Research Article: 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

Date Published: October 2, 2017

Publisher: BioMed Central

Author(s): Lauretta E. Grau, Abbie Griffiths-Kundishora, Robert Heimer, Marguerite Hutcheson, Amy Nunn, Caitlin Towey, Thomas J. Stopka.


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.

Interviews 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.

Eight 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.

The 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.

Partial Text

The HIV care continuum (HCC) framework assesses patients at various steps of human immunodeficiency virus (HIV) diagnosis and care—from identification of cases, to linkage to care and antiretroviral treatment, to retention in care, and ultimately to viral suppression [1]. Each step builds upon the previous, and the proportion of PLWH within each step has important implications for achieving the ultimate goals of viral suppression and reduced HIV transmission [2]. Monitoring the outcome at each HCC step enables us to better identify where and how to intervene—be it a specific HCC step, geographic area, or at-risk population. The HCC is also a tool by which to monitor the UNAIDS 90-90-90 goal of identifying 90% of those infected, linking 90% of those identified to treatment, and achieving 90% viral suppression among those in treatment; it is believed that reaching this goal by 2020 would end the HIV epidemic by 2030 [3].

The HCC strengths and successes noted by participants in the nine cities were many, although the 90-90-90 goal of the Joint United Nations Programme on HIV/AIDS [3] was not yet met by any of the ASOs participating in this study. ASO administrators were quick to note steady improvement in HCC outcomes over time, however. The most substantial HCC challenges noted were in linking and retaining HIV patients with multiple co-morbidities (substance use disorder, hepatitis C viral infection, mental health problems) and essential needs such as housing, food security, and transportation. These findings were consistent with previous studies and were thought to occur at all levels of the modified social ecological model [16, 19, 52–54].




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