Harm reduction interventions in HIV care: a qualitative exploration of patient and provider perspectives

The cultural, political and fiscal context

In the US, the dearth in services can be explained by the philosophical, legal and funding barriers to providing syringe exchange. For example, a ban has prohibited the use of federal funding for NSPs for several decades, relegating most NSPs to acquire funding through other means. Even recent changes to this legislation through the congressional Omnibus that allow funding for other services within NSPs, while helpful, still prohibit the use of funding for the actual syringes. The lack of a comprehensive harm reduction approach can perhaps be best explained by the dominant cultural paradigm in the United States as it relates to substance use, which assumes that those who use substances have no control over their use, responds to patient use in a shame-based manner, and assumes they are either in recovery or relapse—rather than recognizing a vast area between those two stages (Fitzgerald, 1996). In particular, the perception that drug use and addiction are moral problems perpetuates punishing approaches to drug use rather than facilitating accessibility to treatment. For example, in 2012, drug charges accounted for over 50% the federal prison population, with 80% of those due to possession only (Drug Policy Alliance, 2014).

In the US, drug-related stigma has vast implications. Discrimination is associated with poorer health—both physical and mental, and alienation is associated with poor mental health (Ahern, Stuber & Galea, 2007). Considerable negative stereotypes associated with being a “drug user” persist, and serve to delegitimize persons who use drugs, which is further compounded with the stigma of being HIV positive (Ware, Wyatt & Tugenberg, 2005). Stigma may also result in engagement in riskier behavior, and interfere with a drug user’s willingness to use harm reduction services in the community (such as syringe exchange services) due to fear or embarrassment (Simmonds & Coomber, 2009), making the need to access harm reduction services in other venues even more urgent. While harm reduction services are often a bridge to healthcare or treatment, they rarely exist within healthcare environments in the US. Rather, syringe provision has occurred in clinical care on a prescription program basis (Rich et al., 2001), but even that approach has been limited. Stigma within the HIV care system is also problematic. For example, PWIDs are often presumed to be incapable of adherence and subsequently denied access to life-saving antiretroviral therapy (ART), despite evidence that PWIDs can be adherent, particularly when opioid substitution therapy is provided (Wolfe, Carrieri & Shepard, 2010; Lert & Kazatchkine, 2007). Despite the availability of buprenorphine for office-based medical management of opioid addiction, 96% of states do not have the treatment capacity to properly address their rates of dependence (Jones et al., 2015). Problems of access are further compounded by racial disparities, as African-Americans are less likely to access substance abuse treatment, and typically receive lower doses of methadone in treatment than Caucasians (Rosen, 2004). This is particularly problematic considering the disproportionate rates of HIV and drug use in African-Americans, who also experience more problems related to their drug use than other racial groups (NIDA, 2003).

Chicago’s climate is similar, particularly as it relates to racial disparities. For example, arrests for possession have historically demonstrated who is most affected by drug policies. African-American males are arrested for possession of marijuana at fifteen times the rate of Caucasian males within Chicago (Substance Abuse and Mental Health Services Administration, 2013). Inside Cook County (which encompasses both Chicago and some surrounding suburbs), African Americans are more than twice as likely to be prosecuted for drug crimes than Whites, and also suffer sentencing disparities (Lyons et al., 2013).

With limited funding, harm reduction services are still delivered through a few programs in Chicago, most notably the Chicago Recovery Alliance, and Community Outreach Intervention Projects, who provide fixed-site and outreach based services to PWIDs and other people who use drugs in Chicago. However, funding constraints limit opportunities for expansion to meet current need, particularly into additional suburban and rural areas. Thus, more options are necessary to ensure safer injection and reduction of harm among Chicago IDUs.

An untapped opportunity for expansion within the city exists in HIV care clinics, where PWIDs are accessible and clinicians are expected to engage in some level of prevention work with patients. In 2003, the Centers for Disease Control and prevention (CDC) began to focus on the need for prevention in the HIV care environment. HIV care clinicians were ideal targets for training as they already had daily access to those infected with HIV. A few nationally diffused interventions were shown to produce patient-level behavior change when counseling was initiated by the clinician (Richardson et al., 2004, for example), but measured outcomes were related to reducing risks from sexual exposures. In available evidence-based curricula, messages regarding drug use have mainly focused on: (1) abstaining from drug use or, (2) using clean needles, messages that do not meet the needs of all PWIDs or those using stimulants like crack cocaine. More options for messaging and interventions would better meet the needs of HIV-positive patients in the city, if the patients and providers are willing to participate.

