Barriers and facilitators to integrated mental health and HIV care: administrator and provider perspectives

Abstract

Since the 1980s when the HIV epidemic began, HIV and substance use have been intricately linked. A promising area for improving access to care and treatment for people living and aging with HIV and substance use is through integrated care (i.e., “the systematic coordination of general and behavioral healthcare”). There is a recognized need to increase collaboration and integration of mental health, substance use, and primary care providers, including infectious disease specialties. We conducted in-depth interviews with 15 administrators (e.g., clinic managers and care coordinators) and 21 providers (e.g., Physicians, Advanced Practice Providers (APPs), nurses) across Georgia between January 2021 and November 2022. Interviews explored administrator and provider perceptions of clinic integration and their desire to increase integration. Data were analyzed using inductive and deductive thematic analysis guided by the Consolidated Framework for Implementation Research. Overall, study participants in a variety of public, private, and community healthcare settings across the state recognized the benefits of integrated behavioral and physical healthcare and noted some facilitators. However, they reported significant individual-, organizational-, and community-level barriers to implementing it in practice. Our findings highlight opportunities for improvement at the provider, organization, and policy/system levels.

Since the beginning of the epidemic, HIV infection and substance use have been intricately linked. Injection drug use continues to drive HIV transmission (Li et al., 2023; Lombardi et al., 2024) and evidence indicates that ongoing drug use following HIV infection can accelerate the progression of HIV infection and increase the potential for negative health outcomes, including accelerated damage to the brain, higher viral loads, poor medication adherence, and higher AIDS-related deaths (Campbell et al., 2013; Dash et al., 2015). Given the interconnected complexities of HIV infection, substance use disorders, and mental health concerns, there is an ongoing need for improved access to streamlined care.

This suggests that the most effective response to HIV infection is the integration of mental health and substance use prevention and treatment services in primary care settings. Evidence shows that doing so when caring for people with co-occurring healthcare needs results in higher engagement, treatment compliance, and better outcomes (Antonini et al., 2012). However, individuals with co-occurring conditions often experience a fragmented care system (Han, 2018). In recognition of this, policymakers and healthcare advocates, including the Substance Abuse Research Consortium (Rutkowski et al., 2012), have identified the need to increase integrated care, defined here as “the systematic coordination of general and behavioral healthcare.”

Outside the HIV care arena, multiple studies have identified several benefits of integrated care for both patients and providers. These include overall satisfaction, improved convenience, a better understanding of care plans, and enhanced agency in the treatment of patients (Egan et al., 2011) as well as an appreciation for additional mental health support when managing chronic health conditions in the primary care setting (Balasubramanian et al., 2017). Other studies have found that an integrated care approach can reduce waiting times for access to and treatment for depression and post-traumatic stress disorder (Cornwell et al., 2021), reduce hospital readmission rates, and improve patient self-management and satisfaction (Berge et al., 2017). Despite this, there can be substantial barriers to integrated care, including reimbursement issues, limited resources, and workforce shortages (Urada et al., 2014) as well as interprofessional tension, lack of collaboration, and concerns about counselor competency (Li et al., 2023; Lombardi et al., 2024). While some of these issues are amenable to integrated care training, team-based activities, such as warm handoffs, verbal feedback, and conjoint appointments, are not sustainable in a non-collaborative environment (Funderburk et al., 2023). For example, clinics operating outside health management organizations (HMOs) reported more challenges in making successful linkages between primary care and mental health services than clinics in HMO settings (Trude & Stoddard, 2003). Contrasting philosophies of care, such as client-centeredness versus harm reduction, also impact service integration (Guise et al., 2017). Further, provider and administrator beliefs about and histories of integrated care may influence their desire to engage in integrated care initiatives and determine the overall success of its implementation.

Because of the complex physical and behavioral health needs of people living with HIV, gaining a full understanding of the interlinked barriers and facilitators to begin, expand, and sustain integrated care for patients being treated for HIV is particularly critical. In this study, we investigated the barriers to and facilitators of incorporating integrated care into HIV primary care settings across Georgia.

