“It’s Never Just About the HIV:” HIV Primary Care Providers’ Perception of Substance Use in the Era of “Universal” Antiretroviral Medication Treatment

Abstract

Antiretroviral therapy (ART) is recommended for all people living with HIV (PLWH), regardless of disease status. Substance use disorders (SUD) are common barriers to successful HIV treatment; however, few studies have comprehensively explored how HIV primary care providers take SUDs into account in the context of universal ART implementation. This study uses thematic analysis of qualitative interviews to explore providers' (N = 25) substance use assessment and factors associated with ART initiation. 64% of providers had 15 or more years of HIV treatment experience. Almost all providers agreed with the guidelines for universal ART initiation despite the presence of SUD. Still, identification and management of SUD is challenged by inconsistent assessment, providers' misperceptions about SUD and patients' willingness to discuss it, and lack of accessible treatment resources when SUD is identified. Greater guidance in systematic SUD assessment and management, combined with integrated addiction services, could enhance universal ART implementation among PLWH/SUD.

A client-centered relational framework on barriers to the integration of HIV and substance use services: a systematic review

“…Many articles investigating the client’s perspective identified providers’ biases and concerns about clients’ characteristics—for example, clients’ difficulties in adhering to medical treatments, lack of readiness to initiate treatment, denial of HIV status, or inability to keep appointments [40, 42, 43, 45, 46, 49–51, 61]. Another type of client-provider barrier was providers’ lack of awareness, knowledge, skills, experience, or confidence in serving clients diagnosed with co-morbidities and/or in carrying out specific treatment models [10, 43, 44, 47, 48, 51]. Poor provider-client relationships, including poor communication, confidentiality issues, and mutual distrust, were identified in many articles [46, 50, 51, 56, 57, 59].…”

“…Another type of client-provider barrier was providers’ lack of awareness, knowledge, skills, experience, or confidence in serving clients diagnosed with co-morbidities and/or in carrying out specific treatment models [10, 43, 44, 47, 48, 51]. Poor provider-client relationships, including poor communication, confidentiality issues, and mutual distrust, were identified in many articles [46, 50, 51, 56, 57, 59]. One study also pointed out providers’ mental health status and stressful life conditions as a potential barrier [43], and thus highlighted the need of self-care among providers for carrying out services effectively.…”

“…Examples include inflexible HIV testing hours [55], long waitlists [46, 56, 60], difficulty in obtaining appointments [56], and lack of regular medication refills or follow-up visit arrangements [53]. Our review identified the following key barriers within the client-organizational domain: lack of training resources or low training quality [54, 55], high caseload [43, 49], and burdensome paperwork [44, 51, 59]. Other key barriers include lack of access to consultants and services from other professions [10, 44, 46, 47, 59], ineffective interagency referral structure [10, 51], and poor inter- and intra-agency communication [51, 58].…”

“…Our review identified the following key barriers within the client-organizational domain: lack of training resources or low training quality [54, 55], high caseload [43, 49], and burdensome paperwork [44, 51, 59]. Other key barriers include lack of access to consultants and services from other professions [10, 44, 46, 47, 59], ineffective interagency referral structure [10, 51], and poor inter- and intra-agency communication [51, 58]. This review found that some HIV clinics were in areas with a relatively lower volume of SUD clients; thus, providers in these clinics had limited knowledge and experiences of working with dual-diagnosis clients [44, 48, 49].…”

“…Barriers under this domain were grouped based on structural issues that lead to (a) socioeconomic and health-related disparities for clients, (b) deficiencies in resources and social support available to clients, and (c) stigmatization and discrimination of clients’ behaviors and socioeconomic conditions. The review found that individuals with both HIV and SUDs may face poverty, homelessness, social instability, and an unfair criminal justice system [41, 42, 50, 51, 59, 60]. Collectively, these conditions contribute to further barriers, such as multiplication of competing demands [10, 45, 56], and are particularly related to late access of HIV and/or SUD treatment [49].…”