An estimated 48% of people with HIV (PWH) in the United States (US) have a diagnosed substance use disorder (SUD) [1]. Compared with PWH who do not use drugs, PWH who use drugs experience lower rates of retention in HIV care[2, 3] and viral suppression [4–6], thereby increasing risk of morbidity and mortality[7, 8]. PWH who use drugs are also more likely to present to care with advanced HIV diagnosis[9, 10]. Moreover, injection drug use increases the risk of HIV acquisition and transmission, with an estimated 10% of new HIV diagnoses attributed to injection drug use in 2018[11].
Harm reduction is an approach to care for people who use drugs (PWUD) that incorporates not only services and resources (e.g., naloxone, sterile syringes, fentanyl test strips—structural harm reduction), but also patient-provider relationships that are non-judgmental and respectful of patients’ autonomy, defined as relational harm reduction[12]. Harm reduction is aimed at minimizing harm associated with drug use, rather than requiring abstinence. In a previous study, we outlined a set of six harm reduction principles in medical settings, which can be used to guide providers’ interactions with patients (citation redacted for peer review).
Yet, substance use-related stigma, particularly stigma enacted by providers and experienced in the healthcare setting, overwhelmingly contributes to disparate outcomes among PWUD. A recent editorial by the director of the National Institute on Drug Abuse (NIDA) urges healthcare providers to provide compassionate, non-stigmatizing care to PWUD, noting the alternative may exacerbate drug use[13]. Continued conflation of drug use as “abuse,” which implies that any drug use is wrong, pervades social messaging[14]. Indeed, research shows that providers are not immune from this social messaging, with some providers regarding PWUD as “criminal”[15]. To avoid experiences of stigma and discrimination when receiving health care services, PWUD may seek to avoid stigma by concealing their drug use from providers, minimizing symptoms of pain, and even delaying care altogether[16, 17]. PWUD may even avoid calling emergency medical services for fear of arrest[18]. These negative experiences in healthcare settings decrease trust in the medical system, raising risk of adverse health outcomes such as death from injection-related infections[17], relying on non-prescription medication to alleviate pain[19], and leaving the hospital against medical advice[20]. However, patients who feel respected by and trust their providers are more likely to experience positive health outcomes. For PWH, this translates into disclosing more information to and having a better relationship with providers,[21] better adherence to antiretroviral therapy (ART) [22–24], and high rates of retention in care[25, 26]. For PWUD, greater trust in their provider is associated with positive expectations for their interactions with their providers and is mediated by perceived provider support for harm reduction[27]. PWUD also cite the harm reduction principles of humanism, pragmatism, autonomy, individualism, incrementalism, and autonomy without termination[12], as well as ongoing support, reliability, and provider expertise in treating substance use disorder[28], as cornerstones of strong patient-provider relationships.
To better serve the needs of PWUD, scholars and providers have recommended integrating harm reduction into primary care and other settings that do not explicitly serve PWUD and have recognized the importance of the patient-provider relationship as a form of harm reduction[29]. Indeed, harm reduction has been recognized as one of the key components of the US Department of Health and Human Services’ Overdose Prevention Strategy[30], and the Health and Medicine panel of the National Academy of Sciences, Engineering and Medicine has recommended incorporating harm reduction strategies into infectious disease and opioid use disorder care[31]. Since the elimination of the X-Waiver in 2023, any provider can prescribe buprenorphine without having to register with the Drug Enforcement Administration[32], a requirement that was previously noted as a significant barrier to prescribing medication for opioid use disorder (MOUD) [33]. Yet, despite the importance of integrating harm reduction principles into health care settings, little is known about the extent to which this is done in healthcare settings outside of specialty care for PWUD or about providers’ knowledge and use of harm reduction beyond physicians. A previous scoping review focusing on harm reduction for people who use opioids identified 25 studies that examined physicians’ knowledge and perceptions of harm reduction for people who use opioids[34]. Knowledge gaps include those related to prescribing medication for opioid use disorder and using naloxone, and uncertainly about their legality. Physicians’ perceptions of harm reduction highlighted the prevalence of stigma and concerns about medication diversion[34]. Finally, the scoping review revealed system and institutional barriers to the provision of high-quality care for PWUD, such as those related to insurance coverage, reimbursement, and organizational policies. Similarly, a survey of Veterans Affairs providers identified low levels of knowledge regarding use of naloxone[35].
Despite the high SUD comorbidity rate among PWH, no extant research, to our knowledge, has focused on HIV providers’ knowledge of or attitudes towards harm reduction. Moreover, little is known about medical providers’ knowledge of harm reduction beyond structural strategies like MOUD and naloxone. Given the variability of these services across different settings and political contexts, the role of relational harm reduction in medical settings is important to understand.
Thus, in the current paper, we qualitatively explore providers’ knowledge of and use of harm reduction via individual in-depth interviews, to operationalize how relational harm reduction is both characterized and employed in HIV care settings The current work is part of our larger study aimed at developing a harm reduction intervention for PWH who use drugs (citation redacted for peer review).