Methods

Participant recruitment

This qualitative study explored primary care providers’ and administrators’ perceptions of the barriers and facilitators of implementing integrated care for the treatment of individuals living with co-occurring HIV, mental health issues, and substance use disorders. The study was approved by the Institutional Review Board of Emory University (#01314) on [9/4/2020]. We distributed an email survey to administrators and healthcare providers in HIV primary care settings throughout the state of Georgia that solicited information about their workplace and invited them to participate in a follow-up qualitative interview. Our purposive study sample comprised of a diverse set of healthcare settings, including regional departments of public health, university-affiliated HIV clinics, and private practices offering care to people living with HIV. Initial outreach efforts were successful in recruiting 15 administrators (clinic managers and care coordinators) and 21 healthcare providers (e.g., Physicians, Advance Practice Providers, Registered Nurses). Snowball sampling was used to identify additional participants. Each enrolled workplace was entered into a drawing for a $225 contribution to their patient services and each interview respondent received a monetary gift card (initially $25, increased to $60 owing to COVIDrelated recruitment challenges in the field) for their participation. Recruitment, which was substantially affected by the COVID-19 pandemic, took 23 months (from January 2021 to November 2022).

Data collection

In addition to the emailed recruitment survey described above, data collection included a brief online survey using the Integrated Practice Assessment Tool (IPAT), which is based on the Center for Integrated Health Solutions (CIHS) criteria for integration, and individual 20–78 min (average length = 42 min) remote, in-depth semi-structured interviews conducted via Zoom. Oral consent was obtained from each prospective participant prior to the initiation of data collection. The IPAT (Figure 1), designed to be easy to use and consisting of eight yes/no questions, the last being a compound question, was administered to all participants to identify the level of integration at each workplace based on a respondent’s perspective. Semi-structured interviews included questions about their experiences with, and desire for, pursuing integrated care. Example questions and probes are outlined on Table 1. Questions were customized based on the level of integration identified from the IPAT tool. We also collected sociodemographic information such as respondents’ age, gender, race, work tenure (current and previous roles), and education. The interviews were recorded digitally on the Zoom platform and transcribed verbatim. Three researchers (the principal investigator and two research assistants) conducted interviews.

Figure 1.

IPAT decision-making tool based on the Center for Integrated Care’s Integrated Practice Assessment Tool (IPAT). https://hrsa.gov.behavioral-health/integrated-practice-assessment-tool-ipat.

Table 1.

Sample interview questions.

Main question	Topics for probes (not exhaustive)
1. When I use the term “integrated care,” what does it mean to you?	[If definition is far from the definition we have, share the definition so we are all using similar references for the remainder of the interview]
2. [Share level identified on IPAT and what that means.] How effective do you think this level of integrated care is for meeting the needs of patients with co-occurring HIV and substance use disorders/mental health needs?	Areas of improvement; success stories; benefits of working at this level of integration
3. If not fully integrated: Have you or your leadership considered working toward a higher level of integration?	Preparation for change; perceived barriers; challenges in current environment; discussions with leadership
If fully integrated: What changes were made in your practice to achieve this level of integration?	Challenges encountered; success stories; champions
4. How will/did the infrastructure of your organization affect the implementation of integrated care?	Social architecture; maturity of clinic; size; physical layout; funding; collaboration and communication with internal and external colleagues; working around structural challenges
5. Tell me a little about the broader needs and preferences of the individuals being served by your organization? what kinds of care or support do your patients need that they can’t access here currently?	Housing; financial assistance; comorbidities; Any differences by age, race, gender; substance use services
6. For patients with substance use disorder, to what extent do you/other providers/the providers use medications for treatment (e.g., buprenorphine, naltrexone)?	Challenges; referral networks; barriers to use; If physician, probe on waiver to prescribe
7. How satisfied are you with access to mental health services, including addiction treatment here?	Desire for change; barriers, success stories
8. Is there anything I did not ask about the care provided in your clinic that you would like to add?

Data analysis

We used a combination of inductive and deductive thematic analyses to identify barriers to implementing or expanding behavioral health services within a primary care setting. First, we developed an initial codebook of a priori codes based on the Consolidated Framework for Implementation Research (CFIR). Two trained research assistants coded the data separately to test for concordance and reliability using NVivo 12 (QSR Software) to manage the data and facilitate the analysis. During open coding, when emergent themes and concepts were identified based on the interview guide and a priori codes, the most frequent and salient codes were used to generate specific codes that allowed for a more nuanced dive into the data. This included axial coding, which involved a focused analysis of one category at a time (Glaser and Strauss). The initial codes included “desire for change,” “patient needs,” and “administrative barriers.”

