Provider Perspectives on Integration of Substance Use Disorder and HIV Care in Vietnam: A Qualitative Study

Abstract

UNAIDS recommends integration of medications for substance use disorders (SUD) with HIV care to improve HIV outcomes. Yet, integration of HIV and SUD services remains limited in many countries. The objective of this study was to assess provider perceptions of care integration in Vietnam. Qualitative interviews were conducted with 43 providers (nurses, physicians, counselors, pharmacists, and clinic managers) in 8 HIV clinics in northern Vietnam, 2013–2015. Providers identified five themes informing HIV and SUD treatment integration: (1) treatment for alcohol use disorder is often neglected compared to other SUD treatment; (2) structural challenges must be addressed to increase integration feasibility; (3) workforce limitations; (4) societal and healthcare stigmatization of SUD; and (5) providers’ conflicting views regarding integration challenges. The experience of providers in Vietnam may be useful to other countries attempting to integrate HIV and SUD services.

Introduction

People who inject drugs (PWID) bear a disproportionate burden of HIV, with an estimated HIV prevalence of 17.8% among PWID worldwide.¹ Strategies to reduce injection drug use including medications for opioid use disorder (MOUD) such as methadone and buprenorphine have the potential to reduce the burden of HIV among PWID, 82.9% of whom inject mainly opioids.¹ Provision of MOUD has been associated with improved HIV outcomes among PWID, including increased antiretroviral therapy (ART) initiation and adherence, enhanced viral suppression, and, among PWID in Asia specifically, reduced mortality.² Methadone maintenance treatment (MMT) is associated with decreased HIV risk behaviors including sharing of injection equipment, sex with multiple partners, and unprotected sex.³ MOUD also has the potential to enhance the preventative benefits of ART at the population level, which could result in fewer new HIV infections among PWID.⁴ UNAIDS has called for expanded access to MOUD for improving HIV outcomes and decreasing HIV transmission.⁵ Countries in which any level of MOUD is available, however, account for just 64% of the estimated global population of PWID. Even in these countries, access to MOUD remains limited, reducing its potential population-level benefits.¹

The close link between HIV and opioid injection presents an opportunity to expand treatment access through integration of MOUD with HIV care. Treatment integration can improve management of both HIV and opioid use disorder (OUD), facilitate greater adherence to treatment, and decrease acute care visits and costs.^{6, 7} The WHO consequently recommends incorporation of HIV care and social services into drug disorder treatment.⁸ However, significant barriers exist to widespread integration of MOUD and HIV care, including financing, recruitment and training of staff, and difficulties combining the distinct clinical practices of separate medical subspecialties.⁶ Integration of social services including behavioral health services may improve outcomes of OUD treatment; however, evidence of this has been inconclusive.^9-11 It is possible that similar challenges to those facing integration of HIV care and MOUD have also limited the effectiveness of previous attempts to integrate behavioral health services with treatment for OUD.

Several of these challenges are closely related to the attitudes of healthcare providers toward integration of MOUD and HIV care. For example, the perception that PWID are unlikely to adhere to HIV treatment has been demonstrated among providers in Ukraine¹², Western Europe¹³, and North America.^{13, 14} This has traditionally contributed to reluctance among providers to initiate ART in this population, in part due to concerns over contributing to antiretroviral drug resistance.¹³ When HIV screening and treatment services have been incorporated into existing substance use disorder clinics, overburdening of staff and provider unwillingness to perform tests or disclose new HIV diagnoses have been cited as barriers to successful integration.⁶ In other studies, MOUD providers have expressed optimism that OUD treatment facilitates more effective HIV care, as regular appointments give providers ample opportunities to encourage testing and link patients to HIV treatment services.¹²