The integration of particular interventions in HIV care may be lifesaving for those who are not accessing it elsewhere. In particular, a harm reduction (client-centered, nonjudgmental) approach may enhance the level of trust between provider and patient, and allow space for specific interventions: safer injection counseling, safer stimulant use counseling, overdose prevention, and syringe/needle exchange or distribution. These interventions can provide the means to prevent additional viral infections (HCV, for example) or other complications, such as abscesses, cellulitis, endocarditis, necrotizing fasciitis, etc. These infections occur at various points during the injection process, from the sharing of syringes, to the sharing of paraphernalia (cookers, cotton filters, water, etc.), to the reuse of one’s own injection equipment, to the splitting of drugs between users in liquid form (Roman-Crossland, Forrester & Zaniewski, 2004). Although the sharing of syringes is a well-known risk, the harms related to the sharing of other equipment may not be well understood by the clinician, or the patient. The entire injection process can vary from user to user, as can the equipment. Only by exploring each individual user’s process can clinicians assist in offering options that reduce harm associated with a given injection. With proper instruction, clinicians may be able to offer a multitude of harm reduction interventions, and assist the patient in identifying steps toward healthier use which are realistic to the patient, with an approach based on trust and acceptance, rather than stigma and judgment. However, little is known about how providers or patients would feel about having a harm reduction approach and interventions within the HIV care visit, a gap in the literature this study began to explore.

Selection and description of participants

To focus on those who suffer the greatest impact related to their drug use in Chicago, a purposeful sample was selected from three Ryan White-funded clinics located in areas of Chicago with a high prevalence of HIV and drug use, in underserved, low-income African-American communities. The sample was designed to be ‘information rich’ (Patton, 2002) in its ability to yield insight into this group of patients’ perspectives on harm reduction interventions in the care visit. Inclusion criteria for the patient sample included: being 18 years or older, able to speak English, having HIV, Hepatitis B or Hepatitis C infection, and actively using either heroin or crack cocaine (based on a short screening instrument). It was understood that all patients would be living with HIV infection given their care within the HIV clinic. Patients were recruited by placing flyers in each clinic that included the purpose of the study, the desired target population, and the IRB protocol number. In addition, clinics referred patients who met inclusion criteria. All subjects were offered the opportunity to be interviewed on-site at the clinic, or at another location. Patients were compensated $20.00 for their time, with careful consideration to determine a modest amount which would not coerce patients to participate clinicians were also a purposeful sample, with the aim of interviewing all prescribing clinicians in each of the selected clinics. Inclusion criteria for clinicians included: being 18 years of age or older, able to speak English, and currently providing services (including prescribing medications) to HIV/AIDS patients who actively use drugs. Clinicians were recruited with letters explaining the purpose of the study and IRB protocol information, and follow-up calls were made to encourage participation and facilitate scheduling. Clinicians were compensated for their time with a combination of training vouchers and a resource package containing tools and guidelines to assist the clinician in treating HIV, Hepatitis and addiction. The study was approved for human subjects’ research by the Institutional Review Board (IRB) at the University of Illinois—Chicago, Protocol #2007-0116.

Data collection, analysis, and assurance of rigor

The majority of interviews were conducted within the clinics in a private space. In two cases, patients chose an alternate location to preserve their privacy. Written informed consent was received from all eligible subjects, and all agreed to be audio-taped for transcription. Audio recordings were transcribed by a professional transcription service and then verified for accuracy. All transcripts were entered into ATLAS.ti, a software program that aids the analysis and management of qualitative data (Muhr & Friese, 2004).

