Exploring How Substance Use Impedes Engagement along the HIV Care Continuum: A Qualitative Study

Abstract

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.

A Longitudinal Analysis of Antiretroviral Adherence Among Young Black Men Who Have Sex With Men

“…These findings are not surprising, as drug us is commonly used as a copy strategy for dealing with an HIV diagnosis 44 and can impede engagement in HIV care. 45 In previous research with HIV-infected YBMSM, researchers demonstrated a relationship between anxiety and alcohol and marijuana use, which contributed to poor medication adherence. 46 Substance use is a barrier to ART initiation and engagement in care, can reduce confidence in one’s medication management skills, and contribute to depression.…”

“…46 Substance use is a barrier to ART initiation and engagement in care, can reduce confidence in one’s medication management skills, and contribute to depression. 45 …”

“…51 Finally, our findings highlight the need to incorporate substance use treatment into programs for HIV-infected youth. Substance use is strongly associated with poor engagement along the HIV care continuum 45 and it is clear that it negatively influences ART adherence for YBMSM. Research should continue to explore effective interventions to improve initiation and adherence with ART, especially among YBMSM.…”

The “Safe Sex” Conundrum: Anticipated Stigma From Sexual Partners as a Barrier to PrEP Use Among Substance Using MSM Engaging in Transactional Sex

“…While we did not find an association between transactional sex and HIV stigma as a barrier to PrEP use, we did not assess stigma specific to transactional sex or substance use, which may be more relevant as a barrier to PrEP use and healthcare access for this population [23, 24]. In fact, Underhill et al found that stigma associated with substance use was prevalent among MSM who engage in transactional sex, and that it was more commonly cited as a barrier to healthcare access and PrEP initiation than sexual behavior and HIV risk-related stigma [17].…”

HealthCall delivered via smartphone to reduce co-occurring drug and alcohol use in HIV-infected adults: A randomized pilot trial

“…However, substantial disparities remain (Hall et al, 2013) since African-Americans and Hispanics are at greater risk for HIV infection (Giordano et al, 2010; Harrison, Song, & Zhang, 2010; Siddiqi et al, 2015), and for failure to achieve viral suppression once infected (Castel et al, 2016; Xia, Sun, Wiewel, & Torian, 2017). HIV-infected individuals with alcohol and drug problems are also more likely than others to have poor health behaviors (Crane et al, 2017; Metrik, Caswell, Magill, Monti, & Kahler, 2016; Young, Wood, Dong, Kerr, & Hayashi, 2015), lower engagement in and utilization of HIV care, and lower ART adherence (Gwadz et al, 2016; Lake et al, 2017; Lucas, 2011). Further, the dual use of illicit drugs and alcohol, more than the use of either one alone, is associated with poor quality of HIV care (Dickson-Gomez, Bodnar, Petroll, Johnson, & Glasman, 2015; Korthuis et al, 2012), viral resistance to treatment, and HIV disease progression (Azar et al, 2015; Baum et al, 2009; Lima et al, 2014).…”