Integrated HIV care and service engagement among people living with HIV who use drugs in a setting with a community‐wide treatment as prevention initiative: a qualitative study in Vancouver, Canada

Abstract

Introduction: Social-structural inequities impede access to, and retention in, HIV care among structurally vulnerable people living with HIV (PLHIV) who use drugs. The resulting disparities in HIV-related outcomes among PLHIV who use drugs pose barriers to the optimization of HIV treatment as prevention (TasP) initiatives. We undertook this study to examine engagement with, and impacts of, an integrated HIV care services model tailored to the needs of PLHIV who use drugs in Vancouver, Canada – a setting with a community-wide TasP initiative. Methods: We conducted qualitative interviews with 30 PLHIV who use drugs recruited from the Dr. Peter Centre, an HIV care facility operating under an integrated services model and harm reduction approach. We employed novel analytical techniques to analyse participants’ service trajectories within this facility to understand how this HIV service environment influences access to, and retention in, HIV care among structurally vulnerable PLHIV who use drugs. Results: Our findings demonstrate that participants’ structural vulnerability shaped their engagement with the HIV care facility that provided access to resources that facilitated retention in HIV care and antiretroviral treatment adherence. Additionally, the integrated service environment helped reduce burdens associated with living in extreme poverty by meeting participants’ subsistence (e.g. food, shelter) needs. Moreover, access to multiple supports created a structured environment in which participants could develop routine service use patterns and have prolonged engagement with supportive care services. Our findings demonstrate that low-barrier service models can mitigate social and structural barriers to HIV care and complement TasP initiatives for PLHIV who use drugs. Conclusions: These findings highlight the critical role of integrated service models in promoting access to health and support services for structurally vulnerable PLHIV. Complementing structural interventions with integrated service models that are tailored to the needs of structurally vulnerable PLHIV who use drugs will be pursuant to the goals of TasP.

Social and structural factors associated with greater time with a plasma HIV-1 RNA viral load above log10(1500) copies/ml among illicit drug users

“…As PWUD often contend with substantial contextual barriers to engagement in HIV treatment and care, including criminalization, stigma, discrimination, poverty and housing instability, support interventions that are responsive to these vulnerabilities may be more likely to promote the successful management of HIV and decrease risk of onward transmission [63,64]. For example, recent studies have found that complementing TasP initiatives with low-barrier programs that are tailored to the specific needs of PWUD and address multiple social and structural barriers to care simultaneously may help to promote ART adherence and VL suppression [63,64]. Thus, such programs should be scaled up as part of broader TasP-based efforts, and future research should continue to investigate how these may be optimized to better facilitate engagement and retention in HIV care among PWUD.…”

Assessing the impact of food insecurity on HIV medication adherence in the context of an integrated care programme for people living with HIV in Vancouver, Canada

“…While food provision can provide other benefits (e.g. the mitigation of hunger (24) (a physical sensation experienced by those with severe FI) (46) , entry points to health-care services (25) , promotion of social interactions (41,47) and support for development of daily routines (25,45) ), the root driver of FI in resource-rich settings is inadequate financial resources (43,(48)(49)(50) . Our study further demonstrates this as FI remains prevalent among DPC clients despite the provision of food.…”

“…In particular, the food programme at the DPC can be conceptualized within the organization's broader harm reduction mandate, which aims to improve health and reduce health-and drug-related harms (21,41,45) . For example, the food programme at the DPC has been shown to be an integral element of the Centre and a primary access point for individuals interacting with the space (25,45) . Overall, the benefits of integrated care models that include food provision must consider how programming may positively impact clients through a harm reduction approach, even if experiences, such as FI, remain prevalent.…”

“…The present study used data from a community-based observational study exploring the impact of the DPC's services on health outcomes and HIV-related care for marginalized PLHIV. The quantitative study, described in detail elsewhere (21,25) , is comprised of a longitudinal cohort of DPC clients who participated in baseline (n 121) and follow-up (n 102) socio-behavioural surveys. Participant recruitment was conducted by peer research associates (i.e.…”

HIV Serostatus and Having Access to a Physician for Regular Hepatitis C Virus Care Among People Who Inject Drugs

“…That HIV-seropositive PWID were more likely to engage in HCV care may be partially attributable to HIV care facilities which are operating under an integrated care model. 30 Previous research has demonstrated the importance of integrated care models on mitigating barriers to HCV care for HIV-seropositive populations. For example, a recent retrospective review of HIV/HCV co-infected patients in New York found that HCV therapy can be safely integrated into HIV primary care settings with encouraging SVR rates (92%).…”