Injection drug use has been a major contributor to the spread of HIV in Vietnam, with PWID accounting for 36.1% of all newly identified HIV cases in 2015.¹⁵ However, prevalence of HIV among PWID in Vietnam has fallen from 29.3% in 2001¹⁶ to around 9.5% in 2018¹⁷, a trend which coincides with the expansion of treatment and harm reduction services. Accelerated declines in HIV incidence were observed immediately following the 2004 introduction of ART in Vietnam and the expansion of MMT in 2010.¹⁷ As of 2016, an estimated 44,479 patients, or 22% of PWID, were receiving MMT across 241 MMT delivery sites in Vietnam, up from a total of just 584 MMT patients at 6 sites in 2008.¹⁸ This dramatic expansion, funded in part by foreign donor organizations, highlights an important advance in the treatment of OUD and HIV in Vietnam.

The rapid growth of MOUD and ART in Vietnam over the past decade has given rise to new challenges, including a shortage of clinical personnel experienced in providing both MOUD and HIV care. Decrease in foreign donor support has led the Government of Vietnam to begin more closely incorporating MOUD and ART services into the national healthcare system, requiring the system to provide more care with fewer resources and potentially compounding these workforce challenges. Understanding the attitudes of providers toward integration has the potential to elucidate specific barriers to recruitment, training, and retention of a workforce capable of providing both HIV care and MOUD. However, little is known about provider attitudes toward integrating HIV and MOUD in Vietnam. This study aims to describe and provide context to current workforce challenges within Vietnam’s evolving system of HIV and OUD care. The experience of providers in Vietnam may be useful to other countries attempting to integrate care.

Methods

Study Setting

The study was conducted at eight HIV clinics across four cities and provinces (including Hanoi, Phu Tho, Thanh Hoa, and Bac Giang) in Vietnam. HIV clinics were eligible if they had high OUD prevalence and were interested in participating in the Buprenorphine to Improve HIV Care Engagement and Outcomes (BRAVO) Randomized Trial (ClinicalTrials.gov NCT01936857), which compared integrated HIV clinic-based buprenorphine with referral for MMT treatment strategies for OUD in people living with HIV/AIDS. The BRAVO study was specifically designed to investigate HIV clinic-based treatment strategies. As such, clinics providing only MOUD were not included in the study, although it is possible that these clinics may have been providing MOUD to people living with undiagnosed or untreated HIV or who were separately receiving HIV treatment at another site. The study was approved by the Institutional Review Boards of Oregon Health and Science University and Hanoi Medical University.

Clinics were categorized according to four levels of HIV and OUD care: (1) no integration, (2) partial integration in same location with different staff, (3) partial integration with same staff and different locations, and (4) full integration. Clinics with no integration offered outpatient services for HIV prevention and management and did not operate a MMT clinic or provide other SUD treatment services. Patients with SUD were referred to external providers for treatment. In partially integrated clinics with the same location and different staff, separate personnel offered MMT and HIV services separately on the same premises, with both clinics managed by the same leadership team. In partially integrated clinics with the same staff and different locations, the same providers offered MMT and HIV care, but services were located at different sites due to community objections that forced separate locations for MMT and HIV care services. In fully integrated clinics, patients received outpatient HIV care and MMT at a single location, provided by the same healthcare providers. The aim of this qualitative study was to describe the experiences and perspectives of providers across the spectrum of HIV and OUD care in Vietnam. While individual providers’ attitudes toward the relative advantages and disadvantages of each model of integration were elicited, the study design did not otherwise allow for cross-model comparisons.

Participants

Healthcare providers were interviewed by trained study team staff during site selection and the early stages of study implementation, from 2013 to 2015. All healthcare providers in each site were invited to interviews, subject to their availability and willingness to participate. Participants vary by their position including nurses, physicians, counselors, pharmacists, and clinic managers (Table 1). A total of 48 interviews were conducted with 43 healthcare providers (20 females, 23 males) working in substance use disorder and/or HIV treatment. Five healthcare providers in two clinics in Hanoi were interviewed on two occasions, first in 2013 and subsequently in 2015, with the aim of investigating changes resulting from the adoption of an integrated treatment model in these clinics during the interval period.

