appropriate ways to be effective. Furthermore, the National HIV/AIDS Strategy (NHAS) outlines some strategies for reducing HIV-related disparities, including strengthening the enforcement of civil rights laws that relate to language services and linking PWH to culturally and linguistically appropriate care [24]. Our findings demonstrate that most HIV care facilities are taking steps to “provide meaningful access to people with LEP,” as required by Title VI of the Civil Rights Act of 1964 and Section 1557 of the Patient Protection and Affordable Care Act [25, 26].

HIV care facilities that accepted Medicaid, ADAP, or other Ryan White coverage were more likely than those that did not to provide language interpretation services. Having language interpretation services available in facilities that accept health insurance or coverage options for people with low incomes and those who are uninsured or underinsured is important because studies have found that people with LEP are more likely to be poor, uninsured, or publicly insured than people without LEP [6-8].

Facilities that provided various clinical and supportive services were more likely than those that did not to also provide language interpretation services. People with LEP have reported difficulty accessing care (e.g., making appointments, locating a clinic); being unaware of social services and entitlements available to them; and housing and transportation barriers [9, 19]. Because people with LEP experience these challenges, facilities that provide clinical services (e.g., clinical case management, pharmacy) and supportive services (e.g., housing, transportation) might better meet their needs than facilities that do not provide such comprehensive care. In one study, unmet needs for key HIV support services (case management, medicines through ADAP, and patient navigation) were associated with not being retained in care and not being virally suppressed [27]. Thus, it is important for health care facilities to address the clinical and supportive service needs of PWH with LEP to ensure they can remain engaged in care and become or remain virally suppressed.

Our results were subject to several limitations. The MMPFS used a census of HIV care facilities where a representative sample of PWH received HIV care; therefore, facility-level estimates do not represent all U.S. HIV care facilities. The MMPFS asked about “language interpretation services,” without specifying that such services were offered by a professional. Therefore, some facilities that reported providing language interpretation services could be doing so with non-professional interpreters. We also did not assess the use and quality of language interpretation services in the facilities surveyed. For instance, we did not assess whether the facilities provided language interpretation services in the languages of the populations served; whether the facilities provided language interpretation services for free; how language interpretation services were provided (e.g., in person, video, telephone); and if written translation of important documents (e.g., informed consent forms) was provided. Furthermore, we could not assess whether people with LEP who sought care at facilities with language interpretation services used the service and whether the service was available in their primary language. Last, our limited sample size prevented us from assessing differences in health outcomes of PWH with LEP who received care at facilities with (vs. without) language interpretation services. Future studies can examine the extent to which health care facilities caring for PWH with LEP are implementing the National Culturally and Linguistically Appropriate Services (CLAS) standards, which create “a blueprint” for health care organizations to provide care and services that consider people’s cultural beliefs and practices, preferred languages, and health literacy [28].

We found that most PWH with LEP obtained HIV care at health care facilities that provided language interpretation services. Furthermore, most HIV care facilities surveyed provided language interpretation services. These are positive findings since language interpretation services can enable clear communication between patients with LEP and their health care providers. Furthermore, providing language interpretation services supports the EHE strategy of treating PWH with LEP rapidly and effectively to reach sustained viral suppression; and is a step towards providing meaningful access as required by Title VI of the Civil Rights Act of 1964 and Section 1557 of the Patient Protection and Affordable Care Act. While most HIV care facilities provided language interpretation services, we could not assess how and if they were accessed by PWH with LEP. Future studies should explore this limitation of our analysis.