Black women comprised 59% of women living with HIV infection in 2014 and 61% of diagnoses among women in 2015 (CDC, 2016b). Reducing disparities in HIV diagnoses and improving the health of persons living with HIV infection (PLWH), including black women, aligns with national prevention goals (Office of National AIDS Policy, 2015). Early diagnoses, linkage to care, and retention in care are important steps for reducing HIV disparities and preventing HIV transmission (Skar- binski et al., 2015). Greater than 90% of new HIV infections are attributable to PLWH who are unaware of their status or not in care (Skarbinski et al., 2015).

Black women experience disparities in HIV treatment and care. Data from 61 health department jurisdictions indicated black women newly diagnosed with HIV and linked to HIV care within 90 days of diagnosis increased from 33.8% in 2012 to 50.1% in 2014 (Stein, Pierce, Hollis, & Smith, 2016). However, this was below the national target of 85%. Identifying factors associated with disparities in HIV treatment and care for black women is critical to increase the percentage who know their HIV status, are in HIV care, and are virally suppressed (Office of National AIDS Policy, 2015).

Thirty-six years after the identification of HIV infection in the United States (U.S.), there are no literature reviews focused exclusively on contextual factors that facilitate or limit access to HIV treatment and care among black women (Kennedy & Jenkins, 2011; Stampley, Mallory, & Gabrielson, 2005; Waite, Braw- ner, & Gipson-Jones, 2008). Such a review could identify the scant literature available regarding HIV treatment and care, support the need for more HIV research and interventions, and inform the quality of HIV treatment and care provided by healthcare professionals to black women. The purpose of this literature review is to identify possible social and structural factors related to the disparities in treatment and care among black women living with diagnosed HIV infection (BWLH).

The systematic review was conducted in six stages using PubMed, PsycINFO, Scopus, Embase, Global Health, OVID/Medline and Google Scholar. First, we searched for studies that enrolled BWLH published between January 2005 and December 2016. Second, we excluded abstracts, unpublished dissertations, editorials, commentaries and studies that were conducted outside of the U.S. Third, we limited the results to five areas of inquiry that address disparities in HIV treatment and care among black women: 1) biomedical (care, treatment, antiretroviral therapy (ART), medication adherence, viral suppression); 2) structural determinants of health (access to HIV care, patient-provider communication, quality of HIV care); 3) social determinants of health (stigma, discrimination, medical mistrust); 4) psychosocial context (peer support and mental health); and 5) social and sexual networks (sexual mixing, partner characteristics) (Office of National AIDS Policy, 2015; Maulsby et al., 2014). Fourth, we focused on studies that had majority representation of BWLH in the U.S., by requiring that the study population was >60% black and 100% female. Published quantitative and qualitative research studies that met the above inclusion criteria were included in the full-text review (Figure 1). Fifth, we extracted and summarized these data in a summary table that highlighted the author names, year, location, study design, sample size, age, HIV continuum of care category, and major findings (Hall et al., 2013) (Table 1). Sixth, we reviewed the articles and utilized direct content analysis to identify common themes for barriers and facilitators for HIV care (Hsieh & Shannon, 2005) (Table 2).

We screened 534 relevant titles and abstracts; 49 were selected for full review; 16 articles met inclusion criteria for final analysis (Figure 1). The 16 studies were conducted throughout the U.S. including the Northeast (n = 5), Southeast (n = 6), Midwest (n = 4), and West (n = 1) (Table 1). Barriers and facilitators of care and ART adherence emerged during the review and are summarized in Table 2.

Our review suggests that social and structural factors, including suboptimal patient-provider communication, HIV-related stigma, lack of social support, and unmet needs (e.g., transportation, financial stability, and childcare) all contribute to challenges in HIV treatment and care for black women. Available studies (Table 1) suggest that social and structural factors (Table 2) need to be considered by providers, and underscore the importance of relationships and communication between patients, providers, and the support networks of BWLH.

The finding of healthcare provider stigma as a barrier for HIV care and treatment is of concern and is aligned with a study which reported negative clinical encounters by black compared with white HIV-infected women (Beach et al., 2011). Training physicians to more effectively engage patients in non-stigmatizing dialogue and empowering black women to address specific topics with their providers may be important strategies for improving communication and satisfaction with HIV care services (Beach et al., 2011).

These studies suggest important roles for interventions through healthcare providers (Gaston, Gutierrez, & Nisanci, 2015). Culturally tailored communication strategies, developed with affected communities of black women, is also an additional tool for improving care for BWLH (Arya, Behforouz, & Viswanath, 2009). It is vital that we improve trust, increase culturally appropriate care, and actively follow-up on missed visits, to strengthen engagement and retention in care for BWLH (Aziz & Smith, 2011; El-Bassel, Caldeira, Ruglass, & Gilbert, 2009). Moreover, addressing depression, unmet needs (i.e., childcare, unemployment, and housing), and increasing peer-support may be well-received if these factors are considered as part of care for BLWH (Rao et al., 2012; Toth et al., 2013).

This review has limitations. First, nine of 16 (60%) studies included small sample sizes, larger samples of black women will be needed for future studies, to provide for more robust analyses and be generalizable to larger groups of women. Second, factors such as geographic location may play unique role for black women, especially in the southern U.S., an area which has a historical context of institutional racism (i.e., limited or no resources available due to a lack of insurance coverage) which may create additional HIV prevention and care challenges for people of color (Adimora, Ramirez, Schoenbach, & Cohen, 2014). Third, many of the studies were qualitative and included face-to-face interviews; social desirability biases may have played a role in some responses. Using computer-assisted quantitative surveys may offer additional privacy and decrease this type of bias.

Given the disproportionate burden of HIV infection among black women in the U.S., (CDC, 2016b) the development of social and structural interventions that increase accessibility and acceptability to services are vital. Moreover, of 84 Centers for Disease Control and Prevention evidence-based HIV interventions (CDC, 2016a), none were developed exclusively for BWLH. In order to reach national HIV prevention goals for women of color, future studies, with larger samples of BWLH, are needed to increase the number of culturally appropriate interventions and evidence-based practices for addressing social and structural factors that impede treatment and care for BWLH. Findings discussed in this manuscript support the need to address the ongoing disparities in HIV treatment and care among black women.