The second level of analysis involved grouping codes, creating subcodes and categories, and summarizing content. The codes were collapsed and expanded to derive major categories and subcategories related to the barriers and facilitators of integrated care. We also examined perceived effectiveness and desire to implement or increase integration. During the final analysis, we used the perceived integration level, clinic size, and other sociodemographic attributes of the participants and their workplaces to examine variations in themes based on these attributes. Theoretical and analytical memos were written throughout data collection and analysis to capture reflections, questions, and potential biases. We considered the analysis complete upon reaching theoretical saturation and agreement across team members.

Findings

Participant characteristics

Descriptive information from the 21 providers and 15 administrators is presented in Table 2. The mean age in years was 41.9 (standard deviation [SD] = 11.36) years among providers and 43.7 (SD = 9.32) years among administrators. The average number of years working in HIV Care was 10.48 (SD = 8.60) among providers and 11.20 (SD = 8.31) among administrators. The average tenure in the current workplace was 6.8 years (SD = 5.86) across both groups. Table 3 displays workplace characteristics, including levels of integration for three healthcare settings: “public” (health department and hospital), “private” (hospital and private practice), and “community” (nonprofit centers).

Table 2.

Participant characteristics.

Characteristic	Administrator (n = 15) Number (%) or Mean (SD) (range)	Provider (n = 21) Number (%) or Mean (SD) (range)
Gender
Male	3 (20)	4 (19.05)
Female	12 (80)	17 (80.9)
Racea
Black	6 (40)	6 (30)
White	8 (53.3)	10 (50)
Asian	0	3 (15)
Mixed/Multiple Races	0	1 (5)
Age	43.7 (11.4) (24-55)	41.9 (9.3) (29-66)
Workplace Tenure	5.99 (4.9) (0.25–16)	7.93 (6.8) (1-21)
Tenure in HIV Care	10.48 (8.6) (1-35)	11.2 (8.3) (1-25)

^aOne administrator did not provide their race.

Table 3.

Organizational characteristics (N = 36).

Integrated care level	Number (%)
1	3 (8.3)
3	6 (16.7)
4	5 (13.8)
5	17 (47.2)
6	4 (11.1)
Type of organization
Public – State	13 (36.1)
Public – Hospital	8 (22.2)
Community not-for-profit	7 (19.4)
Private – Hospital	2 (5.6)
Private Practice	2 (5.6)
Number of full-time providers
1–5	13 (36.1)
6–10	9 (25)
11+	14 (38.9)

Participants described the level of integration in their clinics using the IPAT tool (Figure 1) from Level 1 (minimal collaboration) to Level 6 (full collaboration in a transformed/merged integrated practice). We had participants at every level of integration except for Level 2 (basic collaboration at a distance). Qualitative interviews revealed individual-, organization-, and community-level facilitators and barriers to increasing or maintaining integration. Below, we describe these overlapping factors and how they limit or foster the desire to increase integrated behavioral healthcare in HIV primary care settings, including substance abuse services.

Individual-level barriers to integrated care

Participants were almost unanimous in wishing for more integrated behavioral and physical healthcare delivery in their practices, which would benefit patients with HIV, and in identifying significant barriers to bringing this about, including limits on their available time and/or a lack of interest among their leadership or peers. For example, one provider discussed the competing priorities of their time, which prevented them from thinking about adding services.

It’s hard to work on something [telemedicine] that can basically help us engage more with the services for mental health with the patients, because sometimes [staff] are in a hurry trying to get things done and sometimes they try to get [patients] in and out. Right now, open enrollment, for me, it’s a lot of stuff going on. ‘Cause that’s part of my job, trying to get them to get insurance and stuff. Right now it’s kinda hard. You spend a lot of time on that, and then sometimes you don’t focus on the other stuff. Maybe have more stuff that can do more for the patients, especially the behavioral health.

(Provider (P)14, Level 5, Suburban Community nonprofit).

This sentiment was echoed by other providers, who also noted that it is likely that all individuals in their settings are feeling constrained. As one case manager said:

All the people on the care team have to take a certain amount of time in their schedule to [change the practice], and we’re understaffed. I think everybody has more to do than they feel like they can do comfortably in the time they have to do it. I think resources and time constraints are big.

(P04, Level 4, Urban Public Hospital Clinic).

