Substance Use Disorder and HIV/AIDS: Addressing Dual Crises

Kelly Dyer, MD, third-year infectious disease clinical fellow, Infectious Disease, Perelman School of Medicine, University of Pennsylvania, first developed an interest in HIV/AIDS during her time as a research assistant for a multicenter randomized controlled trial that was exploring how to engage and retain people living with HIV and substance use in care. The front-row seat she had from her work in the community opened her eyes to the many care barriers patients often face and led her to a great appreciation for the herculean effort many patients made to attend their HIV visits.

Much of her work since that period before medical school is now concentrated in better addressing barriers to care for vulnerable patient populations, including accessing HIV care and pre-exposure prophylaxis (PrEP) in Atlanta, Georgia, and the syndemics of substance use disorders (SUD) and infection through the lens of the opioid epidemic.

At the recent AIDS 2024 conference in Munich, Germany, she presented the research, “Integration of Comprehensive Infectious Disease Screening Within an Inpatient Detoxification Unit in Philadelphia: Capitalizing on Engagement Opportunities to reduce Harm and Improve Patient Outcomes,” and spoke with The American Journal of Managed Care^® (AJMC^®) about her research.

This interview has been lightly edited for clarity.

Kelly Dyer, MD | Image Credit: Perelman School of Medicine

AJMC: Your research focuses on how social factors affect infectious disease outcomes and improving health equity. What are the top factors contributing to health care disparities in HIV care linkage, retention, PrEP implementation, and SUD?

Dyer: This is a tough question to answer, as I think the barriers patients face really vary based on the social and political context in which they reside. I spent over a decade in Atlanta, which is home to some of the highest rates of uncontrolled HIV and new HIV diagnoses in the US. During my time there, I became intimately familiar with barriers to HIV linkage and retention specific to that community. I came to see the 2 biggest barriers, at least in that city, as lack of adequate public transportation infrastructure and stigma. Patients and study participants regularly shared with me that they had to take a day off work, walk 2 miles to the bus stop, and take several busses to make it to their clinic visits. Similarly, shame surrounding sexual preferences driven by widespread conservative values frequently led to ongoing denial about HIV diagnoses with subsequent missed visits or pills. Both issues disproportionately affected minority patients living outside the city center.

With regards to PrEP implementation, the issues are similar but not the same. Internalized stigma certainly still plays a role in suboptimal PrEP uptake among eligible patients and, I believe, is at least partially to blame for unequal uptake of PrEP by race. However, other issues also exist. Lack of perceived risk is something that I have noticed in Atlanta and Philadelphia, particularly among patients with injection drug use.

Another major barrier to PrEP implementation that I have developed a growing appreciation for is called “the purview paradox.” Often, the providers who are best situated within the health-care system to deliver PrEP—for example, primary care providers, obstetricians/gynecologists, etc—are often unfamiliar with the medications and, therefore, unlikely to prescribe them. By contrast, the providers who have the most familiarity with the antiviral medications used for PrEP—such as infectious disease providers—are the least likely to encounter patients who might be eligible. As a result, instead of patients being able to get their PrEP and primary care needs met in one place, they often must schedule a visit with an infectious disease provider as a separate appointment. We have not yet succeeded in making PrEP delivery a patient-centered experience in this country.

For patients with SUD, many of the above barriers to care, including stigma and issues with transportation, also apply. However, additional barriers drive poor outcomes in this group. In particular undertreatment of substance use withdrawal during inpatient admissions and lack of trauma-informed approaches to their addiction and addiction care contribute to medical mistrust and health care avoidance in this population.

Overall, the sheer volume of barriers faced by vulnerable patients across the board should compel us as providers to seek out the most patient-centered and convenient solutions for our patients. Doing so will require ongoing creativity and a willingness to disrupt the status quo.

AJMC: Can you explain why individuals with SUD are at a higher risk for infectious diseases compared with those without SUD, and why screening rates among this population are low?