Table 1.

Site characteristics

Site	Year	Model	Gender	Participants
				Number	Positions
1	2013	Same staff, different location	1 female 4 males	5	- 2 physicians - 3 nurses + counselors
2	2013	No integration	3 female	3	- 1 physician - 2 nurses + counselors
3	2013	No integration	1 female 1 male	3	- 2 physicians - 1 nurse/counselor
4	2013	Same location, different staff	2 female 1 male	3	- 2 physicians - 1 nurse/counselor
5	2013	Same location, different staff	3 male	3	- 1 physician - 2 nurses/counselors
6	2014	Same location, different staff	2 males	2	- PAC leader/physician - 1 MMT physician
7	2015	Same location, different staff	5 females 7 males	12	- 5 physicians - 3 nurses - 2 pharmacists - 1 counselor - 1 leader
8	2015	Same location, same staff	1 male 5 females	6	- 2 physicians - 1 leader - 1 nurse - 1 counselor - 1 pharmacist
1	2015	Same staff, different location	3 males 1 female	4	- 2 physicians - 1 counselor - 1 pharmacist
2	2015	Same location, different staff	5 females	5	- 2 physicians - 1 nurse - 1 counselor - 1 pharmacist
5	2015	Same location, different staff	1 male 1 female	2	- 1 nurse - 1 counselor

Data Collection and Analysis

Interviews, each of which lasted between 30 and 60 min, were digitally audio-recorded with the consent of the participants. Interview guides included the following topics: (1) general information about the clinic; (2) HIV care and SUD treatment services provided by the clinic; (3) challenges of working in HIV care and SUD treatment; and (4) views on integration of HIV and SUD treatment in the clinic and different models of integrating HIV and SUD care.

All interviews were transcribed verbatim in Vietnamese. A codebook consisting of 25 different codes, including codes developed prior to interviews and those which emerged from analysis of the transcripts, was developed by the study team, and all data were iteratively coded and cross-coded by at least two coders using Atlas.ti 7.1 software (ATLAS.ti Scientific Software Development GmbH, Berlin). The study team used thematic analysis with a mixed deductive and inductive approach at the semantic level to analyze key topics. The specific focus was on provider perceptions of integration; the current situation of integration in different clinics, facilitators, and barriers to the integration of HIV; and substance use disorder treatment and how to improve the integration of these two services. Themes related to provider perspectives on service integration included perceived impact of substance use, alcohol versus other substances, structural challenges, capacity challenges, societal challenges and stigmatization, and conflicting views regarding solutions to integration challenges. All interviews were conducted and analyzed in Vietnamese and subsequently translated into English.

Results

Five themes emerged regarding care SUD and HIV care integration: (1) treatment for alcohol use disorder is often neglected compared with other SUD treatment; (2) structural challenges must be addressed to increase integration feasibility; (3) workforce limitations; (4) societal and healthcare stigmatization of SUD; and (5) providers’ conflicting views regarding integration challenges.

Treatment for Alcohol Use Disorder Is Often Neglected Compared to Other SUD Treatment

Providers drew a clear contrast in perceptions between alcohol and other substances, minimizing the need for addressing alcohol use in HIV treatment settings. Most participants acknowledged widespread alcohol use among their HIV patients but expressed ambivalence, rather than concern, toward alcohol use:

“In this clinic, there are 12-15 patients who drink about 2 liters per day. The number of patients drinking some small glasses per day are too many to count.”

“30-40% of [HIV] patients drink alcohol, but none of them at an addictive level.”

Participants from two clinics in Hanoi stated that alcohol use was widespread among their patients, although rates of alcohol misuse had reportedly fallen in recent years. Outside of Hanoi, multiple participants reported that few of their HIV patients used alcohol; however, no official data on alcohol use was available to substantiate these estimates. A sole participant highlighted the negative impact of alcohol on patients’ liver function.