Some healthcare providers with co-located or collaborative care felt that they were unable to make changes on their own (to move to a care model that was fully integrated). As highlighted by the following advanced practice provider (APP), the coordination needed to increase integration can be insurmountable:

In order for me to really provide integrated care it means I have to find a way to make it work out by carving time out of my own schedule [and] coordinating with the other side. Some people just don’t have the ability – some of our clinicians don’t have the ability to do that.

(P03, Level 3, Urban Public Hospital Clinic).

For others, time was less of a barrier than the perception that colleagues and/or leadership did not see value in integrated care. As one administrator lamented,

The reason why I say [that we could not increase integration] is because I know sometimes there are some administrators or even some providers who don’t see the importance of integrated substance abuse or even behavioral health with HIV care. [We need to] remember, the reason why we’re where we are… how the patient got to where they are right now is because of behavioral health needs.

(Administrator (A)14, Level 6, Suburban Public Health Clinic).

In some cases, providers and administrators in the same healthcare setting noted that if their workplace provided integrated care, it was in name only because they faced practical barriers to connecting across groups. One nurse practitioner was convinced that a colleague was actively thwarting the efforts to provide integrated care. When she tried to bring this up with clinical leadership, her concerns were not addressed, and they were not even acknowledged:

I wrote a strongly worded letter about the lack of integration, how [her colleague] was subverting the efforts of communication. That I thought it was grossly inappropriate, blah, blah, blah. I wrote this letter to our manager. The head of the – clinical director, my manager, and the medical director, and her. I got nothing. Not one response. Nothing. Never was acknowledged.

(P9, Level 5, Urban Public Hospital Clinic).

Even in cases in which leadership outwardly promoted the value of integrated care, interview respondents noted that there was no systematic commitment to its sustained implementation. As one APP shared:

I think that [leadership] definitely sees the benefit of [integrated care]…Partly because I think the clinical team and the clinical sort of leadership have said “we need to do better about integrating, we need time carved out to do case conferences or ability for us to actually have our way to talk to clinicians from other areas.” On that I think they’re interested and they’re supportive, but when it comes down to…setting up a more systems-level strategy or blocking out time in our schedules in order to case conference – at that level, I haven’t really seen a big push or commitment…I do think that they definitely see the value of it, but it hasn’t gotten to the point of where it’s kinda okay, let’s get this done, and there’s some tangible kind of commitment to the whole…you know, I don’t blame ‘em. This is sort of a nice sort of fluffy thing that we should work towards but is it kind of critical that this happen today, tomorrow?

(P03, Level 3, Urban Public Hospital Clinic).

Organization-level barriers to integrated care

Both administrator and healthcare provider interviewees also described structural-level barriers within healthcare settings, including conflicting policies and confusing administrative configurations. This was particularly pronounced for participants working in an environment operating under parallel but separate administrations (e.g., university-based clinicians working in a public hospital), as the lack of a unified organizational structure made it difficult to achieve true integrated care. As one physician noted:

I think because we have mostly university clinicians but public hospital staff, there is a university/hospital division or split that makes it hard to implement new change because again, the administrative direction of the clinic comes from…it’s…it’s under the hospital chain of command, I guess. I think that improving understanding and linkages between the systems would make it easier – systems meaning University and Hospital – to implement change in the clinic.

(P07, Level 3, Urban Public Hospital Clinic).

A lack of clarity also exists in less organizationally complex settings. As one administrator said:

I think we have to make a more standard practice; I think we have to have policies written. I think we need to put those things in place and develop actual standards that people know when they come to work here; this is the expectation.

(A05, Level 3, Community nonprofit)

Participants across the board also viewed rapid staff turnover and limitations on organizational resources such as space, money, and internal staffing models as structural barriers to the implementation of integrated care. For example, one case manager said,

I think it’s largely lack of resources. I think the leadership would jump at the opportunity to do all of these things if there weren’t the constraints. It’s not lack of caring or lack of interest. [Our system] has its own brand of dysfunction as well, and funding problems. Enormous.

