Implementation of integrated stepped care for unhealthy alcohol use in HIV clinics
© Edelman et al. 2016
Received: 8 May 2015
Accepted: 23 December 2015
Published: 13 January 2016
Effective counseling and pharmacotherapy for unhealthy alcohol use are rarely provided in HIV treatment settings to patients. Our goal was to describe factors influencing implementation of a stepped care model to address unhealthy alcohol use in HIV clinics from the perspectives of social workers, psychologists and addiction psychiatrists.
We conducted two focus groups with Social Workers (n = 4), Psychologists (n = 2), and Addiction Psychiatrists (n = 4) involved in an ongoing randomized controlled trial evaluating the effectiveness of integrated stepped care for unhealthy alcohol use in HIV-infected patients at five Veterans Health Administration (VA) HIV clinics. Data collection and analyses were guided by the Consolidated Framework for Implementation Research (CFIR) domains, with a focus on the three domains which we considered to be most relevant: intervention characteristics (i.e. motivational interviewing, pharmacotherapy), the inner setting (i.e. HIV clinics), and characteristics of individuals (i.e. the providers). A multidisciplinary team used directed content analysis to identify major themes.
From the providers’ perspective, the major implementation themes that emerged by CFIR domain included: (1) Intervention characteristics: providers valued tools and processes for facilitating patient motivation for treatment of unhealthy alcohol use given their perceived lack of motivation, but expressed a desire for greater flexibility; (2) Inner setting: treating unhealthy alcohol use in HIV clinics was perceived by providers to be consistent with VA priorities; and (3) Characteristics of individuals: there was high self-efficacy to conduct the intervention, an expressed need for more consistent utilization to maintain skills, and consideration of alternative models for delivering the components of the intervention.
Use of the CFIR framework reveals that implementation of integrated stepped care for unhealthy alcohol use in HIV clinics is facilitated by tools to help providers enhance patient motivation or address unhealthy alcohol use among patients perceived to be unmotivated. Implementation may be facilitated by its consistency with organizational values and existing models of care and attention to optimizing provider self-efficacy and roles (i.e. approaches to treatment integration).
Unhealthy alcohol use, defined as the spectrum of drinking including at-risk drinking and alcohol use disorders , is common among HIV-infected patients and associated with a range of adverse health outcomes. Unhealthy alcohol use among HIV-infected patients is associated with poor antiretroviral therapy (ART) adherence [2–8]; impaired treatment response; and decreased quality of HIV care [5, 6, 9]. In turn, individuals who stop drinking experience an improved response to HIV therapy [5, 10]. Further, unhealthy alcohol use increases the risk of important medical comorbidites, such as cardiovascular disease , liver disease  and malignancy  and is associated with sexual risk behaviors and ongoing HIV transmission [14, 15].
Integration of treatment for unhealthy alcohol use into HIV clinics
Despite the high prevalence and adverse effects of unhealthy alcohol use, few effective interventions for unhealthy alcohol use are offered in HIV clinics [16–21]. Interventions that have been shown to be effective for decreasing unhealthy alcohol use in uninfected patients, including brief interventions for at-risk drinking , Motivational Enhancement Therapy, and alcohol pharmacotherapies [23, 24] are not routinely provided in HIV clinics [25, 26]. One advantage of integrating the treatment of unhealthy alcohol use into HIV clinics is that it provides “one stop shopping” and limits potential losses to follow-up seen with referral to off-site treatment. However, integrated treatments are often based on screening strategies and must contend with low levels of knowledge regarding alcohol-associated health risks and motivation among non-treatment seeking individuals [27, 28]. Also, providers often neglect to discuss or recognize unhealthy alcohol use [29–32] and are underprepared to provide treatment . In addition, treatments for unhealthy alcohol use are not uniformly effective, which provides a rationale for stepped care approaches. Stepped care approaches, which have been applied to chronic disease conditions (e.g. depression and hypertension), typically start with a low-intensity evidence-based intervention with increasing the intensity of treatment if patients fail to respond to initial treatment strategies [34, 35].
