There are opportunities for leveraging and further utilizing telehealth beyond the pandemic [34]. However, addressing issues related to access, disparities, protocols, and policies are critical in making this happen.

Broadband access, referred to as the delivery of high-speed internet, is a requirement in delivering telehealth services [35, 36]. Unfortunately, broadband equity remains a persistent problem in the USA, causing a digital divide (i.e., the gap between people with affordable access, skills, and support to engage in online platforms versus people who are unable to) [35, 36]. It is a serious issue of concern because not every community has the ability to access and utilize reliable high-speed internet to meet their technology-based needs [37]. To be factual, only 5% of households with income above $75,000 did not have broadband in 2018, compared to 38% of households with income below $20,000 [37]. A more recent report from the Center of Medicare and Medicaid Services revealed that although telehealth utilization was up 63 folds during the pandemic, users were mostly urban residents and non-black [38]. Broadband access is critical in HIV care because rural residents represent six percent of PWH [39]. Hence, investment in broadband access, particularly in rural regions, and closing the digital divide gap in minority populations are keys to ending the HIV epidemic [40]. High-speed internet or a stable network is highly essential even among those with access as they impact patient-provider telehealth visit experience and successful engagement [23].

The lack of compatible technological devices also precludes the delivery of telehealth services regardless of broadband access. According to one study, some of the major barriers that prevented patients from video visit attendance was a lack of broadband access and compatible devices [19]. Another study reported that a third of all video clinic visits were discontinued due to patients' lack of digital access [41]. Findings from these studies further illustrate the significance of technological devices and the need to prioritize them alongside broadband access. As transportation is a determining factor in whether a patient will show up for their clinic appointment, telephones, computers, and stable high-speed internet are the primary vehicles for telehealth delivery. Particularly, the lack of these devices will make exploring telehealth as an option for health care delivery among PWH impossible and inhibit our understanding of how telehealth influences HIV treatment outcomes. In addition, investment in telehealth access in rural regions, underserved populations, and eligible patients in need of support is invaluable. For instance, Georgia state invested in its Project Extension for Community Healthcare Outcomes collaborative by ensuring adequate broadband access in rural areas, equipping its rural health departments with necessary equipment (including clinical and technological devices), and training staff to deliver telehealth services. The Georgia program led to improved HIV care visit attendance. It enabled the state’s rural health departments to have the capacity for telehealth services and equipped facilities close to rural residents who previously traveled to cities for HIV care [42]. Thus, other government programs may consider expanding their support to sponsor similar initiatives or create subsidized programs to cover the cost of technical devices for eligible patients.

Another issue widely discussed in the literature is billing and reimbursement. Reimbursement of healthcare should not be exclusive to mode of delivery, as telehealth remains a critical tool for healthcare delivery [43]. Inequitable reimbursement and lack of insurance coverage for some telehealth services continue to be barriers to telehealth utilization among providers and patients [25, 42]. For instance, providers may avoid offering patients the option of telehealth if they know their insurance will not cover the cost of their visit. Likewise, patients may hesitate to utilize telehealth to avoid paying out of pocket [34]. The implication is that seeking care from other providers under specific telehealth platforms in an effort to avoid paying out of pocket may negatively impact patient-provider relationships and can result in poor self-management of chronic conditions [44].

Access to telehealth is critical for improved health outcomes. To sustain telehealth among current users and promote adoption for new users, we need to invest in broadband access, close the digital divide gap, support residents and healthcare organizations in rural regions, and regulate payment policies to cover telehealth services.

Telehealth utilization, satisfaction, and health outcomes among PWH are not evenly distributed. Specific groups report lower utilization and satisfaction than others. Also, the association between telehealth utilization and HIV outcomes differ across groups and is lower in some groups. Consistent across studies in literature, disparities mostly exist based on factors related to race, age, and educational level. For instance, one New York study found that PWH 50 years or older described telehealth as “too negative” for having fewer interpersonal components, particularly patient-provider relationship elements. Also, participants in the New York study with less formal education that utilized telehealth had poorer health outcomes than patients with high educational levels [45]. Similarly, in another study, racial minority telehealth users, particularly African Americans, had higher odds of unsuppressed viral loads than other racial or ethnic groups who utilized telehealth [13]. Furthermore, racial minority groups and non-English speakers have been found to experience more difficulty with telehealth and are less likely to use telehealth [15, 19, 25].

The findings described above suggest low telehealth technology literacy among the groups experiencing low satisfaction with telehealth and poor health outcomes. The excess burden of poor HIV outcomes has been linked to low health literacy and level of education [46]. Thus, training patients on navigating telehealth platforms is vital, in addition to closing the digital gap. Regardless of patients’ prior telehealth experience, healthcare providers should consider incorporating checklists in their protocol to ensure patients can navigate telehealth platforms before proceeding with telehealth visits. We cannot rule out that the lack of this procedure is why some patients opt for telephone visits instead of videoconferencing. Therefore, it is recommended that healthcare organizations adopt and implement telehealth platforms that are user-friendly and easy to navigate. Adopting these platforms and investing in patient education may increase utilization, improve health outcomes, and sustain telehealth in this population.

Digital health generally encompasses telehealth, telemedicine, mobile health, telecare, and other terms that are used interchangeably [2, 3]. Though related, these words have different meanings and may confuse patients when used by the same or different providers. For patients with low technology literacy levels, these terminologies may overwhelm them, causing them to be hesitant to try telehealth. Also, some healthcare providers using these words might not realize how they differ and may unintentionally use them interchangeably. Reinforcement through restudying original material improves knowledge retention [47]. Therefore, we recommend constantly training healthcare providers and patients to increase their knowledge of telehealth. In addition, visual explanations are effective in aiding learning [48]. Thus, visual educational materials describing these terms and their differences may be invaluable in improving telehealth literacy among patients and providers.

A persistent and significant concern regarding telehealth utilization among patients is the issue of data security [26, 42, 45, 49]. Consistently reported in the literature, patients are concerned about the breach of data. Various software packages are used in health care delivery; while some organizations have their own software, others consult third parties. For example, the University software, known as “OneChart,” is the only telehealth platform allowed at our institution. Regardless of the type of software package, having a regulatory government agency that oversees these platforms and ensures they meet specific requirements would be instrumental in earning patients' trust in telehealth and reassuring them of protected data. Such standardization may consequently lead to resolving the issue of reimbursement (for instance, having policies in place to guide payers on approved or certified software packages).

As we continue to utilize telehealth in health care to manage chronic diseases, it is critical to keep patients and providers abreast with new developments. Particularly in HIV care, constant training and investment in protecting patient data are paramount to positive patient-provider experiences and the sustainability of telehealth in HIV care [42].