“In this clinic, many patients drink alcohol in different levels. There are some patients who drink up to about 2 liters per day. In routine health checkup, there are some patients who have some symptoms of cirrhosis. Recently, we have just found some patients…oh 2 patients diagnosed with hepatic cirrhosis.”

By contrast, the use of other substances was universally viewed as an important factor affecting HIV care and substance use treatment. Participants reported widespread drug use even among patients receiving MMT, including a variety of substances such as heroin, methamphetamine, and MDMA.

“Beside alcohol use, one of other serious problem is that patient uses multiple substances, meaning that they use both heroin and amphetamine type stimulants during the treatment. One patient has died because he did not comply with ARV as well as methadone treatment due to the use of ‘ice’ [methamphetamine] in the process of treatments.”

Structural Challenges Must Be Addressed to Increase Integration Feasibility

Beyond their individual clinics, participants voiced difficulty overcoming challenges of the broader healthcare system in Vietnam. For example, no alcohol screening services were available to patients in three clinics. Similar difficulties were encountered when screening HIV patients for drug use. In one clinic in 2013, for example, clinicians were only able to ascertain whether patients used drugs by their reported history, as no urine toxicology screen was available. Even when patients with substance use disorders could be identified, significant structural barriers existed which impeded access to treatment. The number of MMT clinics was insufficient to meet demand, and the locations of these clinics were not always accessible to patients. In the absence of integrated treatment models, moreover, patients could only be referred to these clinics without any continuity of care. Information regarding substance use treatment at the referral clinic rarely returned to the referring provider.

“In 2013, the MMT clinic was far from [HIV clinic name], which was inconvenient for patients to travel, so it made patients reluctant to access MMT treatment.”

“Methadone treatment is not available, we only discuss drug use during the counselling portion of ART to help them [patients] understand the harmful effects of drugs and encourage them to reduce their drug use. If the patient wants to receive methadone treatment we introduce them to [name of clinic] methadone clinic, or else refer them to [name of hospital] if their condition is more serious.”

More fundamentally, the persistence of social policies in Vietnam addressing substance use disorder as a criminal infraction served to perpetuate structural barriers to effective treatment. For example, patients were required to undergo a complicated application process including certification by local authorities in order to commence MMT treatment, exposing them to not only administrative but potentially criminal liability.

“There is no uniformity regarding drug use as a crime or as a disease between police and the health sector. Methadone patients can be arrested for a positive drug screen, even if they are in the induction period.”

Despite these structural barriers, certain existing practices and systems for the treatment of substance use disorder served to lay the foundation for integration of SUD and HIV care. This was seen most prominently in one clinic, which transitioned from “no integration” to the “fully integrated” model in 2015. One participant noted the importance of the clinic’s location near a bus station:

“This clinic…is located near the bus station that is a transportation system hub, so the patients living far from the clinic have easy access to the service. Moreover, establishing the clinic within the general hospital helps patients hide their HIV and MMT treatment information and avoid stigma.”

One participant from a clinic operating under the “same staff, different location model” commended the training of providers in both MMT and ART management, along with the close working relationship with a local hospital which allowed for easy patient referrals to other services.

“Staff were fully trained in methadone treatment and ART treatment. The clinic has a good relationship with Dong Da hospital, so it is easy to refer patients to other service such as tuberculosis, mental health and liver disease. MMT and OPC are same staff so healthcare staff can understand the overall health conditions of the patients. And also the clinic is supported by the community groups to remain the good ART retention. This is good foundation for methadone treatment.”

Workforce Limitations

Healthcare providers cited challenges of human resources and technical capacity as further barriers to integration of substance use treatment and HIV care. For example, providers at one clinic had never received training in SUD screening or treatment. The communication skills of clinical staff were not always sufficient for the task of building strong therapeutic relationships with patients, and some providers did not strictly adhere to standard treatment protocols. A provider at one fully integrated clinic highlighted concerns that lack of adherence to SUD treatment protocols might jeopardize treatment safety:

“The first difficulty is adherence. If we plan to distribute take-home medicine, how can we check their compliance? Another issue is that the side effects of this medication because this is the first time BUP was introduced in Vietnam, I do not fully understand its safety level.”