The innovation: integrated stepped care for unhealthy alcohol use in HIV clinics
To address a need for effective treatment models for unhealthy alcohol use among HIV-infected patients through HIV clinics, we are conducting the Starting Ethanol Treatment in Primary care Trial (STEP Trials), a series of three linked multi-site randomized clinical trials designed to evaluate the implementation and effectiveness of integrated stepped care among HIV-infected patients with unhealthy alcohol use. Briefly, HIV-infected patients are recruited into one of three trials based on their alcohol use—(1) at-risk drinking , (2) moderate alcohol consumption in the presence of liver disease (MALD) (defined as any alcohol consumption in the past month in the presence of a FIB-4 score greater than 1.45, a validated marker of liver fibrosis [12, 37, 38], or active Hepatitis C virus infection based on serology and presence of a detectable viral load) or (3) alcohol abuse or dependence criteria . Each trial compares integrated stepped care to treatment as usual.
Patients are recruited from one of five Infectious Disease Clinics within the Veterans Health Administration (VA). Patients in the stepped care arm receive evidence-based interventions of increasing intensity (or not) based on their response to initial treatments. Social workers deliver a brief intervention (the Brief Negotiated Interview [BNI]) [40–42] with a two-week telephone booster to patients with at-risk drinking or MALD; Psychologists deliver four sessions of Motivational Enhancement Therapy ; and Addiction Psychiatrists provide Addiction Physician Management, with an emphasis on offering pharmacotherapy. Addiction Psychiatrists were encouraged to prescribe pharmacotherapy based on what they thought was most likely to benefit the individual patient. This includes Food and Drug Administration (FDA) approved pharmacotherapies for alcohol dependence (i.e. disulfiram, naltrexone, acamprosate) and prescribing of medications with evidence of efficacy (e.g. topiramate, gabapentin).
To enhance implementation and consistency of the intervention across sites, providers received an initial training and are provided with manuals and structured encountered forms to guide each visit. Providers are also given a “Feedback Form” to review patient-specific data, including self-reported alcohol use, other substance use, level of bother by alcohol use, motivation for treatment, and biomarkers known to be impacted by alcohol [liver function, HCV status, HIV biomarkers, and VACS Index score (a validated prognostic marker of morbidity and mortality found to be responsive to levels of alcohol use)] [44–46] with the patient. Visits with providers occur within the HIV Clinic or nearby available office-space. The STEP Trials is occurring in the context of current VA initiatives focused on developing patient-centered medical homes, known as Patient Aligned Care Teams (PACTs), and its extensions (i.e. Primary Care-Mental Health Integration [PC-MHI] and Health Promotion and Disease Prevention [HPDP] Programs) [47, 48]. These VA programs have been developed to promote the use of multidisciplinary teams to address a range of health related issues in the context of co-located and collaborative care within primary care settings .
Consistent with effectiveness-implementation hybrid study designs intended to evaluate a clinical intervention while collecting data on implementation , we conducted the current qualitative study to examine perspectives of providers on the implementation of integrated stepped care for unhealthy alcohol use and inform implementation efforts in other HIV clinical settings. Given its suitability for examining factors impacting implementation of clinical interventions across different settings and disciplines, including addiction treatment, we used the Consolidated Framework for Implementation Research (CFIR) to guide data collection and a directed content analysis [50–54].
Study design and participants
Pre-implementation provider integration into HIV clinic and additional considerations by site
HIV clinic characteristics
Providers at geographically dispersed VA-based locations
The two focus groups were facilitated by investigators with experience conducting qualitative research [62–68]. One focus group (facilitated by EJE, DAF, NH and SM) consisted of Social Workers and Psychologists and the other (facilitated by EJE, DAF, LEF) consisted of Addiction Psychiatrists.
