The structural and health policy environment for delivering integrated HIV and substance use disorder treatments in Puerto Rico.
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.
Department of Healthcare Policy & Research, Weill Cornell Medical College, 425 East 61st Street, Suite 301, New York, NY, 10065, USA. jal2033@med.cornell.edu.
Jared A
JA
Leff
Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY, USA.
Diana
D
Hernández
Department of Healthcare Policy & Research, Weill Cornell Medical College, 425 East 61st Street, Suite 301, New York, NY, 10065, USA.
Paul A
PA
Teixeira
Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY, USA.
Pedro C
PC
Castellón
Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA.
Daniel J
DJ
Feaster
Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA.
Allan E
AE
Rodriguez
Department of Medicine, University of Puerto Rico School of Medicine, San Juan, Puerto Rico, USA.
Jorge L
JL
Santana-Bagur
Puerto Rico Department of Health, San Juan, Puerto Rico, USA.
Sandra Miranda
SM
De León
Iniciativa Comunitaria de Investigación, San Juan, Puerto Rico, USA.
José Vargas
JV
Vidot
Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY, USA.
Lisa R
LR
Metsch
Department of Healthcare Policy & Research, Weill Cornell Medical College, 425 East 61st Street, Suite 301, New York, NY, 10065, USA.
Bruce R
BR
Schackman
D019033:Delivery of Health Care, Integrated / Q000458:organization & administration*; D015658:HIV Infections / Q000188:drug therapy*; D006291:Health Policy; D006301:Health Services Needs and Demand; D006630:Hispanic or Latino / Q000706:statistics & numerical data; D006801:Humans; D008605:Mental Health Services / Q000458:organization & administration; D058991:Patient Protection and Affordable Care Act; D011647:Puerto Rico; D015819:Substance Abuse, Intravenous / Q000534:rehabilitation; D019966:Substance-Related Disorders / Q000534:rehabilitation*; D014481:United States
AIDS; HIV; Injection drug use; Mental health; Qualitative analysis