In this observational study, HIV-infected persons with opioid dependence received only half of HIV quality of care indicators but experienced improved quality of HIV care when treated with bup/nx compared with referral for other treatment. Integration of bup/nx treatment into HIV practices represents an opportunity for increasing engagement in and receipt of HIV care processes associated with higher quality HIV care. Improvements in quality of care were the result of improvements over a broad spectrum of HIV quality of care indicators, including those from the monitoring, prevention, and counseling domains of quality.
This study’s main finding that patients receiving bup/nx experienced greater improvements in quality of HIV care than those referred for other treatment is consistent with HIV providers’ experience managing multiple chronic conditions. HIV primary care providers are accustomed to managing patients with chronic relapsing conditions such as opioid dependence and well positioned to engage patients in treatment,36
improve linkages between addiction and medical services,37
and facilitate relapse prevention.38,39
In previous studies, office-based buprenorphine treatment was associated with high patient satisfaction rating20
and engagement of previously untreated opioid-dependent patients compared with methadone maintenance.21
Office-based buprenorphine may be a tool for increasing patient activation among HIV-infected patients with coexisting substance use, leading to improved HIV self management.40
Alternatively, it is possible that opioid-dependent patients directly engaging in office-based bup/nx treatment empower their HIV providers to deliver more comprehensive care. Additional studies are required to elucidate patients’ reasons for increased activation and patient satisfaction with office-based bup/nx treatment.
Despite improved care associated with bup/nx treatment, HIV-infected participants with opioid dependence received only half of the indicated HIV care items. This low percentage of HIV quality of care indicators achieved, however, is comparable to summary scores of overall healthcare quality in the US population. In a random sample of people living in 12 communities throughout the United States, participants received only 54.9% of recommended care. Although the quality of care for specific chronic conditions varied widely, care for HIV infection was not assessed.25,35
Individual HIV quality of care indicator levels in our study, however, were lower than those reported in HIV-infected populations in Ryan White-funded settings,41
Veterans Administration HIV clinics, or a national probability sample of HIV-infected Americans.5
These differences are likely explained by the fact that the current study enrolled HIV-infected patients with substance use disorders, representing a potentially more challenging population to engage.
This study demonstrates the feasibility of using a summary quality of care score to assess the quality of HIV care. This approach, validated in other medical conditions and populations, has the advantage of providing an overall benchmark of quality of HIV care that accounts for differences in eligibility criteria for individual quality indicators. Absolute improvements in quality of care, however, were small. Further studies are required to validate this approach more broadly in other HIV-infected populations and assess correlations with clinical outcomes.
In contrast to studies of healthcare quality in the general population,35
no associations among age, gender, and race/ethnicity and quality summary scores were identified. We hypothesize that potential variations in quality of care by demographic characteristics may be outweighed by the effect of active opioid dependence on HIV care. Systemic interventions to improve engagement in treatment of opioid dependence such as bup/nx may have a greater effect on receipt of recommended HIV care than interventions tailored to nonmodifiable patient characteristics.
The current findings should be interpreted in light of several potential limitations. First, the observational and nonrandomized nature of this study allows for the introduction of potential unmeasured confounders and biases. For example, the majority of participants received bup/nx versus referral for other treatment. Patients may have differed in their predisposition to pursue HIV care. There was, however, a non-significant trend toward greater HIV clinic visits and quality summary scores at baseline among participants referred for non-bup/nx treatment, suggesting that potential selection bias may be biasing our results toward the null rather than overestimating the effect of bup/nx. Also, the small number of participants receiving “other” treatment may have resulted in insufficient power to detect difference in measured confounders. Still, this is the largest assembled evaluation of HIV-infected, opioid-dependent patients to date, and inclusion of known confounders (age, opiate of choice, and stimulant use) was accounted for in multivariable models. Second, HIV clinical sites varied in their development of models for bup/nx integration.23
Bup/nx was, however, typically administered by providers using standard bup/nx treatment guidelines24
in real-world HIV treatment settings. Third, participating HIV clinic providers and staff received substantial training and expert support in implementation of office-based bup/nx, and patients benefited from a grant-supported bup/nx clinical coordinator. Observed improvements in quality of HIV care among patients engaged in office-based bup/nx may not be generalizable to HIV practice settings lacking such support. Finally, we were only able to assess a limited number of HIV quality of care indicators for 12 months of follow-up in the current study, making it possible that inclusion of a greater number of care indicators might attenuate the observed effects of bup/nx treatment on quality of HIV care. Still, the number of HIV quality of care indicators observed in this study exceeds those reported in prior studies5,41
and represents consensus recommendations from multiple agencies.
In summary, HIV-infected patients with opioid dependence who received bup/nx treatment experienced improved receipt of recommended HIV care over 12 months follow-up. Participants, however, received only approximately half of recommended HIV care, indicating that broadly targeted interventions are required to improve the quality of care for this particularly vulnerable population. Integration of office-based bup/nx into HIV practices represents one innovation for closing this gap in the quality of HIV care by increasing engagement in and receipt of recommended HIV care.