Focus group procedures
Based on the CFIR framework  and multi-disciplinary input, we used grand tour questions (i.e. open ended questions intended to stimulate discussion), and probes (i.e. prompts) to examine the perceived impact of intervention characteristics, inner setting and characteristics of the individuals (Fig. 1) on the delivery of integrated stepped care for unhealthy alcohol use in HIV clinics (Text Box) . These CFIR domains were chosen as the focus of this investigation as they were the most directly relevant to the experiences of the providers delivering this innovative intervention and consistent with prior guidance regarding how to apply the CFIR [54, 59].
Text Box: Focus Group Guides: Example Grand Tour Questions with Probes
Intervention Characteristics : Can you tell me about your experiences with treating HIV-infected patients for their unhealthy alcohol use in the context of the STEP Trials ?
How does the integrated stepped care approach compare to other treatment approaches?
What made it easier?
What make it more difficult?
Does the intervention feel like something you would create? How would you change it?
Intervention Characteristics: How did you find the patients responded to your treatment and the integrated stepped care treatment approach, in general?
How motivated were patients to participate?
What seemed to impact their motivation?
How could this have been improved?
Characteristics of the Individuals: What was your experience with delivering the intervention?
What aspects did you find most effective?
What aspects did you find least effective?
How did it fit in with your other roles and responsibilities?
How comfortable are you in delivering this type of intervention?
What changes would you make in the training materials to increase their usability?
Inner Setting: Can you tell me more about how you communicated with others involved in the care of your patients with unhealthy alcohol use?
What about social workers/psychologists/psychiatrists?
What about the patients’ primary care provider?
Inner Setting: How important is treating unhealthy alcohol use to your supervisor? To the VA?
Does this get measured in any way?
What kinds of resources are dedicated to this?
Do you think your supervisor would support you to do this kind of work even after the trial ends?
Describe some of the complexities in implementing this treatment model with regards to the duration, scope, disruption of other activities, number of steps.
Six individuals of our multidisciplinary team, including members not present at the focus groups and one member not previously involved in the project, applied content analysis with a deductive approach to code the transcripts [56, 57]. Team members were trained on the CFIR framework  in advance and used the domains and constructs as predetermined codes . The transcripts were independently reviewed line by line, and elements of the CFIR domains and constructs were assigned to meaning units (i.e. transcript text) . Team members met to discuss emerging ideas, resolve discrepancies and reach consensus regarding the codes. One author (EJE) then re-reviewed the transcripts to systematically apply these codes. To organize the data and facilitate retrieval, we used qualitative analysis software (AtlasTi version 6.2, Berlin, Germany). We organized the transcript text by domains and constructs and then re-reviewed the quotes for themes and illustrative text and discussed as a group. To increase the rigor of our approach, we reviewed a summary of our findings with participants to confirm that we had accurately understood and conveyed their experiences .
Relevant CFIR Domains with definitions as applied to integrated stepped care for unhealthy alcohol use
I. Intervention characteristics: integrated stepped care for unhealthy alcohol use
Evidence strength & quality
Providers’ perception of the quality and validity of evidence supporting the belief that integrated stepped care for unhealthy alcohol use will lead to decreased unhealthy alcohol use
Providers’ perception of the advantage of implementing integrated stepped care for unhealthy alcohol use versus an alternative solution
The degree to which integrated stepped care for unhealthy alcohol use can be adapted, tailored, refined, or reinvented to meet local needs
Perceived difficulty of implementation, reflected by duration, scope, radicalness, disruptiveness, centrality, and intricacy and number of steps required to implement
Design quality & packaging
Perceived excellence in how integrated stepped care for unhealthy alcohol use is bundled, presented, and assembled
II. Inner domain: HIV clinics
Networks and communications
The nature and quality of webs of social networks and the nature and quality of formal and informal communications within VA-based HIV clinics and across providers
The absorptive capacity for change, shared receptivity of involved individuals to integrated stepped care for unhealthy alcohol use and the extent to which use of it will be rewarded, supported, and expected within the VA
