Predictors and Consequences of Negative Physician Attitudes Toward HIV-Infected Injection Drug Users

Harvard University, Cambridge, Massachusetts, United States
Archives of Internal Medicine (Impact Factor: 17.33). 04/2005; 165(6):618-23. DOI: 10.1001/archinte.165.6.618
Source: PubMed


We evaluated physicians' training, experience, and practice characteristics and examined associations between their attitudes toward human immunodeficiency virus (HIV)-infected persons who are injection drug users (IDUs) and quality of care.
Cross-sectional surveys were conducted among a probability sample of noninstitutionalized HIV-infected individuals in the United States and their main HIV care physicians. Physician and practice characteristics, training, HIV knowledge, experience, attitudes toward HIV-infected IDUs, stress levels, and satisfaction with practice were assessed. The main quality-of-care measures were patient exposure to highly active antiretroviral therapy, reported problems, satisfaction with care, unmet needs, and perceived access to care.
Nationally, 23.2% of HIV-infected patients had physicians with negative attitudes toward IDUs. Seeing more IDUs, having higher HIV treatment knowledge scores, and treating fewer patients per week were independently associated with more positive attitudes toward IDUs. Injection drug users who were cared for by physicians with negative attitudes had a significantly lower adjusted rate of exposure to highly active antiretroviral therapy by December 1996 (13.5%) than non-IDUs who were cared for by such physicians (36.1%) or IDUs who were cared for by physicians with positive attitudes (32.3%). Physician attitudes were not associated with other problems with care, satisfaction with care, unmet needs, or perceived access to care.
Negative attitudes may lead to less than optimal care for IDUs and other marginalized populations. Providing education or experience-based exercises or ensuring that clinicians have adequate time to deal with complex problems might result in better attitudes and higher quality of care.

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Available from: Paul D Cleary, Sep 17, 2015
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    • "Third, we recruited mainly providers specialising in cardiology. We expect that providers' attitudes towards patients who use substances would vary by individual, but also by clinical training, as well as by exposure to and experience with patients who use substances (van Boekel 2014, Ding et al. 2005). With a larger sample size, future research can investigate questions that this study was not able to address, such as the effectiveness of CHC or its weight relative to the structural barriers of stigma. "
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    ABSTRACT: Diverse aspects of life and lifestyles, including stigmatised attributes and behaviors are revealed as providers and patients discuss health. In this article, we examine how the stigma associated with substance use issues shapes clinical interactions. We use the theoretical framework of cultural health capital (CHC) to explain how substance use stigma is created, reinforced and sometimes negotiated as providers and patients engage in health interactions. We present two main findings using examples. First, two theoretical concepts – habitus and field – set the social position and expectations of providers and patients in ways that facilitate the stigmatisation of substance use. Second, we found both providers and patients actively exchanged CHC as a key strategy to reduce the negative effects of stigma. In some clinical encounters, patients possessed and activated CHC, providers acknowledged patient's CHC and CHC was successfully exchanged. These interactions were productive and mutually satisfying, even when patients were actively using substances. However, when CHC was not activated, acknowledged and exchanged, stigma was unchallenged and dominated the interaction. The CHC theoretical framework allows us to examine how the stigma process is operationalized and potentially even counteracted in clinical interactions.
    Full-text · Article · Sep 2015 · Sociology of Health & Illness
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    • "PLHIV who use drugs are one population that commonly experiences suboptimal access to and utilization of HAART [5]. Poor HIV treatment outcomes among drug-using populations are driven by intersecting social determinants of health [6], including homelessness [7], stigma [8, 9] and drug law enforcement [10, 11]. Despite evidence suggesting that PLHIV who use drugs may benefit from HAART [12] and attain high levels of adherence [13], physicians in many jurisdictions do not initiate HAART with PLHIV who use drugs, with drug use and potential non-adherence often cited as justifications for denying treatment [14, 15]. "
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    ABSTRACT: Introduction Improvements in the availability and effectiveness of highly active antiretroviral therapy (HAART) have prolonged the lives of people living with HIV/AIDS. However, mortality rates have remained high among populations that encounter barriers to accessing and adhering to HAART, notably people who use drugs. This population consequently has a high burden of illness and complex palliative and supportive care needs, but is often unable to access these services due to anti-drug policies and discrimination. In Vancouver, Canada, the Dr. Peter Centre (DPC), which operates a 24-bed residential HIV/AIDS care facility, has sought to improve access to palliative and supportive care services by adopting a comprehensive harm reduction strategy, including supervised injection services. We undertook this study to explore how the integration of comprehensive harm reduction services into this setting shapes access to and engagement with care. Methods Qualitative interviews were conducted with 13 DPC residents between November 2010 and August 2011. Interviews made use of a semistructured interview guide which facilitated discussion regarding how the DPC Residence's model of care (a) shaped healthcare access, (b) influenced healthcare interactions and (c) impacted drug use practices and overall health. Interview transcripts were analysed thematically. Results Participant accounts highlight how the harm reduction policy altered the structural-environmental context of healthcare services and thus mediated access to palliative and supportive care services. Furthermore, this approach fostered an atmosphere in which drug use could be discussed without the risk of punitive action, and thus increased openness between residents and staff. Finally, participants reported that the environmental supports provided by the DPC Residence decreased drug-related risks and improved health outcomes, including HAART adherence and survival. Conclusions This study highlights how adopting comprehensive harm reduction services can serve to improve access and equity in palliative and supportive care for drug-using populations.
    Full-text · Article · Mar 2014 · Journal of the International AIDS Society
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    • "The emphasis on punishment of IDU for their behaviours also fuels negative public opinion of this population, including among healthcare workers, which makes ensuring access to prevention and treatment of HIV challenging if not impossible [8,9]. For example, throughout the Asia-Pacific region, many IDU encounter delays in the provision of healthcare services, refusal of treatment by healthcare workers, as well as breaches of confidentiality, including sharing of information between healthcare workers and police [10,11]. In some settings, individuals are registered as drug users within national or regional databases upon seeking care or treatment [8]. "
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    ABSTRACT: HIV infection among people who inject drugs (IDU) remains a major global public health challenge. However, among IDU, access to essential HIV-related services remains unacceptably low, especially in settings where stigma, discrimination, and criminalization exist. These ongoing problems account for a significant amount of preventable morbidity and mortality within this population, and indicate the need for novel approaches to HIV program delivery for IDU. Task shifting is a concept that has been applied successfully in African settings as a way to address health worker shortages. However, to date, this concept has not been applied as a means of addressing the social and structural barriers to HIV prevention and treatment experienced by IDU. Given the growing evidence demonstrating the effectiveness of IDU-run programs in increasing access to healthcare, the time has come to extend the notion of task shifting and apply it in settings where stigma, discrimination, and criminalization continue to pose significant barriers to HIV program access for IDU. By involving IDU more directly in the delivery of HIV programs, task shifting may serve to foster a new era in the response to HIV/AIDS among IDU.
    Full-text · Article · Oct 2013 · Harm Reduction Journal
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