Optimizing Care for HIV-Infected People Who Use Drugs: Evidence-Based Approaches to Overcoming Healthcare Disparities

Abstract

Substance use disorders (SUDs) and human immunodeficiency virus (HIV) are pervasive epidemics that synergize, resulting in negative outcomes for HIV-infected people who use drugs (PWUDs). The expanding epidemiology of substance use demands a parallel evolution of the HIV specialist-beyond HIV to diagnosis and management of comorbid SUDs. The purpose of this paper is to describe healthcare disparities for HIV-infected PWUDs along each point of a continuum of care, and to suggest evidence-based strategies for overcoming these healthcare disparities. Despite extensive dedicated resources and availability of antiretroviral therapy (ART) in the United States, PWUDs continue to experience delayed HIV diagnosis, reduced entry into and retention in HIV care, delayed initiation of ART, and inferior HIV treatment outcomes. Overcoming these healthcare disparities requires integrated packages of clinical, pharmacological, behavioral, and social services, delivered in ways that are cost-effective and convenient and include, at a minimum, screening for and treatment of underlying SUDs.

Barriers to HIV Care and Treatment Among Participants in a Public Health HIV Care Relinkage Program

“…Substance use is clearly associated with worse HIV-associated health outcomes. 26 Creative, evidencebased, effective solutions to improve HIV care outcomes for persons who use methamphetamine and other substances are undoubtedly needed. Depression, while more challenging to address than practical barriers to care and treatment, can be successfully addressed with the primary HIV care setting.…”

Substance use and its impact on care outcomes among HIV-infected individuals in Manitoba

“…Injection drug use accounts for a significant proportion of HIV-infections in Manitoba, while non-injection drug and alcohol use can result in high risk behaviours leading to the transmission of HIV and increased comorbidity 3,11 . There is evidence to suggest that substance use is a predictor of a more rapid HIV disease progression regardless of adherence to antiretroviral therapy 12 .…”

“…HIV education has also been found to be an effective tool for engaging patients in the healthcare system and improving health outcomes 13 . We know that the effective treatment of substance use disorders improves HIV treatment outcomes, including access to and retention in care programs 11 . Therefore, a comprehensive, multidisciplinary, patient-centred approach to care with the utilization of cognitive behavioural therapy, pharmacotherapy and patient education must be utilized in order to engage patients in care and improve health outcomes for HIV-infected individuals 22,23 .…”

Prevalence and Predictors of Substance Use Disorders Among HIV Care Enrollees in the United States

“…With regard to HIV transmission, effectiveness of universal test-and-treat approaches is diminished among persons with SUD (9, 10). Post-diagnosis linkage to care occurs less often among persons with SUD (11), likely due to a complex mix of system, provider, and patient factors (12). Even after care linkage, persons with SUD visit clinic inconsistently, initiate antiretroviral medication at later stages of illness, and display poor adherence (13–18).…”