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

Background. A culture of stringent drug policy, one-size-fits-all treatment approaches, and drug-related stigma has clouded clinical HIV practice in the United States. The result is a series of missed opportunities in the HIV care environment. An approach which may address the broken relationship between patient and provider is harm reduction—which removes judgment and operates at the patient’s stage of readiness. Harm reduction is not a routine part of care; rather, it exists outside clinic walls, exacerbating the divide between compassionate, stigma-free services and the medical system. Methods. Qualitative, phenomenological, semi-structured, individual interviews with patients and providers were conducted in three publicly-funded clinics in Chicago, located in areas of high HIV prevalence and drug use and serving African-American patients (N = 38). A deductive thematic analysis guided the process, including: the creation of an index code list, transcription and verification of interviews, manual coding, notation of emerging themes and refinement of code definitions, two more rounds of coding within AtlasTi, calculation of Cohen’s Kappa for interrater reliability, queries of major codes and analysis of additional common themes. Results. Thematic analysis of findings indicated that the majority of patients felt receptive to harm reduction interventions (safer injection counseling, safer stimulant use counseling, overdose prevention information, supply provision) from their provider, and expressed anticipated gratitude for harm reduction information and/or supplies within the HIV care visit, although some were reluctant to talk openly about their drug use. Provider results were mixed, with more receptivity reported by advanced practice nurses, and more barriers cited by physicians. Notable barriers included: role-perceptions, limited time, inadequate training, and the patients themselves. Discussion. Patients are willing to receive harm reduction interventions from their HIV care providers, while provider receptiveness is mixed. The findings reveal critical implications for diffusion of harm reduction into HIV care, including the need to address cited barriers for both patients and providers to ensure feasibility of implementation. Strategies to address these barriers are discussed, and recommendations for further research are also shared.

Relationship with participants 6. Relationship established Was a relationship established prior to study commencement? There was an established relationship with clinical leadership at the clinic sites for study buy-in, but not the patient participants. 7. Participant knowledge of the interviewer What did the participants know about the researcher? e.g. personal goals, reasons for doing the research -Clinic sites were informed that the project was part of fulfilling a doctoral dissertation. Individual participants were informed of the purpose of the study (per informed consent requirements established by the IRB). 8. Interviewer characteristics What characteristics were reported about the interviewer/facilitator? e.g. Bias, assumptions, reasons and interests in the research topic There is mention of hiring an independent coder to mitigate any bias from the PI's harm reduction experience, but this can be expanded if desired.
Domain 2: study design Theoretical framework 9. Methodological orientation and Theory What methodological orientation was stated to underpin the study? e.g. grounded theory, discourse analysis, ethnography, phenomenology, content analysis Phenomenology Participant selection 10. Sampling How were participants selected? e.g. purposive, convenience, consecutive, snowball Purposive 11. Method of approach How were participants approached? e.g. face-to-face, telephone, mail, email Flyers in the clinics with tear-off tabs including the researcher's phone number; also, referral from care providers. 12. Sample size How many participants were in the study? N = 38 13. Non-participation How many people refused to participate or dropped out? Reasons? No one refused participation or dropped out. One person who expressed interest did not meet the inclusion criteria.
Setting 14. Setting of data collection Where was the data collected? e.g. home, clinic, workplace Clinic and university office (for two participants who wanted to keep their participation anonymous from the clinic staff) 15. Presence of non-participants Was anyone else present besides the participants and researchers? No. Private space was used for all interviews.
16. Description of sample What are the important characteristics of the sample? e.g. demographic data, date The most important characteristics were: living with HIV/AIDS, actively using heroin, cocaine/crack, and being a patient of one of three chosen publicly-funded HIV clinics. All patient participants were African-American. Age and Level of education are provided as well (in table form in the manuscript). Provider participants had one important characteristic: currently providing care in the chosen clinics, at the mid-level provider level or higher (non-prescribing providers were not included). Research shows that patients respond differently to advice from providers at the mid-level and MD levels, so they were the focus.

Data collection
17. Interview guide Were questions, prompts, guides provided by the authors? Was it pilot tested? Yes, the interview guide was developed by the author, and pilot tested.

Repeat interviews
Were repeat interviews carried out? If yes, how many? No repeat interviews were needed. 19. Audio/visual recording Did the research use audio or visual recording to collect the data? Yes, audio recording occurred with participant permission. 20. Field notes Were field notes made during and/or after the interview or focus group? Only minimal note taking occurred to focus on maximizing eye contact and interaction with participants.

Duration
What was the duration of the interviews or focus group? Approximately an hour, with some minor variation when participants were particularly brief or verbose. 22. Data saturation Was data saturation discussed? Yes. 23. Transcripts returned Were transcripts returned to participants for comment and/or correction? Transcripts were not returned, but the researcher engaged participants in member-checking immediately following interviews.

Domain 3: analysis and findings
Data analysis 24. Number of data coders How many data coders coded the data? 2 25. Description of the coding tree Did authors provide a description of the coding tree? The coding process is explainedfrom the development of index codes (driven from the research questions, interview guide, and concept map) to grounded codes that emerged naturally from the data. 26. Derivation of themes Were themes identified in advance or derived from the data? Index codes were identified in advance based on the questions, and additional codes emerged while coding, but themes emerged naturally from the data. 27. Software What software, if applicable, was used to manage the data? AtlasTi 28. Participant checking Did participants provide feedback on the findings? Provider participants gave feedback on the findings when results were reported back to the clinics. Patient participants were not approached a second time, but member-checking was done post-interview, and member-checking of themes was completed with community members that fit the inclusion criteria for the study. The researcher did not have easy access to the patients a second time.

Quotations presented
Were participant quotations presented to illustrate the themes / findings? Was each quotation identified? e.g. participant number Quotes were identified with basic descriptors to ensure anonymity (gender and drug of choice only).

Data and findings consistent
Was there consistency between the data presented and the findings? Yes 31. Clarity of major themes Were major themes clearly presented in the findings? Yes 32. Clarity of minor themes Is there a description of diverse cases or discussion of minor themes? Yes # Human Studies Please provide an empty copy of the human participant consent form you used as a confidential Supplemental File here <https://peerj.com/manuscripts/7559/files/>. Done