Several participants were straightforward in their acknowledgment of staff shortcomings in both technical and interpersonal skills and explicit in their calls for better training for healthcare providers. Participants working under both the “same location, different staff” and “same staff, different location” models cited a lack of adequate training in SUD screening, diagnosis and treatment of overdose, and treatment of specific substance use disorders, as well as limited clinic space and low physician morale as key challenges faced by their respective clinics.

“Staff need to be better-trained. We should open more functional rooms in OPC [outpatient clinic], and the important thing is that doctors must love their work. OPC staff should be well-trained in addiction screening. Also we need to provide more services for patients in the clinic.”

“Need more clinical trainings for healthcare providers, train them how to detect patients with substance use, how to identify clinical symptoms of overdoses and other responses, how to treat such cases. Those are for healthcare providers in general. More specifically for those who are physicians, they need advanced trainings such as courses on identifying different types of substances, how to treat for each specific patient.”

From an organizational standpoint, existing clinic workflows did not sufficiently emphasize substance use disorder treatment across integration models, leading clinical staff to view SUD care as an ancillary “side job,” secondary to their other duties. Moreover, the requirement of directly observed MMT dosing for clinics operating under the partially and fully integrated models meant that clinic staff had to work on weekends and during holidays. Task shifting among clinic staff and physicians alike, in addition to the wide breadth of physician responsibilities, made it difficult to consistently and carefully supervise SUD treatment. One participant described the heavy burden of completing required MMT reporting paperwork for the district health center while simultaneously caring for over 700 patients 7 days a week, in the context of a shrinking HIV care budget and a system-wide transition to insurance-based payments. Similar issues were highlighted by another participant, who reported that providers at their clinic were strained not only by a reduction in staffing but also by the newly created need to travel long distances between separate HIV and MMT clinics operating under the “same staff, different location” model, causing inconvenience for providers and patients alike.

“The number of staff reduced from 14 staff to 11 staff in this clinic; this leads to lack of personnel to manage both the treatments. Along with the increased number of patients, it causes an overloaded situation. In addition, OPC and MMT are located in two different distant places so staff has to spend time in travelling between them every day.”

Despite the clear need for well-trained staff, it was observed that economic incentives and working conditions were not always favorable for attracting and retaining valuable employees. Compensation across all clinics was relatively poor, and clear opportunities existed for many clinical staff to make use of their technical skills to earn more money by, for example, opening their own pharmacy.

Societal and Healthcare Stigmatization of SUD

Stigmatization of patients by clinical staff mirrored the larger narrative to which people living with HIV were subjected throughout society in general. Some misconceptions regarding HIV transmissibility persisted among clinic staff, who were sometimes reassigned to work in HIV clinics from other healthcare system positions: one participant working under the “same staff, different location” model reported that some healthcare staff sought to “keep their distance” from patients with HIV, while another noted that staff members assigned to work in the HIV clinic were initially worried about being infected with the virus. The latter participant further reported that such attitudes may have led some potential employees to avoid joining the HIV clinic staff in the first place, out of fear of working in close proximity to patients with HIV.

“The prejudice against HIV patients has been embedded in healthcare providers. I still remembered the time when this department [OPC] was established to provide services for HIV patients, many healthcare staff were afraid of taking the position.”

Patients receiving SUD treatment were also subject to adverse treatment from society at large, frequently maligned and ostracized from their families and communities:

“Stigma pervasively exists in the society and even within families. Family members have verbal assaults towards them, refuse to eat together.”

“You already knew that HIV patients were stigmatized by the community, society. The community disliked them: the drug users, the addicts. Even their families disgraced them, so did people in the community.”