A deductive analysis approach was used to generate themes, since the goal was to explore pre-determined concepts from the perspectives of the participants (Patton, 2015). Thus, the first step in the analysis was the creation of an index code list for both the clinicians and the patients, based on the research questions, interview guides, and concept maps. These broad categorical codes and their definitions were used in the initial process of open coding. Initial coding occurred while interviews were ongoing. Emerging, unanticipated themes were used to create additional codes for analysis, and relationships among codes were identified (a process referred to as axial coding) resulting in more refinement of the code list, with changes in codes recorded by the researcher for transparency in process. During the process, the data was coded three times. The first round was done manually, printing all transcripts and assigning codes in the margins, and noting any emergent themes. The second round was done within ATLAS.ti, without making reference to the first round to ensure fresh thinking about the data. At this point, codes were refined again, and a third round ensued, comparing the previous rounds and utilizing the constant comparative method to ensure fidelity to the code definitions. Additionally, an experienced independent qualitative researcher coded a subset of interviews to assess the thoroughness of code definitions and to mitigate any researcher bias. The Principal Investigator had experience in harm reduction, and the external coder did not—allowing for fresh thinking about the data and code definitions. Inter-rater reliability was calculated with Cohen’s Kappa which accounts for concordant coding that might occur by chance (Cohen, 1960), making it a more robust measure of inter-rater reliability. Kappa results were interpreted with the use of guidelines published by Landis & Koch (1977), which provide a benchmark for discussion around discordant coding.

To assure scientific rigor within a qualitative, constructionist paradigm, researchers must establish and enhance trustworthiness (Lincoln & Guba, 1985). This study employed strategies to enhance all four components of trustworthiness: credibility, transferability, confirmability and dependability. Participants were engaged in member-checking, the technique that is most critical in establishing credibility (Lincoln & Guba, 1985), by ensuring that notes taken during the interview were accurate representations of the realities shared by the participants, both in their individual contributions and to vet emerging themes in the data. This was done throughout the interview as needed and as a final step in the interview process, summarizing both emerging themes and specific passages in the notes to ensure fidelity to participant experience. Peer debriefing was also used, by engaging in a purposeful discussion with peers who work in HIV care environments (a former PWID and a former non-injection drug user) during instrument development, and to verify emerging themes. These peers were able to provide insight and feedback on interpretation of study data by the researcher to identify any potential bias (see Lincoln & Guba, 1985). Triangulation of data sources was used in the data collection process by inquiring about the same concepts from differing perspectives (Patton, 2015), applied here as both patient and provider views on the same issues. Similarly, it was used in data analysis by employing an independent coder to code a subset of interviews for the purposes of comparing findings and calculating the IRR, called “triangulating analysts” (Silverman & Marvasti, 2008). Although the results here cannot be broadly generalized, they may be transferable to clinics in urban areas that serve similar populations (see the following sections for details: ‘The Cultural, Political and Fiscal Context’, the ‘Selection and Description of Participants,’ as well as ‘Sample Demographics’). As such, comprehensive descriptions of the urban setting and clinic populations may assist in determining transferability to similar settings. In addition, thick description was achieved with detailed notetaking related to participants, clinic context/interactions, and perceived relationships, in addition to the evolution in the coding process. When combined with raw data (transcripts and audio files) such materials become an audit trail of the research, to facilitate replication of the study methods to verify results. This audit trail works to ensure the “confirmability” and the “dependability” of the results generated in this research (Lincoln & Guba, 1985).

Sample Demographics

A total of 32 patient participants were screened and N = 31 were determined to be eligible based on the inclusion criteria. All 31 eligible subjects consented to the process, agreed to be audio taped, and participated in the interviews (N = 31). All participants were African-American. The gender breakdown was intentionally skewed towards males to approximately match the Chicago PWID population (G Scott, N Prachand & C Ciesielski, 2005, unpublished data) with 8 female participants (26%) and 23 male participants (74%). Although not asked specifically about sexual orientation or gender of sex partners, a portion of male subjects reported having sex with other men (n = 9 or 39% of the males). Approximately half of the participants (n = 15 or 48%) reported injection drug use of heroin, while the other half (n = 16 or 52%) were primarily crack cocaine users with some reports of injection. Most reported polydrug use, particularly the use of alcohol or marijuana in addition to their drug of choice, or the use of both heroin and crack cocaine (n = 8, or approximately 25% of subjects). Most participants were experienced drug users with long careers of using, a high risk group for opioid overdose. See Table 2 for the detailed breakdown by age, and Table 3 for the breakdown by level of education.

As previously mentioned, all clinics were publicly-funded (Ryan White, primarily), and situated in areas of high HIV prevalence and heroin/crack use, in low-income areas of the City of Chicago. All clinics served mainly African-American patients. All three included additional services, including mental health counseling, Ryan White Case Management, and counseling for substance use disorders. All three also had peer group support services available. At each clinic, the physician in charge of HIV care was interviewed, as well as at least one nurse practitioner who provided medical care to the target population, for a total of seven (N = 7) interviews. Although this sample is small, it represented 100% of the HIV care clinicians at the three participating clinics, as each clinic had only one physician providing HIV care and one or two nurse practitioners. The majority of clinicians (five out of seven) had been working in HIV for well over ten years, while one other clinician had been working in HIV for over five years, and another more than two years. Most of the clinicians had very limited experience working with active substance users before beginning their work in HIV. All four of the nurse practitioners were female, and two of the three physicians were male. Four of the providers were African-American (two physicians and two nurse practitioners) and three were Caucasian (one physician and two nurse practitioners).