Tension for change
The degree to which providers perceive the current situation as intolerable or needing change
The degree of tangible fit between meaning and values attached to integrated stepped care for unhealthy alcohol use by involved individuals, how those align with individuals’ own norms, values, and perceived risks and needs, and how this treatment model with existing workflows and systems
Individuals’ shared perception of the importance of the implementation within the VA-based HIV clinics
Readiness for implementation
Tangible and immediate indicators of organizational commitment to its decision to implement integrated stepped care for unhealthy alcohol use
The level of resources dedicated for implementation and on-going operations, including money, training, education, physical space, and time
Access to knowledge & information
Ease of access to digestible information and knowledge about the intervention and how to incorporate it into work tasks
III. Characteristics of individuals: providers
Providers’ belief in their own capabilities to execute courses of action to achieve implementation goals
Individual stage of change
Characterization of the phase a provider is in, as he/she progresses toward skilled, enthusiastic and sustained use of integrated stepped care for unhealthy alcohol use
Overall (n = 9)
Social workers (n = 4)
Psychologists (n = 2)
Addiction psychiatrists (n = 3)
Age, mean (SD) in years
Ethnicity, Hispanic (%)
Gender, Female (%)
Average number weekly patients, mean (SD)
Number HIV-infected, mean (SD)
Number with an alcohol use disorder or alcohol related problem, mean (SD)
Years in current role, mean (SD), [range]
8 (8), [1–24]
5 (7), [1–15]
6 (4), [3–9]
Intervention Characteristics Domain: Integrated Stepped Care Model
Providers indicated that the integrated stepped care model quality, content and packaging facilitated implementation, yet believed it would benefit from adaptability with regards to content, duration and source of the intervention.
Evidence strength and quality
I come from an addiction background before coming to the Infectious Disease clinic, and my mental health background. So motivational interviewing is kind of like magic dust \(\ldots\)
I was thinking about the COMBINE Study and the medical management was a very powerful intervention \(\ldots\) I recall from Project COMBINE that included recommendations of going to AA, but it also included me prescribing medication.
The one where it talked about your drinking [compared to norms], in both my cases they were surprised by the results. It was palpable. You could tell. They \(\ldots\) you know. What do you think of what I’ve just said in terms of, this shows there is such—this high percentile [compared to] drinking [norms] the language is–was surprising to them.
The one thing I probably would change, I think I would want more than, maybe just a little more than four sessions, for me \(\ldots\) My guys worked, so we had to kind of shuffle around to get ‘em in on off days, so committing to 4 sessions was easy. But I felt like they—you were just at that point where you’re holding your kids’ hips as he’s bicycling without training wheels and I just let him go, and he was just taking off—Session number 4. Done. And if I only had just a 5th, maybe just a 5th session, would be the one thing that I would change \(\ldots\) [But] I’m all for \(\ldots\) therapy ending.
\(\ldots\) you start to build a [rapport], and then, because of this session slots issue you cannot see him anymore.
The only other thing too that I also thought about in terms of I think all of our patients, we’re only focusing on alcohol use \(\ldots\) we have like a huge crack epidemic too \(\ldots\) So it’s also interesting to me that we’re only talking to them about how alcohol impacts their body, and I’m ignoring the fact \(\ldots\) he’s like, “No, I did not drink, I just smoked crack yesterday.” Great. You know.
I mean, talking about the relationship between your sex practices and your substance use, talking about the relationship between lack of condom use and substance use, that’s all huge in our clinic. There’s a huge correlation between that. Even to asking them about, are you disclosing your sex—when they go to sex parties, there’s a whole, that’s a whole ‘nother-\(\ldots\) I would totally be interested in seeing how we could do best practices in the VA with prevention positives.
Yeah, unless you had, when they come to the clinic, you provide them with a packet of paperwork for them to fill out, and you have the AUDIT-C or whatever other screening tools you’re using, I think it’s going to be difficult to implement.
Somebody would have to be tracking to make sure that it went the right way. There’s gotta be a way \(\ldots\) in terms of tracking someone would have to be responsible for it. It might be unrealistic to think that with 1100 or 1500 person caseloads, a Social Worker would really be able to do that well. I mean, things would fall through the cracks.