Dyer: Patients with SUD are at a higher risk for infectious diseases for several reasons. Patients with injection drug use incur a risk for blood-borne diseases like HIV and hepatitis B and C from injection-related practices such as sharing needles. Patients with SUD may also have riskier health behaviors that include unprotected sex, sex with partners of unknown HIV status, or numerous partners because of their substance use.

Xylazine, a veterinary anesthetic that has been a rapidly spreading contaminate of fentanyl in the US, causes necrotic skin wounds that pose an infection risk. Unfortunately, Philadelphia is the epicenter for xylazine within the US, and since its introduction, we have seen increases in admissions for infections related to injection drug use, including skin and soft tissue infections, bloodstream infections, infective endocarditis, and osteomyelitis.

Finally, some of the infection risk faced by patients with SUD is related to the overlap between SUD and other social vulnerabilities. For example, patients with SUD are more likely to experience homelessness, and this predisposes them to a higher risk for infections like tuberculosis, which is disproportionately found in homeless shelters and among the unhoused in the US.

Screening rates in this population are low because of the innumerable barriers to care faced by these patients, which can make accessing regular, preventive care prohibitively challenging. If patients are unsure where they are sleeping and if they will have enough food for the day, how can we expect them to make it to their primary care provider visit?

AJMC: In your opinion, what should be the top policy priorities to mitigate these health care disparities?

Dyer: I think creating low-barrier models of care should be our top policy priority for addressing barriers to care. This should include clinics with walk-in visits that don’t require an appointment and centralizing medical appointments to the extent that this is feasible in our highly specialized world. Patients should be able to get their HIV care in the same place that they get their substance abuse treatment, and they should also have the option to see psychiatrists and dentists there, too. We should also be willing to deliver care in whatever venue best suits the patients’ needs. This could look like delivering PrEP at pharmacies, using mobile vans to provide methadone, and hospital visits to complete what are traditionally thought of as outpatient screenings.

AJMC: Could you discuss the findings you presented at AIDS 2024?

Dyer: Our target population consisted of racially diverse patients with a variety of SUD (eg, opiate use disorder, alcohol use disorder, and cocaine use disorder). The hospital where we rolled out our intervention is based in West Philadelphia and largely serves patients who live locally.

Our primary outcome of interest was the proportion of patients admitted to the inpatient substance use detoxification unit who received screening labs after the intervention. Our secondary outcome of interest was to identify the burden of infectious diseases or prevention opportunities among this patient population.

We chose this area of investigation because we were motivated to improve care and reduce barriers for patients living with SUD.

AJMC: Your abstract notes, “No systematic screening existed prior to this intervention.” Could you explain why systematic screening was absent, given that it seems like a logical step during detoxification stays?

Dyer: I think it boils down to 2 issues. The first issue involves the purview paradox previously mentioned. Addiction providers staffing detoxification units do not always want to order these tests when they are not confident that they will be able to interpret or follow up on the results. It is, therefore, our job to build collaborations and ensure they have the support they need to respond appropriately and deliver excellent patient care.

The second issue is competing demands. Health care providers are busy. Prioritizing everything you would like to get done for a patient in the limited amount of time that exists in a day can be a real challenge. As a result, making the right decision the easiest decision becomes especially important. “Nudges” like embedded order-sets and already pended labs can be game changers in this regard.

AJMC: Do you have next steps planned for this research?

Dyer: Our next steps at the time of publication included building an embedded order-set to streamline the ordering of comprehensive infectious disease labs. This has since been created and has successfully improved our screening numbers beyond what was published in the abstract. Now that this has been done, we hope to do several other things. We want to deliver trainings to the addiction medicine–trained staff on the unit to help instill additional confidence in their ability to interpret and act upon screening lab results. In effect, we hope to help mitigate the purview paradox.

We also have an ongoing collaboration with the Philadelphia Department of Public Health (PDPH). We hope that as we identify more hepatitis C through this program, we can leverage PDPH relationships with rehabilitation facilities to expedite treatment initiation. Currently, when patients are discharged from the unit to a rehabilitation facility, they do not start Hepatitis C treatment until they leave. We are hoping to change that. Finally, we are planning to expand the program to other hospitals with the University of Pennsylvania Health system.