Barriers to antiretroviral treatment access for injecting drug users living with HIV in Chennai, South India

Abstract

India’s National AIDS Control Organization provides free antiretroviral treatment (ART) to people living with HIV (PLHIV), including members of marginalized groups such as injecting drug users (IDUs). To help inform development of interventions to enhance ART access, we explored barriers to free ART access at government ART centers for IDUs living with HIV in Chennai by conducting three focus groups (n = 19 IDUs) and four key informant interviews. Data were explored using framework analysis to identify categories and derive themes. We found interrelated barriers at the family and social, health-care system, and individual levels. Family and social level barriers included lack of family support and fear of societal discrimination, as well as unmet basic needs, including food and shelter. Health-care system barriers included actual or perceived unfriendly hospital environment and procedures such as requiring proof of address and identity from PLHIV, including homeless IDUs; provider perception that IDUs will not adhere to ART, resulting in ART not being initiated; actual or perceived inadequate counseling services and lack of confidentiality; and lack of effective linkages between ART centers, needle/syringe programs, and drug dependence treatment centers. Individual-level barriers included active drug use, lack of self-efficacy in ART adherence, low motivation to initiate ART stemming from a fatalistic attitude, and inadequate knowledge about ART. These findings indicate that to facilitate IDUs gaining access to ART, systemic changes are needed, including steps to make the environment and procedures at government ART centers more IDU-friendly and steps to decrease HIV- and drug use-related stigma and discrimination faced by IDUs from the general public and health-care providers. Housing support for homeless IDUs and linkage of IDUs with drug dependence treatment are also essential.

Stigma in the Dutch Health Care Sector: HIV-Positive Substance Users’ Experiences and Health Care Providers’ Perspectives

“…In that study, positive experiences reported included receiving equal treatment, being valued as a partner in one's health, social support provision, and confidentiality assurances while negative experiences included awkward interactions, irrelevant questions, rude treatment, blame, pity, excessive or differential precautions, care refusal, unnecessary referrals, delayed treatment, poor support, and confidentiality breaches. Our current findings are also similar to findings from studies that have investigated health care provision to substance users more generally [6,[36][37][38] as well as studies looking at the interactions between health care providers and substance users with HIV specifically [18][19][20]27]. For example, previous research has shown that substance users have been refused services or prescriptions [6], that substance users have been provided with less information than others and have received poorer quality care [37], and that HIV diagnoses have been provided to substance users in a detached and unsympathetic manner [18].…”

“…As our findings have shown, such attributions are not only felt by substance users with HIV but also expressed by health care providers, and the literature supports this contention [6,39,[41][42][43]. The literature also demonstrates how this discourse of agency can negatively impact the health and well-being of substance users with HIV and inhibit HIV prevention efforts [19,22,24,25,27,28,41]. Tackling such attributions of personal responsibility is thus paramount.…”

“…Stigmatization in health care settings, in particular, has been found to be highly detrimental to the well-being of substance users with HIV [8,19]. In fact, anticipated or enacted stigmatizing reactions from health care professionals can inhibit both substance use dependence treatment and HIV care [8,20,21] through testing delays [22,23], treatment avoidance [19,24,25], late entry into care [24], non-disclosure of substance use and/or HIV status [19,21,26], and poor access to antiretroviral therapy [27], all of which also impede HIV prevention efforts [19,28]. It is therefore important to engage in efforts to reduce the stigmatization of substance users with HIV in health care settings, and to improve interactions between health care professionals and substance users with HIV.…”

Integrating antiretroviral therapy in methadone maintenance therapy clinics: Service provider perceptions

“…Globally, there has been a major challenge to engage people who inject drugs (PWIDs) in appropriate HIV treatment and care (Chakrapani, Velayudham, Shunmugam, Newman, & Dubrow, 2013; Wolfe, Carrieri, & Shepard, 2010; Zhang et al, 2011a). Specific treatment gaps exist in late testing for HIV, low uptake of antiretroviral therapy (ART), low treatment adherence, treatment discontinuation, and the burden of managing comorbidities such as hepatitis C and tuberculosis for PWID (Altice, Kamarulzaman, Soriano, Schechter, & Friedland, 2010; Lucas, Griswold, Gebo, Keruly, & Chaisson, 2006; Wolfe et al, 2010; Wood et al, 2007).…”

Incorporating services for common mental disorders and substance use disorders for people living with HIV along the HIV treatment cascade

“…These barriers occur at the family and social level, at the health care system level and at the individual level [72,73]. Family and social barriers to initiating ART include disenfranchisement, banishment, homelessness, social discrimination; health care system barriers include poor enabling environment, stigma and discrimination and lack of mental health and drug treatment; individual barriers including low self-esteem, poor health knowledge, and low motivation to initiate ART.…”