Stigmatization was at the root of community opposition to the co-location of MMT and HIV treatment clinics at one clinic in 2013, which resulted in that clinic’s adoption of the “same staff, different location” model.

“People in the community objected to establish MMT and OPC clinic in one place here. They already accepted HIV patients, so they did not want to see the additional appearance of people with drug use since they were afraid that PWIDs would bring with them social evils to the community. PWID were isolated even in their families, not only in community, society. Using drug challenged the communication between PWIDs and health staff. They hesitated to tell, to share with healthcare providers.”

However, by 2015, the same clinic staff reported that effective communication and community outreach had resulted in some degree of stigma reduction.

“In general, stigma towards patients (HIV patients) has been greatly reduced both in family and in society recently. This is because communication programs have changed positively in portraying the image of HIV. In the past, the HIV patients normally linked to injecting drug users or commercial sexual worker.”

Participants felt that patients were inclined to hide or lie about their drug use due to fear of stigmatization by healthcare providers, perpetuating mistrust between patients and clinic staff. Notably, one participant working under the “same location, different staff” model stated that this mistrust could be overcome in the long term through development of strong therapeutic relationships. This sentiment was echoed by participants working under the “same staff, different location” model:

“HIV patients normally hide their drug use because they are afraid they will be viewed poorly in the eyes of healthcare staff, and may be thought to have poor adherence.”

“At the beginning, patients do not trust health staff because they are afraid of being disclose, so they often hide their substance use condition. After a while when health staff successfully built the trust, then the patients are ready to share.”

Similarly, some patients’ reluctance to receive SUD treatment, failure to attend scheduled appointments, and continued drug use despite treatment contributed to a sense of frustration among clinic staff, several of whom felt mistreated by patients. This sentiment was reflected in the words of one participant, who stated that despite the genuine concern and support of healthcare workers providing counseling and outreach services, many patients were “rude, unacceptably rude.”

Healthcare providers in HIV outpatient clinics also expressed views reflective of broader societal discrimination against people who use drugs, including descriptions of patients as “lazy,” those who do “not give a damn.” These biases were potentiated by perceptions of inappropriate patient behavior among tired and overburdened clinical staff. Particularly disheartening to providers was the need to clean litter from messy waiting areas and restrooms used by MMT patients, after long days working exhausting shifts in the clinic. However, commentary and complaints highlighted by staff members, despite being expressed in the language or context of stigmatization, were often suggestive of a deeper concern for the well-being of their patients. One staff member working under the “same staff, different location” model noted the need for flexible communication approaches when dealing with patients from “the bottom of society,” while another emphasized the importance of maintaining a gentle attitude toward patients who had long been stigmatized by society, as well as the detrimental impact on patient care of staff losing their temper with non-adherent patients.

“The second difficulty is that we need well-trained staff. [These] kind of patients are those with unstable mood, unexpected behaviors. Therefore, in addition to expertise, it is required for all staff to have medical ethics. Differently speaking, staff must be gentle, making efforts to understand the patients. Because the merely HIV patients have already been stigmatized by community, it is even harder for HIV people with drug use. Some staff felt upset because the patients did not follow their instructions, then they said something unpleasant to patients. Later on, that would cause problems to their work.”

Providers’ Conflicting Views Regarding Integration

Participants expressed a range of views, sometimes conflicting, regarding how to resolve structural, societal, and capacity-related challenges to providing integrated care. Several participants, including those working under the “same staff, different location” model, stated that the “different staff, same location” model was needed to relieve overburdened staff and allow for improved care through specialization of tasks.

“I think it’s better to integrate in one clinic but with two different staff groups. The benefit of staff separation is that we could ensure the quality of the treatment because health staff will be more professionalized, rather than working as part time staff. The second thing is that if we separate two staff, it will benefit both staff since they will have more time to serve patients, more time to update knowledge and learning. But of course, if we separate staff, we will need more staff and must be qualified staff.”

