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HIV Care and Substance Use Disorder
One-Stop Shop: Maintaining Engagement in HIV Care in Persons With Substance Use Disorders

Released: September 13, 2024

Expiration: September 12, 2025

Alexander Wong
Alexander Wong, MD, FRCPC
Activity Information

Activity

Progress
1
Course Completed
Key Takeaways
  • In persons living with HIV and substance use disorders, providing a holistic treatment approach can optimize treatment retention and overcome barriers to care.
  • A multidisciplinary team and colocation of services can better meet the needs of persons living with HIV and substance use disorders, including people of Indigenous descent.

Our HIV clinic is located in the southern half of Saskatchewan, a Canadian Prairie province north of Montana and North Dakota. Our clinic population is unique in that we have a high proportion of persons of female gender, persons younger than 40 years of age, persons who use substances, and persons of Indigenous descent. Transmission of HIV in our setting traditionally had been overrepresented by those with injection drug use, with high proportions of persons initially diagnosed with HIV and hepatitis C virus coinfection.

More recently, the preferred way of consuming substances, such as stimulants and opioids, has shifted from injection to inhalation. Because of the reduction in injection drug use, heterosexual transmission is now the most common method of HIV transmission in our clinic. Hence, we now see far more coinfection of HIV with syphilis, reflecting a concurrent syphilis epidemic across the Prairie provinces.

Holistic Approach
In our clinic, we optimize linkage and retention in HIV care by focusing on identifying individual-level and system-level barriers to care and addressing them in a holistic, one-stop, culturally and patient-centered, low-barrier care environment.

Many of our newly diagnosed and suboptimally retained persons living with HIV have concurrent medical and socioeconomic challenges, including substance use disorder and insecurities with housing, food, and income. To set patients up for success in HIV care, we focus on meeting their basic needs first. Optimizing engagement and retention in HIV care is all about working with patients to identify and address their priorities. Prescribing antiretroviral therapy alone will not make any difference if an individual doesn’t have a safe place to stay, goes hungry, or is struggling with opioid use disorder.

Multidisciplinary Team
To accomplish this work, our clinic is staffed by an interdisciplinary team that includes nursing, social work, pharmacy, and practitioners including primary care providers and specialist physicians. Along with our primary care and HIV-related work, we provide colocated addiction medicine care that includes prescribing full-scope opioid agonist therapy. Our primary care providers are also able to provide women’s health services, which is often difficult for our patients to obtain. We have reasonable off-site access to both safe consumption and needle and syringe exchange programming when needed. We have team members who provide outreach services to locate and help bring people to scheduled appointments. We also provide universal notifications for all our patients admitted for inpatient care. Team members are trained on principles of provision of culturally respectful practice and have an intimate awareness of health issues specific to Indigenous persons, including the history and legacy of residential schools.

Colocating Services
I suspect that the principles of providing competent intercultural care and colocated health and social services for persons living with HIV and substance use disorder are not new to most HIV care providers. However, persons living with both opioid use disorder and HIV also make up a very high proportion of the patients we see. For people who are trying to reduce or end their use of street opioids, we found that retention in HIV care is typically dependent on retention in opioid use disorder care. Patients often struggle with timely access to on-demand addiction-related services, including medical care, counseling, and social support. Colocation of HIV and opioid use disorder services can help address this barrier to care and improve engagement in both HIV and opioid use disorder care.

Flexible Approaches to Opioid Agonist Therapy
Because of the ongoing synthetic opioid crisis across North America, we adopted more flexible approaches to the induction and maintenance of opioid agonist therapy. For example, we use full-agonist opioids, such as slow-release oral morphine and methadone, and the partial-agonist opioid buprenorphine. We have also adapted our clinical approaches to these opioid agonist therapies by using methadone and slow-release oral morphine together, by more rapidly up-titrating methadone and slow-release oral morphine during the induction phase, and by more liberally using newer formulations of extended-release buprenorphine instead of traditional transmucosal forms. These clinical approaches have improved engagement and retention in care.

Regardless of the number of past attempts, successes, or failures, we have an open-door policy because we recognize that patients will often engage and fall off opioid agonist therapy. Although this method is labor-intensive, it is also necessary for optimal engagement when we acknowledge the needs of our patients.

Supportive Clinical Team
Finally, the importance of having a strong clinical team dynamic cannot be overstated. Providing care for people with substance use disorders and HIV is complicated. During the pandemic, nearly 15% of our HIV-positive cohort died, and most deaths were related to either opioid overdose or direct complications from the use of substances. Many clients have tragic backgrounds filled with historical and intergenerational trauma and providing care to these individuals can be very mentally and emotionally taxing.

Many days are filled with happy moments with our patients. Sharing those moments and acknowledging the importance of the team in helping patients achieve great outcomes is what sustains us all amidst this hard work. But being able to share and absorb moments of sadness and sorrow is equally important. None of this work can be done successfully or sustainably by a single individual. Take care of each other and support each other every day in the clinic.

Your Thoughts? 
What are some strategies you use to support retention in care for people living with HIV and substance use disorders? Are there any we have not mentioned? Get involved in the discussion by posting a comment.