Impact of harm reduction care in HIV clinical settings on stigma and health outcomes for PLWH who use drugs

项目摘要 使用毒品的艾滋病毒携带者(PLWH)是艾滋病毒连续护理体系中最脆弱的群体之一， 表现出护理保留率低和临床结果差。艾滋病毒和丙型肝炎(丙型肝炎)经常同时发生 由于共有的脆弱性和传播途径，包括注射吸毒，这也与 有阿片类药物过量的风险。PLWH使用药物的人在医疗保健中经历预期和实施的污名 环境，这导致了不良的临床结果。减少危害(HR)是一种旨在减少 危险健康行为的负面影响，但不一定完全消除，是一种 让吸毒者参与护理的有效方法。尽管经常被认为是结构性的方法， 例如注射器服务，减少伤害也是一种注重非惩罚性、 自主--在患者和提供者之间建立关系。本R01将探索到以下程度 结构型和关系型人力资源方法对艾滋病病毒感染者耻辱经历的护理缓冲 改善初级保健环境，改善患者-提供者关系的质量以及临床结果。这个 这项研究将探索医疗保健提供者对与使用药物的PLWH合作的态度和方式 这涉及到他们对结构性和关系型人力资源的接受和实践。这将通过网络完成- 基于调查(n=125)和定性访谈(n=20)对宾夕法尼亚州匹兹堡和 亚拉巴马州伯明翰这些方法将使用多层次的镜头，与多种类型的提供商接触，如社交 在艾滋病毒初级保健团队工作的工作人员、护士和医生。使用交叉性框架， 这项研究还将评估患者对艾滋病毒提供者的人力资源护理的感知与 在艾滋病毒初级保健环境中预期和实施的污名以及临床结果。数据将是 通过对使用药物的PLWH(n=500)的调查收集的数据，以探索结构性和关系型HR是否能减轻耻辱， 改善患者与提供者的关系，并最终改善通过电子手段衡量的临床结果 健康记录数据包括艾滋病毒病毒载量、在艾滋病毒初级保健中的留存情况、丙型肝炎病毒持续病毒学反应、 阿片类药物使用障碍和/或行为障碍的药物依从性和保留率 药物使用障碍的健康治疗。研究方法将包括对心理测量的评估 一种新的测量工具--PAPHRS量表的特点 关系型人力资源护理。最后，该研究将应用以人为中心的设计方法，让利益相关者参与到 回顾提供者和患者的人力资源护理经验，以制定干预措施 在艾滋病毒初级保健环境中实施人力资源护理。初步探讨了该项目的可行性、可接受性、 新制定的干预措施的适当性将与艾滋病毒提供者一起进行。最终这就是 研究轨迹旨在改善使用药物的PLWH对护理的依从性和健康差距。

Project Summary People living with HIV (PLWH) who use drugs are among the most vulnerable in the HIV continuum of care, exhibiting low rates of retention in care and poor clinical outcomes. HIV and hepatitis C (HCV) often co-occur due to shared vulnerabilities and routes of transmission including injection drug use, which is also associated with risk for opioid overdose. PLWH who use drugs experience anticipated and enacted stigma in healthcare settings, which contribute to poor clinical outcomes. Harm reduction (HR) is an approach that aims to reduce the negative effects of risky health behaviors without necessarily eliminating them completely and is an effective way of engaging people who use drugs into care. Though often thought of as structural approaches, such as syringe services, harm reduction is also a relational approach to care that focuses on non-punitive, autonomy-building relationships between patients and providers. This R01 will explore the degree to which structural and relational HR approaches to care buffer experiences of stigma for PLWH who use drugs in HIV primary care settings and improve the quality of patient-provider relationships as well as clinical outcomes. The study will explore healthcare providers' attitudes towards working with PLWH who use drugs and the ways these relate to their acceptance and practice of structural and relational HR. This will be accomplished via web- based surveys (n=125) and qualitative interviews (n=20) with healthcare providers in Pittsburgh, PA and Birmingham, AL. These methods will utilize a multi-level lens, engaging multiple provider types, such as social workers, nurses, and physicians working in HIV primary care teams. Using an intersectionality framework, the study will also assess the degree to which patients' perceptions of their HIV providers' HR care are associated with anticipated and enacted stigma in HIV primary care settings and with clinical outcomes. Data will be collected by surveying PLWH who use drugs (n=500) to explore if structural and relational HR mitigate stigma, improve the patient-provider relationship, and ultimately improve clinical outcomes as measured via electronic health records data including HIV viral load, retention in HIV primary care, HCV sustained virologic response, medication adherence, and retention in care for Medications for Opioid Use Disorder and/or in behavioral health treatment for substance use disorder. Study methods will include an evaluation of the psychometric properties of the Patient Assessment of Providers Harm Reduction Scale (PAPHRS), a novel scale to measure relational HR care. Finally, the study will apply human-centered design approaches to engage stakeholders in reviewing findings from providers' and patients' experiences of HR care to develop an intervention to operationalize HR care in HIV primary care settings. A preliminary exploration of the feasibility, acceptability, and appropriateness of the newly-developed intervention will be conducted with HIV providers. Ultimately this research trajectory aims to improve adherence to care and health disparities for PLWH who use drugs.