I think the word “brief” can be deceiving sometimes \(\ldots\) I don’t think that 20 min which I think was the original design was always necessarily [enough time]- I think sometimes it drags out more so to 40 something to really bring ‘em around. And then the phone booster depending on, same thing, like the resource needs, can be a challenge. And in my real world I think scheduling a phone appointment, if it’s not [the research coordinator] reminding me that I have to do the phone appointment, and me finding it on my Outlook is challenging, just because I have walk-in clinics.
\(\ldots\) it’s not like we’re seeing this huge amount of patients. But I think that when you’re presenting it to people \(\ldots\) it’d be helpful to kind of inform them of that up front \(\ldots\) but it’s not that big of a workload difference.
Design quality and packaging
Social Worker 1: This is more structured, I didn’t have readiness tools and things like that, but, which are great.
Social Worker 2: I also like the feedback tool, because we don’t always have like their levels right in front of us, I mean we can obviously click through the whole chart and look at all of their labs \(\ldots\) So it puts it in a nice neat package in terms of providing them with the feedback and having all the normative data and everything else.
Psychologist 1: One, we sent them home with a sort of a homework form [and we said, bring it back]. I think that has the effect in some ways of sort of holding them accountable, when you have to write down what you’ve done. Write your sins down.
Psychologist 2: In my experience, the feedback form was absolutely helpful, and because it allowed them to—both of them to, whether they wanted to see how much they were drinking or not, and related it to specific incidents, that allowed them to see those triggers.
I think you can—just by acknowledging, “you’re probably already using these, and you’re probably already doing this, we just want to give you a format and kind of keep track of it.” Because you’re not indicating that you’re adding any more work on \(\ldots\) So you’re not adding on anything more on their caseloads. Especially like if you’re doing it within the ID clinic, and the social workers within the clinic are already meeting with these patients. So, I think it’s just acknowledging that.
For some of my patients, not just in the trial, they’ve had prior experience with disulfiram. And they don’t want to go there. And they lump all the medicines together into I’m talking to them about disulfiram. It doesn’t matter what I say, it’s just like the Charlie Brown, waw waw, waw waw, waw waw. They thinking in their mind, disulfiram, if I slip up I’m going to get sick and die, I can’t take medication. It would be nice to have like a table or something to say, “This is this medicine, it’s what it does; this is this medicine, this one’s different” \(\ldots\)
Inner Setting Domain: HIV Clinics
Addressing unhealthy alcohol use was compatible with norms, values, and basic assumptions of the VA, and integrated care was compatible with VA priorities (i.e. creating a medical home) but implementation seemed to be affected by networks and communication, the implementation climate and readiness for implementation.
Networks and communications
And the doctors refer as they’re seeing patients that have the social work-related concerns, as needed.
One thing I would like is \(\ldots\) a local call—a local meeting—that would be very helpful too. See what’s going on \(\ldots\) It would be nice to hear what’s going on.
Social Worker 1: I know we’re all only a phone call away but we don’t—also if you have elevators at that level where they’re seeing the addiction psychiatrist, they’re not necessarily having contact with us anymore, so there’s not that communication on that level.
Social Worker 2: Oh yeah, we work as a team. I knock on their door, they knock on my door, no, we definitely work as a team, except, the same thing, the addiction psychiatrist is in a separate part of—you know, our building is very large.
Aspects (i.e. sub-domains) of the implementation climate most impacting the implementation climate included the tension for change, compatibility, and relative priority.
Tension for change
That’s something if a position can be carved out \(\ldots\) and there is a need. There is such a need. Because I get so many phone calls.
I would say we’d be supported at the national level \(\ldots\) But right now, frankly our challenge is getting—where we’ve been focusing our energy is getting the specialty programs to prescribe medication for alcohol dependence or use disorders. The uptake is really low, nationally.
It’s basically what we—I mean, at least me, what I have been doing.
