HIV care outcomes and institutional structures : person-centered care for people who use illicit drugs

Background: Although optimal access and adherence to modern antiretroviral therapy (ART) reduces rates of HIV-related morbidity and mortality, HIV-positive people who use illicit drugs (PWUD) continue to experience suboptimal HIV treatment outcomes. This thesis sought to apply institutional perspectives to explore individual and organizational interactions in achieving person-centered care (PCC). This aim was met by first, systematically reviewing literature on medical and social service components linked to methadone maintenance therapy (MMT) in improving HIV care cascade outcomes, and second, in a series of empirical studies, assessing institutional-related structures associated with optimal adherence to ART among HIV-positive PWUD. These studies examined: 1) prescription of complex ART regimens, within a single domain of healthcare provision; 2) MMT-ART co-dispensation practices, within multiple domains of healthcare provision; and 3) the production of material insecurity through healthcare, social care and other institutional relationships. Methods: First, a specific search strategy was used to conduct the systematic review. Second, data from an ongoing prospective observational cohort study linked with comprehensive HIV clinical monitoring records in Vancouver, Canada was used to assess institutional-related structures. Multivariable models were built to estimate the relationships between institutional-related variables and adherence to ART, using longitudinal analytic techniques while controlling for relevant confounders. Results: The systematic review found a low number of studies that described MMT service delivery in detail and a lack of information on the effectiveness of social support within MMT programs on improving HIV care outcomes. Among HIV-positive PWUD in Vancouver, complex ART regimens, as demonstrated by greater number of pills, were significantly associated with suboptimal adherence; MMT-ART co-dispensation was positively associated with optimal adherence in a low-threshold setting; and although material insecurity was associated with institutional structures, it was not significantly associated with adherence. Conclusions: The alignment between institutional domains may potentially enhance HIV care outcomes among PWUD as they navigate institutional structures. Public health strategies that feature PCC approaches are needed to meet the complex needs of PWUD. Thus, future research should explore the application of implementation science as a potential avenue to align treatment and care services across institutions for HIV-positive PWUD.Graduate and Postdoctoral StudiesGraduat