(P04, Level 4, Urban Public Hospital Clinic)

Respondents working within a health system that distributes resources within a collective cap frequently cited that as a structural barrier to integration, proposals to create an integrated care model within one section of a health system could be perceived by others as infringing on the siloed, but jealously guarded, services, expertise, and resources. For example, a second-year fellow shared their experience of resistance to the idea of increasing prescriptions for opioid use disorder medications within the health system’s HIV clinic:

They said, “In our [health system’s dedicated] suboxone clinic, we have psychiatrists and psychologists and counselors and social workers and everybody integrated. Substance use care that is integrated there is where patients come either every day or once a week and they [monitor them].” Their concern was whether [the HIV clinic] would be able to offer similar amounts of support and not just prescribe suboxone. I remember hearing that that was their concern about if we had tried to integrate – take some of their suboxone treatment to [the HIV clinic]. Like they were a little skeptical of how that would work. But I don’t know … [laughter] I was a little bit perplexed.

(P08, Level 4, Urban Public Hospital Clinic)

The lack of consistent staffing was another frequently cited obstacle to achieving continuous integrated care that met patient needs.

Then, I think the last thing is that we just have a lot of staff turnover. I think it makes it hard to provide specialized integrated care when there’s that level of turnover because of the gaps that result when somebody leaves and then somebody’s needing to be hired. It keeps that integration from being seamless.

(P07, Level 3, Urban Public Hospital Clinic)

Interestingly, clinic size was frequently cited as a barrier by respondents on both sides of the size divide, with interviewees who worked in large clinics perceiving that small ones would be better positioned to implement integrated care and respondents who worked in small clinics expressing just the opposite. As an APP working within the Veterans Affairs (VA) system posited,

[Integrated care] is possible at smaller clinics … because then they could do more of the true team-based healthcare, where you have regular meetings between your medical provider, your behavioral health provider, your social worker, et cetera, et cetera. You’re all meeting and talking about patients, which we would do with those smaller places. Here, I think the patient load is too high. It’s across disparate buildings. We now will have our own ID [infectious diseases] clinical psychologist, but if we meet all together, it’s me and then every other medical provider at the same time. I don’t really see regular meeting time being carved out without a significant increase in hiring. That’s not really practical.

(P17, Level 5, Urban VA Clinic)

Conversely, the director of a small clinic posited that integrated care was only possible at larger healthcare sites.

If we had double the number of patients and then unfortunately, we’d have to have more percentage of people with co-occurring disorders to merit having someone on staff full-time or even three-quarter time. Then I think you could really, really integrate some things, but at this point, we get it done as we need to.

(A07, Level 5, Rural Public Health Clinic)

Community-level barriers to integrated care

Participants confirmed that not all barriers were within individual or organizational control. Community-level barriers include legal restrictions on the use of funding, state-level policies, and geographic location. While telehealth and telemedicine can help alleviate this, at least theoretically, reality does not yet live up to the promise. One respondent noted,

Okay. Specifically, our practice, we have tried to outreach to grow – to make partnerships with psychiatrists. They’re limited in our geographic area. We are looking into telemedicine options. System-wide, there’s a shortage of them. I don’t know what kind of – how you would fix that.

(P01, Level 5, Rural Public Health Clinic)

Staffing limitations in rural areas became even more apparent when considering medications for opioid use disorders or psychotropic medications.

The other thing I can think of is just the providers, ‘cause I also don’t know – I would assume that that would be something that only somebody that has medication-dispensing authority would be able to provide to the patient. How many psychiatrists do we have?

(P06, Level 4, Urban Public Hospital Clinic)

Some participants blame race-based political gerrymandering at the state level for reducing the resources available to people with concurrent HIV, mental health, and substance abuse care needs, particularly in rural areas. One administrator fervently stated,

I would like to add that I think that for the HIV space, particularly here in Georgia because of the limited support and resources from non-HIV funding sources that, unlike some other places, like a New York, like L.A., where they use all kinds of resources to serve HIV folk. Usually, it’s the HIV money that serves HIV folks here in Georgia. Lots of times, we have a narrower sphere [of] providers. I think that is a challenge. That can be a challenge for providing services to folk who need it. I think that that impacts too when you start talking about what these supportive type services, like mental health, like behavioral health, like substance use, case management, and the additional supportive services, they don’t tend to have the same level of resource support … I think it’s definitely a Southern issue … I think it’s a lack of support. I think there’s systemic racism that impacts the infrastructure across the South. Think of all the southern states and what – ooh, without being political – just think about what they look like from that standpoint. New York, L.A., different kind of political landscape. The South, [is a] different political landscape than those areas that are more progressive. I think it’s not a coincidence.