In the context of this model, another participant emphasized the need for regular structured communication between the two separate staff cadres in order to ensure comprehensive follow-up of patients. By contrast, other participants working under the “same staff, different location” model firmly believed that the fully integrated model would allow staff to better develop their skills to deliver more holistic care, in particular regarding the interactions between ART and MMT regimens.

“Integration is better than separation of MMT. Particularly, physicians need to advance their expertise because there is an interaction between ARV and methadone so physicians need to update their knowledge. Besides, MMT patients also need to be screened to diagnose their HIV status to access better treatment.”

Others, representing staff from both the “same staff, different location” and “same location, different staff” models, were in favor of full integration. They highlighted the potential benefits of this model for co-ordination between staff leading to more effective care, greater convenience for patients, lower rates of non-adherence, and opportunities for providing ancillary services:

“Actually, it’s better to integrate because physicians should practice both methadone and ARV (HIV) treatment so that they will be able to follow up the patients’ health status in both treatments. For example, physicians check the patient’s health status every day in HIV treatment, then if patients have problems in methadone treatment, they could easily follow up. If the MMT clinic is somewhere else, we also could do that but it could have some [delays].”

“The integrated model of MMT and ART delivery helps patients to better access addiction treatment, and makes more services available to patients. When these services [MMT and ART] are not integrated, doctors can only carry out health check-ups and counsel patients regarding reducing substance abuse. The integrated model brings more effective and convenient care for patients.”

“As a result of the joint staffing system, it is easy for health care staff to meet with patients every day at the MMT clinic and remind them of their upcoming ART appointments. It is also more convenient to refer patients between two services [under the integrated model], which leads to lower drop-out rates.”

Another participant working under the “same location, different staff” model stressed that the fully integrated approach would result in more cost-effective care in a time of declining budgets for treatment of both HIV and substance use disorder.

“Integration would be better to save budget, especially in the funding decline context.”

Discussion

Integration of SUD and HIV treatment services is urgently needed to improve HIV and SUD outcomes, particularly in low- and middle-income countries where resources for stand-alone HIV and SUD treatment systems are limited. The current study documents HIV provider perceptions of care integration in Vietnam and suggests key areas for addressing challenges as care integration proceeds.

Healthcare providers acknowledged the importance of integrating care for patients with SUD but placed less emphasis on addressing alcohol use. While the pace of progression to life-threatening consequence for alcohol use disorder may be slower for alcohol than opioid use disorder, patients with HIV experience substantial morbidity due to alcohol, including accelerated HIV disease progression, ^{19, 20} hepatitis C-related liver disease,²¹ and death.²² An integrated stepped alcohol treatment approach in US Veterans Healthcare Administration HIV clinics improved both alcohol and HIV outcomes ²³ and could be adapted for international settings.

Structural barriers and limited workforce capacity were perceived as challenges to integrating HIV and SUD care. Scale-up of integrated care models must be adapted to local contexts that take into account patient and staff transportation challenges and convenient access. Our findings echo those of a previous qualitative study of Vietnam stakeholders which documented structural challenges such as clinic payment policies and workforce training needs as key barriers to overcome in implementing integrated models of HIV and MMT treatment.²⁴ Workforce training and support are essential aspects of scaling up care integration that have been successfully supported in international contexts through web-based tele-mentoring programs,^{25, 26} and the Substance Abuse and Mental Health Services Administration (SAMHSA)’s addiction technology transfer centers, which support healthcare providers in adoption of evidence-based SUD treatment in diverse treatment settings. Even more fundamentally, improved financial incentives and professional development opportunities would facilitate recruitment and retention of experienced, motivated providers of HIV and addiction care in Vietnam.

