Leff Jared A, Hernández Diana, Teixeira Paul A, Castellón Pedro C, Feaster Daniel J, Rodriguez Allan E, Santana-Bagur Jorge L, De León Sandra Miranda, Vidot José Vargas, Metsch Lisa R, Schackman Bruce R
Department of Healthcare Policy & Research, Weill Cornell Medical College, 425 East 61st Street, Suite 301, New York, NY, 10065, USA.
Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY, USA.
BMC Health Serv Res. 2017 Mar 23;17(1):232. doi: 10.1186/s12913-017-2174-7.
HIV prevalence in Puerto Rico is nearly twice that of the mainland United States, a level that was substantially fueled by injection drug use. Puerto Rico has a longstanding history of health provision by the public sector that directly affects how HIV and substance use disorder (SUD) treatment services are provided and funded. As part of pre-implementation research for a randomized trial of a community-level intervention to enhance HIV care access for substance users in San Juan, Puerto Rico, we sought to understand the structural and health policy environment for providing HIV and SUD treatments.
We conducted semi-structured qualitative interviews (n = 8) with government and program administrators in English and Spanish. Data were analyzed to identify dominant and recurrent themes.
Participants discussed how lack of integration among medical and mental health service providers, lack of public transportation, and turnover in appointed government officials were barriers to integrated HIV and SUD treatment. Federal funding for support services for HIV patients was a facilitator. The Affordable Care Act has limited impact in Puerto Rico because provisions related to health insurance reform do not apply to U.S. territories.
Implications for intervention design include the need to provide care coordination for services from multiple providers, who are often physically separated and working in different reimbursement systems, and the potential for mobile and patient transportation services to bridge these gaps. Continuous interaction with political leaders is needed to maintain current facilitators. These findings are relevant as the current economic crisis in Puerto Rico affects funding, and may be relevant for other settings with substance use-driven epidemics.
波多黎各的艾滋病毒流行率几乎是美国本土的两倍，注射吸毒在很大程度上加剧了这一水平。波多黎各公共部门长期以来一直提供医疗服务，这直接影响了艾滋病毒和物质使用障碍（SUD）治疗服务的提供方式和资金来源。作为在波多黎各圣胡安开展的一项社区层面干预随机试验的实施前研究的一部分，我们试图了解提供艾滋病毒和SUD治疗的结构和卫生政策环境。
我们用英语和西班牙语对政府和项目管理人员进行了半结构化定性访谈（n = 8）。对数据进行分析以确定主要和反复出现的主题。
参与者讨论了医疗和心理健康服务提供者之间缺乏整合、公共交通不足以及任命的政府官员更替如何成为艾滋病毒和SUD综合治疗的障碍。联邦对艾滋病毒患者支持服务的资金是一个促进因素。《平价医疗法案》在波多黎各的影响有限，因为与医疗保险改革相关的条款不适用于美国领土。
对干预设计的启示包括需要为来自多个提供者的服务提供护理协调，这些提供者通常在物理上是分开的，并且在不同的报销系统中工作，以及移动和患者运输服务弥合这些差距的潜力。需要与政治领导人持续互动以维持当前的促进因素。这些发现与波多黎各当前的经济危机影响资金的情况相关，并且可能与其他受物质使用驱动的流行病的环境相关。