The way that we operate is, I see all of our new patients ideally like when either they’re newly diagnosed [with HIV] or new to our clinic. Ideally before their initial physician’s appointment, when they come in and get their initial lab work done? I see them, do a comprehensive bio-psychosocial assessment, and or provide like post-HIV diagnosis counseling, and then see them as needed from there on out, depending on what their resource needs are and psychosocial stressors. And the patients that are long established, I see them either when they come as a walk-into see me because they need something, or because the doctors think that they need to see me, or the nurse or the pharmacist or whomever in the clinic.
I think it would be a great \(\ldots\) the PACT teams all have now a social worker, a nurse. I think that would be where \(\ldots\) And everybody’s supposed to have a primary care. Should be assigned a primary care. So I think adding this [intervention] in that team, would be \(\ldots\) you would catch the majority of people.
So they would be more integrated and they would work more like a team, as opposed to being a group practice of independent providers which is how most mental health clinics are now. And so they’ve been rolling this out for about a year or so, and part of what they’ve talked about is how would you integrate addiction treatment into that.
But we still, like even before this study I was gonna—we used this framework. You know, when you’re dealing with somebody who’s, for example, you go into one of the [clinic] meetings and they’re not taking their HIV meds like they’re supposed to, and they’re developing all this resistance and one of the identified reasons is alcohol, I call them in, talk to them and then hopefully it leads to a referral \(\ldots\) but as our role as social workers to the clinic we’d be neglecting a lot of the other important information if we solely focused on the alcohol without addressing all of the other psychosocial stressors and concerns.
Readiness for implementation
Aspects (i.e. sub-domains) most impacting readiness for implementation included available resources and access to knowledge and information.
We have nurses but our nurses are really directed in nature versus like looking at a framework. This is a lot more probing, and our nurses are much more prescriptive and directive in nature. I don’t know if that’s across the board though.
Access to knowledge and information
But something, I mean it makes sense—pharmaceutical companies don’t just create something and publish some papers and let it go at that. In order to get people to uptake it they do proactively go out and detail. So we really shouldn’t be surprised if we publish a paper and people don’t uptake it either \(\ldots\) if we could convince the ID docs to at least initiate it, to talk about naltrexone a little bit, and maybe we don’t have to burden them with managing it. But if we could get them to just sell it a little better.
Addiction Psychiatrist 1: One guy came almost every session. Unfortunately he just said, “I like to talk to you, not like to take medicine from you.”
Addiction Psychiatrist 2: I have been more successful prescribing SSRI’s and [tricylics rather than acamprosate]. There’s a fair bit of resistance [to pharmacotherapy] \(\ldots\) It’s like, some of—a good number of them have been in AA, so you don’t need a pill—it’s-anything. That resistance, I don’t know—I don’t need a pill to–I can do it on my own. A lot of patients, it’s from the AA end. And probably some of the pressure is also from… their primary care docs or their cardiologists have never thought about naltrexone.
Characteristics of Individuals Domain: Providers (i.e. Social Workers, Psychologists and Addiction Psychiatrists)
Providers endorsed high self-efficacy regarding their implementation, but voiced a need for more consistent utilization of the intervention to maintain skills and discussed alternative models and roles for delivering the components of the intervention.
I’d be seeing them anyways. And so I’m glad to know that you have educated me, and it fits. It definitely fits with what we’re doing.
I think level of engagement has something to do with it. When we talked, I—the first client that I had was just so into it that by the time the second session, he was way ahead, way ahead, and so all I could do was affirm what he was doing.
And there’s too much time in between [patients]. It’s almost like having to relearn it every [time].
Individual stage of change
But if it’s such a brief thing, and they already have a relationship with their physician, doesn’t it make sense to have the physician do this, and then they have the MET with a social worker, I feel like most social workers that I come cross in the VA, could probably do the MET [stuff].