Patient knowledge of harm reduction

Before asking patients how they would feel about incorporating harm reduction into the HIV care visit, they were asked about their own knowledge of harm reduction, and whether they had been participants of any harm reduction programs or trainings. If they had not received any information about harm reduction from programs or trainings, they were asked what they did to reduce harm related to their use, and how they learned to do those things. Participant responses varied, as did their perceptions of the reduction in harm, encompassing everything from avoiding harmful products to avoiding financial harm as a result of their use. The majority of participants learned how to reduce harm as a result of their use by listening to or watching other users, rather than via harm reduction programs. As one participant explains,

You know, people talk about communities and in every community, even those of us that use, it’s someone be able to tell you a safer way to do what you’re doing.

Participants gained valuable knowledge from other users, such as the importance of buying from trusted sources, and using a glass rather than a metal crack pipe. For example, one participant explained:

Well, they would say don’t go over here and buy from this place because they’re not selling real stuff, you know. Their stuff is mixed with something that they don’t know what it is. They had something that they got from them that made them sick. Or they would say, like, they don’t use metal pipes and stuff because you scrape that stuff and the metal get into your system.

Still others cited learning by watching others such as this comment of how a participant decided to begin using a mouthpiece,

I guess from the experience of seeing sores on other people’s mouths.

Other participants were unable to articulate any information learned about reducing harm or recall any sources for information, such as the comment by this participant,

Nobody never talked to me about that. I never knew there were no safety issues in that.

A smaller group of participants cited that they learned how to reduce harm through ‘common sense,’ such as in the following comments:

I don’t want to suck on nothing nobody else been sucking on and spitting all in—it’s just common sense.,

or relied on themselves for information such as this participant,

I teach myself. Through my experiences, you know, word of mouth, and my own knowledge of common sense.

Similarly, some participants reported learning ‘the hard way,’ through experience, such as in the following quotes:

That’s how I learnt not to spend my money and make excuses or taking my money buying drugs, trying to trick myself, well I’m going to get this money next week and I’m going to replace it. There ain’t no such animal…it never got replaced and then I was deeper and deeper in debt

I have learned to pay rent and bills first, and them if I spend whatever’s left, okay, fine, everything’s taken care of. Trial and error. Screwing up.

Of particular interest, only two participants cited harm reduction programs as a learning source for this type of information, and were currently using an exchange for their source of syringes. For safer injection equipment, most participants utilized multiple sources. For example, one patient said,

Well, I have gone to a syringe exchange and I have bought them in the projects.

In fact, almost a third of injection drug using patients had also purchased their syringes on the street at some point, such as this participant,

They sell them on the street. A bag of them for five dollars, a bag of ten for five dollars, or one for one dollar.

Another third of patients had purchased their syringes in the pharmacy or drugstore, like this subject,

We’d go to the drugstore, buy some, we all shared. We could always go buy some, but you know, we didn’t know about that. You bleach it, you run bleach through it, then rinse it with some water. That’s all we thought we ever needed.

Similarly, almost a third of patients reported stealing their syringes from diabetics, usually who were a part of their families. One patient explains,

My mother was a diabetic…. She would leave them. She didn’t keep them for me. She didn’t know she was…yeah, she’d keep them in her empty box container, the red one, and throw them away, but I’d wait and use them.

In this study, very few participants were currently connected to syringe exchange or harm reduction programs, despite their relative geographic proximity to local Chicago mobile sites. In addition, only one provider mentioned making regular referrals to syringe exchange programs. Given the dearth of patient engagement in external harm reduction programs and the lack of provider referrals, it is clear that a gap exists for these patients, even with their own efforts to reduce a range of harms related to their use. It would therefore be helpful to know whether HIV care would be a suitable alternative environment to provide harm reduction interventions to fill this gap. A discussion of patient and provider themes that emerged from the inquiry around its potential are discussed below.

