Barriers and facilitators of the HIV care continuum in Southern New England for people with drug or alcohol use and living with HIV/AIDS: perspectives of HIV surveillance experts and service providers

Abstract

Background Contemporary studies about HIV care continuum (HCC) outcomes within substance using populations primarily focus on individual risk factors rather than provider- or systems-level influences. Over 25% of people living with HIV (PLWH) have substance use disorders that can alter their path through the HCC. As part of a study of HCC outcomes in nine small cities in Southern New England (population 100,000–200,000 and relatively high HIV prevalence particularly among substance users), this qualitative analysis sought to understand public health staff and HIV service providers’ perspectives on how substance use may influence HCC outcomes.MethodsInterviews with 49 participants, collected between November 2015 and June 2016, were analyzed thematically using a modified social ecological model as the conceptual framework and codes for substance use, HCC barriers and facilitators, successes and failures of initiatives targeting the HCC, and criminal justice issues.ResultsEight themes were identified concerning the impact of substance use on HCC outcomes. At the individual level, these included coping and satisfying basic needs and could influence all HCC steps (i.e., testing, treatment linkage, adherence, and retention, and viral load suppression). The interpersonal level themes included stigma issues and providers’ cultural competence and treatment attitudes and primarily influenced treatment linkage, retention, and viral load suppression. These same HCC steps were influenced at the health care systems level by organizations’ physical environment and resources as well as intra-/inter-agency communication. Testing and retention were the most likely steps to affect at the policy/society level, and the themes included opposition within an organization or community, and activities with unintended consequences.ConclusionsThe most substantial HCC challenges for PLWH with substance use problems included linking and retaining in treatment those with multiple co-morbidities and meeting their basic living needs. Recommendations to improve HCC outcomes for PLWH with substance use problems include increasing easy access to effective drug and mental health treatment, expanding case management and peer navigation services, training staff about harm reduction, de-stigmatizing, and culturally competent approaches to interacting with patients, and increasing information-sharing and service coordination among service providers and the social service and criminal justice systems.

The Uses of Self and Space: Health Providers' Approaches to Engaging Patients into the HIV Care Continuum

“…Salient to this is the undercurrent of mental health problems and substance use, which can hinder optimization of provider approaches to engage patients into the care continuum. This finding aligns with other studies documenting the significance of substance use and mental health states in engagement in the HCC, [22][23][24]26,27 and highlights the need for providers to be aware of the context of patients' lives and appreciate potential threats to overall patient well-being and engagement. Another threat to optimal well-being is the patient's health literacy.…”

“…To address the gap in the literature, the aim of this study was to describe provider approaches to engage patients into the HCC. Although the findings from this study support previous understandings about patient-provider interactions in health promotion, [22][23][24][25] contextualizing providers' experiences reveals the intricacies of specific approaches to address patient vulnerabilities. The provider narratives revealed that efforts and approaches aligned across disciplines indicating the influence of evidence-based practice in HIV prevention and treatment.…”

Assessing health professionals’ perception of health literacy in Rhode Island community health centers: a qualitative study

“…Policy-level factors associated with health literacy include factors such as funding for and mandating of health interpreters and health advocates, policies regarding the use of plain language communications, and so forth. The SEM has been used to understand a wide variety of health factors, beliefs, and behaviors, from confidence in the human papillomavirus (HPV) vaccine [ 28 ], to access to human immunodeficiency virus (HIV) treatment [ 29 ], to students’ food choices while at school [ 30 ], to getting the flu shot [ 31 ], to being physically active [ 32 , 33 ], and to sedentary behavior [ 34 ]. The current qualitative study focused on exploring interpersonal and organizational levels of SEM that may impact patients at FQCHCs in Rhode Island.…”

Substance use and the HIV care continuum: important advances

“…Systems issues must also be addressed to close HIV care continuum gaps for people who use drugs. Qualitative interviews with public health and HIV service providers in Connecticut identified the need to increase mental health and substance use services and peer navigation/case management services and the need to decrease service agency stigma as key barriers and potential facilitators for improving HIV testing, engagement, and treatment [ 10 ]. Idrisov et al [ 11 ] reported no association between individual injection use histories and HIV outcomes, suggesting that systems issues may also prove a dominating contributor to HIV outcomes in Russia, obscuring individual factors.…”