The structural and health policy environment for delivering integrated HIV and substance use disorder treatments in Puerto Rico

Abstract

BackgroundHIV prevalence in Puerto Rico is nearly twice that of the mainland United States, a level that was substantially fueled by injection drug use. Puerto Rico has a longstanding history of health provision by the public sector that directly affects how HIV and substance use disorder (SUD) treatment services are provided and funded. As part of pre-implementation research for a randomized trial of a community-level intervention to enhance HIV care access for substance users in San Juan, Puerto Rico, we sought to understand the structural and health policy environment for providing HIV and SUD treatments.MethodsWe conducted semi-structured qualitative interviews (n = 8) with government and program administrators in English and Spanish. Data were analyzed to identify dominant and recurrent themes.ResultsParticipants discussed how lack of integration among medical and mental health service providers, lack of public transportation, and turnover in appointed government officials were barriers to integrated HIV and SUD treatment. Federal funding for support services for HIV patients was a facilitator. The Affordable Care Act has limited impact in Puerto Rico because provisions related to health insurance reform do not apply to U.S. territories.Discussion and ConclusionsImplications for intervention design include the need to provide care coordination for services from multiple providers, who are often physically separated and working in different reimbursement systems, and the potential for mobile and patient transportation services to bridge these gaps. Continuous interaction with political leaders is needed to maintain current facilitators. These findings are relevant as the current economic crisis in Puerto Rico affects funding, and may be relevant for other settings with substance use-driven epidemics.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-017-2174-7) contains supplementary material, which is available to authorized users.

Opioid distribution trends (2006–2017) in the US Territories

“…Puerto Rico has seen implementation of policies and programs for mental health and substance abuse (Leff et al, 2017). Compared to the other locations, methadone was not as prevalent in Guam where oxycodone, morphine, and fentanyl were more common.…”

When “the Cure” Is the Risk: Understanding How Substance Use Affects HIV and HCV in a Layered Risk Environment in San Juan, Puerto Rico

“…The challenges with seeking and maintaining medical care as well as the lack of housing mark key service shortage areas. In addition, there were few accessible and effective SUD treatment programs available to those in need of them (Leff et al, 2017). Furthermore, the existing treatment options often lacked an evidence-based approach as explained by an upper level regional policy director:…”

“…Participants presented unaddressed medical needs ranging from skin abscesses to mental health and chronic illness. Most Puerto Rican residents qualify for state-based health insurance coverage, but lack of enrollment remains a critical issue for PWUD (Leff et al, 2017). Last, an unfortunate casualty of the economic crisis in PR has been the outmigration of professionals (i.e., medical and social service providers) and reduced support for services due to government cuts.…”

“…Recent unpublished data showed that of 548 people who inject drugs (PWID) sampled, 11.7% (n=64) tested positive for HIV where almost half (48.4%, n=31) were unaware of their diagnosis (PRDH, 2015). The recent economic crisis on the island has only served to deepen the despair and associated health risks for people who use drugs (PWUD) (Leff et al, 2017; Roman, 2015). …”

Peer Review #1 of "Opioid distribution trends (2006–2017) in the US Territories (v0.1)"

“…Puerto Rico has seen implementation of policies and programs for mental health and substance abuse (Leff et al 2017). Compared to the other locations, methadone was not as PeerJ reviewing PDF | (2018:08:30550:1:3:NEW 6 Dec 2018)…”