Patient themes

Provider themes

Summary of findings & implications for practice and policy

It is clear that the majority of patients could see the benefit of harm reduction interventions (safer injection counseling, safer stimulant use counseling, overdose prevention, and provision of equipment) as a routine part of the HIV care visit, and expressed enthusiasm about the possibility. This perspective was shared between injection drug users and those who smoked crack cocaine. This may indicate that for this small sample of clinics, harm reduction interventions would be well-received and valued by most patients who are actively using drugs. However, many patients expressed reluctance to discuss their drug use with providers, a certain barrier to meaningful integration of these interventions within the care visit. Perhaps the divide here between expressed optimism and reluctance to talk openly is explained by a social desirability bias (discussed further in limitations), or perhaps due to the perceived potential for harm reduction interventions to offer a more accepting approach that patients find appealing. While these questions might be answered with further research, they do indicate that provider approach matters, as does assessment of individual patient receptiveness. Also of note here is the divergent theme with a small subset of patients who were less receptive to the idea, with emphasis on two concerns: the potential stigma of being labeled a drug use by a provider, or the concern about a dramatic change in tone from their provider. While a harm reduction approach might engender a more accepting tone in the patient-provider relationship, it is clear that training must be provided to facilitate such a change. It is also important to consider these findings in relation to the existing literature in the US, which shows promise for successful integration of OST within HIV care (discussed above) albeit with slow uptake and continued unmet need. Perhaps the same barriers that interfere with wider diffusion of OST in HIV care are also present here.

Providers were indeed more focused on known barriers than patients, while maintaining cautious optimism about the possibility. While all providers seemed to understand the value of harm reduction interventions in mitigating harm in their patients’ lives, physicians cited more barriers and nurse practitioners expressed more optimism. The barriers cited by providers (physicians, in particular) included time, lack of knowledge, role-based barriers, and the patient as a barrier. Providers also reported some discomfort, and cited fears that they were not adequately prepared or knowledgeable enough to start a conversation about reducing harm. In addition, they exhibited a lack of familiarity with harm reduction equipment, which may have contributed to their discomfort in providing specific harm reduction interventions. Although clinicians, particularly the physicians, cited potential barriers to implementation, there is clear potential for Harm Reduction work to occur within this group. The findings indicate that nurse practitioners may be good local champions for diffusion, or to spearhead a pilot study on implementation of a Harm Reduction model in HIV care. It is possible that the difference between nurse practitioners and physicians is due to a difference in exposure to substance use and related issues in their course of study, or reflects the reality that nurse practitioners may have more time with each patient. However, it is unlikely that outside training in Harm Reduction prompted the difference, as 100% of physicians and 75% of NP/APNs in this study reported receiving it. Nevertheless, NPs/APNs cited fewer barriers to incorporating it into practice, and expressed openness or enthusiasm about the possibility. Yet, the number of NPs/APNs was incredibly small, so further examination of receptiveness of this group is certainly warranted.

A clear strategy to address most of the barriers identified in this study is to provide training. Training of providers might include incorporating a harm reduction philosophy and strategies to encourage patient disclosure of drug use, practical training around delivery of harm reduction interventions, treating addiction with opioid substitution therapy in the context of HIV care, and addressing drug-related stigma. A systematic review of efforts to change provider knowledge and attitudes related to addiction treatment indicated that participation in workshops facilitated changes in knowledge, attitudes, and even skill development (Walters et al., 2005), but ability to sustain such changes over time was not clear. Perhaps findings from this study can provide practical guidance on the content of trainings, or medical education curricula, starting on a local pilot basis and expanding nationally after such efforts have been properly evaluated. The national AIDS Education and Training Center (AETC) network is one promising resource which can relay these important skills into the training of HIV providers, in partnership with harm reduction organizations. Some AETCs have been implementing Harm Reduction training for more than a decade, although a more wide-scale, national approach would be expedient in diffusing this effort, capitalizing on expert AETC faculty in collaboration with harm reduction organizations. Partnership with a local harm reduction program may also assist in providing necessary equipment (safer injection kits, safer crack smoking kits, and naloxone for overdose prevention efforts). These partnerships can be identified and facilitated on a national level through engagement and discussion with the national AETC clinician training network and the Harm Reduction Coalition.

