TY - JOUR
T1 - Exploring How Substance Use Impedes Engagement along the HIV Care Continuum
T2 - A Qualitative Study
AU - Gwadz, Marya
AU - de Guzman, Rebecca
AU - Freeman, Robert
AU - Kutnick, Alexandra
AU - Silverman, Elizabeth
AU - Leonard, Noelle R.
AU - Ritchie, Amanda Spring
AU - Muñoz-Plaza, Corinne
AU - Salomon, Nadim
AU - Wolfe, Hannah
AU - Hilliard, Christopher
AU - Cleland, Charles M.
AU - Honig, Sylvie
N1 - Funding Information:
The authors wish to thank the men and women who participated in the study, the Peter Krueger Center for Immunological Disorders at Mount Sinai Beth Israel, Spencer Cox Center for Health at Mount Sinai St. Luke?s-Roosevelt Hospital Center, and Gay Men?s Health Crisis for making this study possible. Special thanks to Rob Shiau at the Peter Krueger Center, Imtiaz Waldin at GMHC, and Zach Hennessey, MA, Victoria Sharp, MD, and Antonio Urbina, MD, at Spencer Cox for facilitating study implementation, as well as Dr. Donna Mildvan at Mount Sinai Beth Israel. This work would not have been possible without Dawa Sherpa, BA and Amy Braksmajer, PhD; as well as members of the Heart to Heart Collaborative Research Team: Lisa Sanfilippo, RN; Andrea Wagner, RN; Angela Banfield, MPH; Isaiah Pickens, PhD; Kelly Bolger, MA; Marion Riedel, PhD; DeShannon Bowens, MSW; Mindy Belkin MA; and Dr. Monica Gandhi, who was supported by NIAID/NIH R01AI098472. The authors particularly wish to acknowledge our Program Officer at the National Institute of Mental Health (NIMH), Michael Stirratt, PhD, Program Chief at the NIMH Division of AIDS Research for scientific guidance throughout the study.
Funding Information:
The study was supported by the National Institutes of Mental Health (R34MH093352) and the Center for Drug Use and HIV Research (CDUHR; P30DA011041).
Publisher Copyright:
© Copyright © 2016 Gwadz, de Guzman, Freeman, Kutnick, Silverman, Leonard, Ritchie, Muñoz-Plaza, Salomon, Wolfe, Hilliard, Cleland and Honig.
PY - 2016/4/8
Y1 - 2016/4/8
N2 - Drug use is associated with low uptake of HIV antiretroviral therapy (ART), an under-studied step in the HIV care continuum, and insufficient engagement in HIV primary care. However, the specific underlying mechanisms by which drug use impedes these HIV health outcomes are poorly understood. The present qualitative study addresses this gap in the literature, focusing on African-American/Black and Hispanic persons living with HIV (PLWH) who had delayed, declined, or discontinued ART and who also were generally poorly engaged in health care. Participants (N = 37) were purposively sampled from a larger study for maximum variation on HIV indices. They engaged in 1–2 h audio-recorded in-depth semi-structured interviews on HIV histories guided by a multilevel social-cognitive theory. Transcripts were analyzed using a systematic content analysis approach. Consistent with the existing literature, heavy substance use, but not casual or social use, impeded ART uptake, mainly by undermining confidence in medication management abilities and triggering depression. The confluence of African-American/Black or Hispanic race/ethnicity, poverty, and drug use was associated with high levels of perceived stigma and inferior treatment in health-care settings compared to their peers. Furthermore, providers were described as frequently assuming participants were selling their medications to buy drugs, which strained provider–patient relationships. High levels of medical distrust, common in this population, created fears of ART and of negative interactions between street drugs and ART, but participants could not easily discuss this concern with health-care providers. Barriers to ART initiation and HIV care were embedded in other structural- and social-level challenges, which disproportionately affect low-income African-American/Black and Hispanic PLWH (e.g., homelessness, violence). Yet, HIV management was cyclical. In collaboration with trusted providers and ancillary staff, participants commonly reduced substance use and initiated or reinitiated ART. The present study highlights a number of addressable barriers to ART initiation and engagement in HIV care for this vulnerable population, as well as gaps in current practice and potential junctures for intervention efforts.
AB - Drug use is associated with low uptake of HIV antiretroviral therapy (ART), an under-studied step in the HIV care continuum, and insufficient engagement in HIV primary care. However, the specific underlying mechanisms by which drug use impedes these HIV health outcomes are poorly understood. The present qualitative study addresses this gap in the literature, focusing on African-American/Black and Hispanic persons living with HIV (PLWH) who had delayed, declined, or discontinued ART and who also were generally poorly engaged in health care. Participants (N = 37) were purposively sampled from a larger study for maximum variation on HIV indices. They engaged in 1–2 h audio-recorded in-depth semi-structured interviews on HIV histories guided by a multilevel social-cognitive theory. Transcripts were analyzed using a systematic content analysis approach. Consistent with the existing literature, heavy substance use, but not casual or social use, impeded ART uptake, mainly by undermining confidence in medication management abilities and triggering depression. The confluence of African-American/Black or Hispanic race/ethnicity, poverty, and drug use was associated with high levels of perceived stigma and inferior treatment in health-care settings compared to their peers. Furthermore, providers were described as frequently assuming participants were selling their medications to buy drugs, which strained provider–patient relationships. High levels of medical distrust, common in this population, created fears of ART and of negative interactions between street drugs and ART, but participants could not easily discuss this concern with health-care providers. Barriers to ART initiation and HIV care were embedded in other structural- and social-level challenges, which disproportionately affect low-income African-American/Black and Hispanic PLWH (e.g., homelessness, violence). Yet, HIV management was cyclical. In collaboration with trusted providers and ancillary staff, participants commonly reduced substance use and initiated or reinitiated ART. The present study highlights a number of addressable barriers to ART initiation and engagement in HIV care for this vulnerable population, as well as gaps in current practice and potential junctures for intervention efforts.
KW - African-American
KW - Black
KW - HIV care continuum
KW - Hispanic
KW - antiretroviral therapy
KW - barriers
KW - drug use
KW - qualitative
UR - http://www.scopus.com/inward/record.url?scp=85008679918&partnerID=8YFLogxK
UR - http://www.scopus.com/inward/citedby.url?scp=85008679918&partnerID=8YFLogxK
U2 - 10.3389/fpubh.2016.00062
DO - 10.3389/fpubh.2016.00062
M3 - Article
AN - SCOPUS:85008679918
VL - 4
JO - Frontiers in Public Health
JF - Frontiers in Public Health
SN - 2296-2565
M1 - 62
ER -