(A05, Level 3, Urban Community Non-profit)

Other state- or district-level policies, particularly for respondents from public health departments, were factors beyond their individual or organizational control. For example, one public health department administrator said,

Our district is very good about lettin’ us – you know, we’re HIV. We’re the specialists, you know that. But there’s – I think it all has to do with the where the funds lie and who it’s goin’to – it’s, like, I feel like – I don’t know if this is true – but I feel like the district is like, “Well, we don’t want to step on their toes. You know, that’s their – that’s mental health spent. That’s their funding. That’s theirs.” They don’t want to ever overstep their boundaries.

(A11, Level 0, Rural Public Health Clinic)

Funding restriction concerns are often referenced in the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act. As one provider said, when asked what they thought might be the biggest potential barrier to integrated care:

My guess might be funding, ‘cause we’re a Ryan White-funded clinic, so I don’t know if that would require another level of Ryan White funding that we currently are not receiving. ‘Cause I don’t know if that falls under a certain category in Ryan White. Yeah, honestly, I have no idea. To me, that sounds like a funding problem.

(P06, Level 4, Urban Public Hospital Clinic)

Individual and organizational facilitators to integrated care

Although not as commonly discussed as barriers, providers and administrators noted facilitators of integrated care at the individual and structural levels. These included, but were not limited to, supportive leadership, strong community partnerships to fill service gaps, and physical spaces of buildings. No facilitators were identified at community-level.

At the individual level, having a team member takes the initiative to convene case conferences or collaborative care is seen as a good first step to increase collaboration within a clinic. As one physician said:

I do think that when it’s initiated by a member of the care team, it’s easy to conference people in. If I were to ask three or four people in the clinic, ‘Hey, I – you guys are all involved in this patient’s care and I am worried about them for x, y and z reason. I wanted to know if we could powwow about it, Everyone would say yes and we could arrange a time.

(P07, Level 3, Urban Public Hospital Clinic)

Supportive leadership and leadership giving autonomy to administrators to develop programs also facilitated moving toward higher levels of integration. As one administrator noted:

You can all of the ideas, the wonderful ideas in the world, but, at the end of the day, the – you’re not the final decision maker. I’ve been blessed to have leaders that have given me the green light to say, “Look, however, this is your program. You’re the one responsible for it. If it succeed, it’s on you. If it fails, it’s on you”.

(A14, Level 6, Suburban Public Health Clinic)

Respondents described the physical space and layout of the building as structural-level facilitators to increase integration. Some clinics were in the process of expansion during this study, and they designed the space with integrated care in mind. As noted by the administrator:

One of the things that we’re in preparation of that just because just so that we can keep our capacity is when we expand in that suite above us, one office is gonna be set aside specifically and only for mental health or substance abuse counseling. It’s gonna have, in that one room, the capability of two people sitting very comfortably face-to-face if we can get the psychiatrist to come onsite, which we’re hoping we should be able to, but then also have the ability for telemedicine.

(A11, Level 0, Rural Public Health Clinic)

As highlighted by an APP in a different clinic with a higher level of integration also going through expansion, having systems in place to ensure communication when the physical space becomes larger is a necessary facilitator to maintain and perhaps expand the integrated services in place. This provider noted:

Well, the actual [space] – it’s gonna spread us out for sure. I would rather have the size. I don’t think it’s a matter of distance physical as it is distance communication wise. We have the ability to communicate. We are active on teams. We have a communication system through our EMR [electronic medical record]. Everybody would be very easy to contact. I feel like the physical size to expand what we have to offer people for the most part would be a good thing.

(P15, Level 3, Urban Community non-profit)

Finally, having strong partnerships with other agencies that meet the needs of patients, beyond what a clinic can offer, was viewed as a facilitator. This was especially important for participants in rural areas and those with limited funding for programs. The following example is provided by an administrator:

That was a no-brainer partnership to partner with those agencies that are providin’ the services that you can’t provide, that you’re not funded for. I’m not funded for behavioral health. The agency that’s funded for it – there are quite a few different agencies in Georgia that are funded for it, and one of them being [private clinic]. I met with them, met with their program manager at the time. We had a sit down, talked about what I wanted, what I was expecting, and saw that the relationship, the partnership was a good fit.