While lack of knowledge and discomfort can be addressed with comprehensive training, time and role-based barriers are system-level factors that require policy change to allow physicians in publicly-funded clinics more time with patients and proper billing for this time. This is an interesting time to consider policy-level change in this manner, as the Affordable Care Act and Medicaid expansion are underway, and likely to offer both opportunity and challenge related to system-level change. Yet, there are advocates working toward system-level change in HIV care and advocates working toward change in drug policy. Pooling or combining these forces may represent the best possibility to advocate for change in this arena to shift resources or allocate funding to harm reduction interventions within HIV care. Having drug policy advocates would be helpful in understanding how to convey the need for harm reduction funding in a climate where some aspects of the federal ban on funding for syringe exchange (as one example) continues.

Until such wide scale change occurs, motivated clinicians may choose to implement Harm Reduction counseling on an individual basis, serving as agents of change to help diffuse further into the care environment. Nurse practitioners may be well-suited for the role of champion, having a position paper delineating the role of the AIDS-certified nurse in areas of Harm Reduction/syringe exchange education, advocacy, treatment expansion, and support in curriculum development (Fisk, 1998). Despite a fifteen-year span since this piece was published, few strides have occurred and new champions must emerge for progress to occur. Thus, it is clear that these champions still work in an environment that is centered in abstinence-based approaches that further disenfranchise or deter the most vulnerable patients. Provider discomfort with harm reduction as it arose in this study is important in illustrating the difficulties that clinicians may face in implementing evidence-based policies that are not publicly supported, and in demonstrating the divide that often occurs between patient and provider when drug use is involved. Small, manageable steps toward integration of harm reduction interventions may offer promise to engage patients and build more successful relationships between provider and patient.

Limitations & implications for research

There are several limitations to note in this research. First, although 100% of eligible providers in the clinics agreed to participate, the sample of n = 7 remains rather small. While the findings here illustrate the perceptions of those providers and may be transferable to similar clinic settings, they may not translate to a larger provider group. Further study is needed to expand to a more representative pool of providers, perhaps a survey-based study to examine the barriers that emerged in this study. Second, sampling was restricted to only three clinics, so the application of these findings should be in context with similar settings and patient populations. Third, both providers and patients understood that the purpose of the study was to discuss perceptions of harm reduction counseling in HIV care. Therefore, they may have felt pressured to provide socially desirable answers to questions pertaining to harm reduction receptiveness. However, the informed consent process was clear in articulating risks and benefits, and that participation in research would not affect patient care services at the clinic. Nevertheless, the openness of patients may be skewed if some participants feared the interview might affect their HIV care services. An additional limitation was the reliance on self-report data, although recall bias related to this limitation may be less applicable here since questions were focused on how participants felt currently, with the exception of learning about harm reduction in the past on the patient level.

Future research might begin with a larger survey, perhaps to a national sample of publicly-funded HIV clinics that serve injection and non-injection drug users, with the goal of confirming the exploratory findings here. Survey questions should be derived from or informed by the themes identified in this research, and should include further assessment of the magnitude and pervasiveness of barriers cited by the physician participants in this sample, as well as the openness and enthusiasm of advanced practice nurses. Similarly, patient attitudes may vary by geographic location and dependent on issues of perceived stigma, national or local drug policy, and the physician-patient relationship. Further exploration of a national patient sample of active drug users is necessary to confirm these findings, while smaller, qualitative studies in specific locations may be more useful in yielding descriptive findings regarding the extent of perceived stigma and local context by particular patient population.

An alternate and more actionable direction would be to use the data generated here to inform the development of training and implementation of harm reduction interventions (counseling plus provision of supplies) to be used in HIV clinic settings. The interventions could then be tested for efficacy in a small pilot study in these three Chicago clinics, and slowly expanded to other settings with appropriate cultural tailoring for the patient population. While the findings here may encourage the development of pilot interventions centered in publicly-funded, Chicago-based clinics in low-income, African-American communities, the ultimate research goal would include a larger-scale feasibility study in a variety of HIV care venues, in the hopes of diffusing effective interventions nationally.

Other research priorities should include studies addressing special populations not covered in this study who experience more intense stigma and punishment with active drug use, such as pregnant women or adolescents. Similarly, studying the potential for harm reduction integration in alternative venues would be useful, particularly where drug-related harm and overdose risk should be mitigated, such as in methadone clinics, drug treatment systems, and correctional facilities. Finally, research to further understand the lack of uptake of OST in HIV clinics in the US, or intervention studies that examine ways to increase uptake, are also needed—to further explore ideas for meeting the needs of PWIDs.