A qualitative investigation of HIV treatment dispensing models and impacts on adherence among people living with HIV who use drugs

Acceptability of long-acting antiretroviral therapy among people living with HIV who use drugs in Vancouver, Canada: A qualitative study

BACKGROUND

People living with HIV (PLHIV) who use drugs face overlapping social-structural inequities that contribute to suboptimal adherence to antiretroviral therapy (ART). Recent research suggests that long-acting antiretroviral therapy (LA-ART) can offer an important alternative to daily oral ART by mitigating adherence barriers, but this work has largely excluded PLHIV who use drugs. We, therefore, explored the acceptability of injectable and transdermal LA-ART among PLHIV who use drugs in Canada, which has no-cost universal access to oral ART. Greater understanding of PLHIV who use drugs' perspectives on LA-ART will be essential to fully leverage treatment advances and maximize its individual- and population-level benefits.

METHODS

From February 2019 to February 2020, we conducted in-depth interviews with 33 PLHIV who use drugs in Vancouver, Canada with suboptimal ART adherence (i.e., ≦  50%). Participants were recruited for interviews through a prospective cohort study. Interviews were audio-recorded, transcribed, and analyzed using inductive and deductive approaches.

RESULTS

Our analysis identified key factors shaping LA-ART acceptability. First, LA-ART enthusiasm was highest among participants who were less satisfied with oral ART regimens due to pill burden or adverse side effects for oral ART and participants who struggled with daily adherence due substance use and social-structural factors (e.g., homelessness, incarceration). Moreover, participants who had physicians they trusted identified their physicians as credible sources of information on LA-ART, and indicated a desire for informed and shared decision-making regarding treatment changes. Finally, participants emphasized that there is no one-size-fits-all treatment approach for PLHIV who use drugs and highlighted the importance of access to a full range of available treatment options, including LA-ART.

CONCLUSIONS

There is potential for high LA-ART uptake among PLHIV who use drugs, particularly those who experience adherence barriers due to their substance use and structural vulnerability. While our findings are limited by the specific population and setting, they nevertheless underscore the need for efforts to ensure universal and equitable access to LA-ART.

Adherence to oral antiretroviral therapy in Canada, 2010-2020

OBJECTIVE

To assess antiretroviral therapy (ART) adherence among people with HIV (PWH) in Canada and identify baseline characteristics associated with suboptimal adherence (<95%).

DESIGN

Retrospective observational study using data from the National Prescription Drug Utilization Information System and Régie de l'assurance maladie Quebec (RAMQ) Public Prescription Drug Insurance Plan.

METHODS

This analysis included PWH aged 18 years or older who initiated an ART regimen and were followed for at least 12 months (2010-2020). Patient characteristics were summarized using medical/pharmacy claims data from seven provinces (Alberta, Manitoba, New Brunswick, Newfoundland and Labrador, Ontario, Saskatchewan, and Quebec). ART regimen at index date (first dispensing of a regimen including a core agent) was defined as a single-tablet or multitablet regimen (MTR). Adherence was calculated using a Proportion of Days Covered approach, based on ART dispensing, recorded between April 2010 and the last available date. Multivariate linear regression analysis was used to determine correlations between suboptimal adherence and baseline characteristics.

RESULTS

We identified 19 322 eligible PWH, 44.7% of whom had suboptimal adherence (<95%). Among 12 594 PWH with evaluable baseline data, 10 673 (84.8%) were ART-naive, 74.2% were men, mean age was 42.9 years, and 54.1% received a MTR as their ART. Based on multivariate regression analysis, suboptimal adherence was significantly associated with multitablet ART ( P  < 0.001) and younger age ( P  < 0.001) but not sex.

CONCLUSION

Almost half of adult PWH in Canada had suboptimal adherence to ART. Better understanding of factors influencing adherence may help address gaps in current care practices that may impact adherence.

Primary care embedded within permanent supportive housing for people who use substances: A qualitative study examining healthcare access in Vancouver, Canada

Marginally housed people who use drugs and alcohol (PWUD/A) face barriers in accessing healthcare services, which may be improved by providing healthcare in housing settings. This case study examines the experiences of healthcare access amongst PWUD/A who live in a permanent supportive housing model in Vancouver, Canada. This model has an embedded multidisciplinary clinic providing in-reach services. Thirty participants were recruited via posters placed throughout the building and semi-structured qualitative interviews were conducted remotely. Interviews were conducted with participants who accessed onsite care regularly (n = 15) and those who do not (n = 15). Data were analysed to identify both a priori and emerging themes. Participants who accessed the onsite clinic reported benefiting from stigma-free care. Close proximity and convenience of drop-in appointments enabled participants to engage with healthcare services more consistently, though hours of operation and privacy concerns were barriers for others. Participants who did not use the onsite clinic highlighted the importance of continuity of care with their pre-existing primary care team, particularly if their clinic was in close geographic proximity. However, they also described utilising these services for urgent health needs or as an occasional alternative source of care. Shared perspectives across all participants emphasised the importance of low-barrier services, including medication delivery, convenience and positive therapeutic relationships. Our findings suggest that embedding access to primary care within supportive housing benefits PWUD/A who have previously encountered barriers to healthcare access. This model could be implemented to prevent utilisation of acute healthcare resources and improve health outcomes amongst PWUD/A.