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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

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      Abstract

      Background 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.MethodsInterviews 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.ResultsEight 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.ConclusionsThe 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.

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          From conceptualizing to measuring HIV stigma: a review of HIV stigma mechanism measures.

          Recent analyses suggest that lack of clarity in the conceptualization and measurement of HIV stigma at an individual level is a significant barrier to HIV prevention and treatment efforts. In order to address this concern, we articulate a new framework designed to aid in clarifying the conceptualization and measurement of HIV stigma among individuals. The HIV Stigma Framework explores how the stigma of HIV elicits a series of stigma mechanisms, which in turn lead to deleterious outcomes for HIV uninfected and infected people. We then apply this framework to review measures developed to gauge the effect of HIV stigma since the beginning of the epidemic. Finally, we emphasize the utility of using three questions to guide future HIV stigma research: who is affected by, how are they affected by, and what are the outcomes of HIV stigma?
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            Author and article information

            Affiliations
            [1 ]ISNI 0000000419368710, GRID grid.47100.32, Yale School of Public Health, ; PO Box 208034, New Haven, CT 06520-8034 USA
            [2 ]ISNI 0000 0000 8934 4045, GRID grid.67033.31, Tufts University School of Medicine, ; Boston, MA 02111 USA
            [3 ]ISNI 0000 0004 1936 9094, GRID grid.40263.33, Brown University School of Public Health, ; Providence, RI 02912 USA
            Contributors
            Lauretta.Grau@yale.edu
            Abbie.Kundishora@gmail.com
            Robert.Heimer@yale.edu
            Marga.Hutcheson@gmail.com
            Amy_Nunn@brown.edu
            Caitlin.Towey@gmail.com
            Thomas.Stopka@tufts.edu
            Journal
            Addict Sci Clin Pract
            Addict Sci Clin Pract
            Addiction Science & Clinical Practice
            BioMed Central (London )
            1940-0632
            1940-0640
            2 October 2017
            2 October 2017
            2017
            : 12
            28965489
            5623965
            88
            10.1186/s13722-017-0088-7
            © The Author(s) 2017

            Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

            Funding
            Funded by: FundRef http://dx.doi.org/10.13039/100000025, National Institute of Mental Health;
            Award ID: P30MH062294
            Funded by: FundRef http://dx.doi.org/10.13039/100000060, National Institute of Allergy and Infectious Diseases;
            Award ID: P30AI042853
            Categories
            Research
            Custom metadata
            © The Author(s) 2017

            Health & Social care

            hiv/aids, substance use, hiv care continuum

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