Providers in our study struggled to resolve their concerns about treatment integration and their reservations about providing SUD treatment services, recognizing that stigmatization of SUD was not helpful and returning to compassionate views of care as core values. This is consistent with findings from patient-based surveys in Vietnam. In one study of people receiving HIV care, the majority favored fully integrated care as a way to improve ease of treatment access, yet discussions of SUD treatment with their providers were uncommon.²⁷ A minority of study respondents preferred non-integrated care out of concerns of experiencing stigma from health providers. These findings are similar to findings from qualitative interviews with patients receiving integrated buprenorphine/naloxone treatment from their HIV providers in the USA, who viewed integrated care as being more patient centered.²⁸

Patients participating in a survey at three HIV clinics in Hanoi echoed provider findings in the current study.²⁹ Survey respondents prioritized the convenience of co-located HIV and MMT services as a way to improve treatment access. However, prior experience of community stigma toward drug use was inversely associated with a preference for integrated care. Addressing stigma at the community level may be a target for improving the acceptability of SUD and HIV treatment integration. Our results support several of the suggestions made by Ojikutu et al.³⁰ for successful, integrated HIV care: co-located services, a culture that promotes a stigma-reducing environment, effective communication strategies, and a focus on quality.

Respondents expressed concern about the stigma they encountered in their community. There is a general sense that integration is viewed as a step forward in service provision, but the implications of that integration can be difficult for clinic neighbors to accept. Integrated clinics confronted a “not in my backyard” (defined as opposition to the locating of something considered undesirable in one’s neighborhood) bias in their communities, leading in some cases to the need for separating their HIV and SUD services. In those cases, collaboration and communication among the staff at the different sites were critical for integrated healthcare. Biases toward certain patients were evident in clinic staff as well, with some staff having a preoccupation with “keeping a safe distance” from clients with HIV. The need for motivated, experienced, compassionate staff to work in addiction and HIV treatment is high.

This study should be interpreted in light of several potential limitations. First, the research focused on HIV providers in eight HIV clinics in Vietnam, limiting generalizability. Despite this, study findings are consistent with those from other regions and may contain useful lesson learned for other countries considering integration of HIV and SUD services. ⁶ Second, purposive sampling was utilized to sample providers; not all clinical staff were interviewed. However, efforts were made to ensure adequate representation of viewpoints from the study clinics. Third, providers from only a few clinics were able to provide follow-up interviews after integration. Finally, a spectrum of pre-existing experiences with integration of HIV/SUD care existed among providers, and our sample size did not allow for comparison with providers who had previously experienced integration with those who had not.

Implications for Behavioral Health

Integration of SUD and HIV healthcare services is a promising approach for improving access to treatment, optimizing care delivery efficiency in resource-limited settings, and improving the lives of people with SUD. Models of integration range from centers where staff are specially trained to provide patients with HIV and SUD care during a single appointment, to improve coordination between separate SUD treatment centers and HIV clinics. Each of these models presents unique opportunities for integration of behavioral health services with treatment of both SUD and HIV. Results highlight opportunities for improving integration including targeted health provider training in SUD and HIV management, stigma reduction interventions for both SUD and HIV, and better communication with patients and staff, especially in models where the location of the services or staff differ. These results, particularly those pertaining to a need for stigma reduction and patient-provider communication, are likely to apply to integration of other behavioral health services into the HIV/SUD treatment paradigm as well. In particular, the field of mental health and SUD counseling is newly emerging in Vietnam. Our results highlight the need for advancing efforts to support growth of behavioral counseling education in Vietnam. Further research into efforts to enhance integration of HIV and SUD in Vietnam and elsewhere is warranted.

This study provides critical insights from the perspective of care providers for integrating HIV and SUD treatment in Vietnam, which could inform integration of other services such as behavioral health within Vietnam in addition to scale-up of integrated HIV and SUD services in other countries. The utility of these insights is not necessarily limited to other countries in Southeast Asia or indeed even to other countries at a stage of economic development comparable to Vietnam. As new modalities of behavioral health services emerge in the USA, or when existing modalities demonstrate benefit for patients with HIV and SUD, it will be crucial to understand the views of providers in order to effectively integrate these services into existing HIV and SUD treatment strategies.