(A14, Level 6, Suburban Public Health Clinic)

Discussion

In Georgia, a state heavily impacted by a syndemic formed from twin epidemics of substance use and HIV, the need to optimize all possible resources in the service of people living with HIV is particularly acute. Numerous studies and the resulting public policies emphasize the importance and effectiveness of integrated care across multiple settings (Aggarwal et al., 2019; Chuah et al., 2017; Dombrowski et al., 2023; Pence et al., 2012; Safren et al., 2009), the implementation of this model has been slow in Georgia for various individual-, structural-, and community-level reasons.

Overall, study participants in a variety of public, private, and community healthcare settings across the state recognized the benefits of integrated behavioral and physical healthcare but felt that they faced significant individual-level barriers to implementing it in practice. These include time constraints and competing priorities as well as a lack of interest in or support from colleagues and leadership. This lack of interest was particularly frustrating in situations in which integrated care was publicly endorsed but not actually implemented by organizational leadership, leading to confusion when conflicts over competing physical, personnel, and/or fiscal limitations on resources arose.

Barriers at the structural level include those caused by organizational inefficiencies, complicated hierarchical structures (e.g., in hospital-based clinics staffed by university-affiliated clinicians), capped resources, space constraints, funding restrictions, and suboptimal staffing models. This finding is consistent with those of previous studies that examined barriers to implementing integrated care (Hussen et al., 2024). Inconsistent staffing or understaffing disrupts continuity, a key feature of integrated care. Both large and small clinics face unique challenges related to their respective sizes and structures. Barriers beyond the control of organizational administration include reliance on restricted funding sources such as the Ryan White CARE Act. The CARE act was named for an Indiana teen who died from AIDS early in the pandemic, “Ryan White” is a highly regulated, irreplaceable source of federal funding for providing health care and other services to people living with HIV (Cheever et al., 2024). Because Ryan White funds are crucial and their use is heavily regulated, concerns about the legalities of using them to implement integrated care were frequently cited and sometimes misinterpreted as a potential barrier to achieving care integration. Additionally, geographic location – specifically, a rural location – was seen as a particularly intransigent barrier because of the uneven distribution of healthcare providers with relevant experiences. For example, 93% (n = 148/159) of Georgia counties are either medically underserved (n = 141) or have medically underserved populations (n = 7) (Sweeney, 2016). Despite these barriers, participants noted that having supportive leadership that fosters integrated care and provides autonomy and support, as well as strong relationships with other agencies, can help fill service gaps and facilitate greater integration.

Our findings highlight opportunities for improvement at the provider, organizational, and policy/system levels. At the provider level, the enhancement of HIV and behavioral healthcare may be considered from at least two broad interrelated perspectives: the first involves training HIV care providers to better diagnose and treat a range of mental health and substance use issues, and second involving improved communication between providers to allow for seamless referral and engagement in behavioral health-specific services. At the organizational level, administrators’ education could also play a pivotal role in facilitating early and adequate behavioral health and HIV care integration. While behavioral health training for staff in existing HIV care systems has been developed, emphasis should also be placed on expanding the curriculum to include healthcare administrators, information that stresses the interrelatedness between behavioral health and HIV primary care, and the consequent need for integrated services. At the larger systems level, federal and state governments must also increase the accessibility of and ideally incentivize essential behavioral training and services to HIV care providers. One recent positive example of such a systems change is the federal level removal of the requirement for an “X-waiver” (Notice of Intent for medical treatment) to prescribe buprenorphine for opioid use disorder (LeFevre et al., 2023). Additional policy-level changes that would aid integration include increasing the accessibility of dedicated funds to centers that provide HIV care and focusing on the equitable distribution of these funds to ensure that the centers with the highest need/in unique settings (for example, in rural areas) receive resources that are proportional to their needs.

This study had several strengths, including the inclusion of providers with different backgrounds and healthcare administrators. Additionally, we included participants from a wide range of organizations across the state, including large metropolitan and urban areas. Together, these findings provide a broader understanding of the barriers faced in multiple contexts. The use of the IPAT as a tool to determine where the participants perceived their workplace to be on a continuum allowed for directed questions and probes about the current state of practice, as well as historical changes or visions for future implementation or sustainment. Despite these strengths, this study had some limitations. This study was approved during the early months of the COVID-19 pandemic, resulting in slow recruitment. Healthcare providers, especially those working for infectious diseases, were highly burdened. Therefore, it is likely that there are providers working in settings with barriers and facilitators different from those we did not reach.