I think that it could also be powerful if the medication was coming from the Infectious Disease doc, the person who saved my life saying, I think it’s important for your health and your management of your HIV disease, that you stop drinking, and I’m willing to work with you \(\ldots\) I do think that there’s something powerful when the doc who’s saved your life says, “I think you should do something.” That carries a lot of weight. As opposed to this other person I referred you to. So that would be my only suggestion. But I don’t know if you could get ID docs to \(\ldots\) I would submit that they have great motivational skills, because if they can get folks to take HIV meds, then they know how to motivate people.
Focusing on three CFIR domains, we examined factors impacting the implementation of a model of stepped care for unhealthy alcohol use in HIV clinics. Based on the experiences of Social Workers, Psychologists and Addiction Psychiatrists from five different clinics, several factors emerged as deserving careful consideration for future implementation efforts. First, the providers deemed patients as not typically seeking treatment, and thus materials and processes for facilitating patient motivation for treatment of their unhealthy alcohol use were key and should have greater flexibility. Second, treating unhealthy alcohol use in HIV clinics was perceived by providers to be consistent with VA priorities, which are focused on both screening for and intervening upon unhealthy alcohol use and promoting medical home models of care. Third, depending on the existing role of the provider, there was variability in the perceptions regarding the ideal model for promoting integrated care. These data represent a novel contribution to the literature as they shed light on important factors deserving consideration in implementation of a stepped care model for unhealthy alcohol use in HIV clinics and identify actionable opportunities for future implementation efforts.
Because HIV-infected patients with unhealthy alcohol use were generally not seeking treatment, an advantage of the integrated stepped care model included the tools and process which facilitated patient motivation for treatment. Prior work has demonstrated that HIV-infected patients drink to cope with negative emotions, to promote social interactions, and in response to social pressure ; these motivations might be a barrier to treatment. The design of the integrated stepped care model (i.e. Social Worker and Psychologist-delivered manualized counseling focused on enhancing patient motivation to change their alcohol consumption and structured, personalized feedback for patients) facilitated its implementation. While the providers found these techniques to be familiar, they found that the integrated stepped care model provided them with new techniques and materials for enhancing patient motivation, which they perceived to be a barrier to promoting treatment. Indeed, these tools may serve to reinforce motivations to decrease alcohol consumption that have been previously identified as reasons that HIV-infected patients limit their drinking (i.e. concerns about the impact of alcohol use on social functioning, lifestyle incompatibility and physical and mental functioning) .
Importantly, treating unhealthy alcohol use through clinic-based settings was perceived by providers to be consistent with VA priorities. Specifically, there have been extensive efforts to promote evidence-based AUDIT-C screening followed by appropriate intervention (i.e. brief intervention, specialty care) for unhealthy alcohol use across VA settings [71, 72]. In contrast, uptake of evidence-based pharmacotherapy for alcohol use disorders has been slow [73–75] despite VA guidelines supporting the use of pharmacotherapy . Addiction Psychiatrists generally recognized accessible pharmacotherapy as an important treatment option for alcohol use disorders, yet reported variable success in initiating treatment. This suggests that patient and HIV provider-targeted education and marketing may be important for improving uptake among non-treatment seeking individuals in the setting of shared-decision making after consideration of all available treatment options .
Furthermore, providers found that the integrated stepped care model was consistent with VA priorities given recent initiatives to develop and evaluate new models for delivering screening and treatment for unhealthy alcohol use. Providers also perceived the integrated stepped care model as consistent with PACT as well as PC-MHI and HPDP initiatives, which has important implications for potential future scalability. Such models tend to promote improved communication and tighter networks and allow for flexibility in session duration and specific content, as desired by providers in this study.
While providers were consistent in their reported beliefs that the integrated stepped care model offered a high quality intervention, there were differences based on provider experience and type regarding the ideal way in which to integrate treatment of unhealthy alcohol use into HIV clinics. For example, while some Social Workers believed it was ideal for social workers to deliver the BNI, other suggested that either Infectious Disease Physicians or nurses might provide these services. Additionally, they felt they had the requisite skills and experience to provide the MET intervention. Similarly, it was suggested by Addiction Psychiatrists that Infectious Disease Physicians might be best positioned to engage patients in treatment for unhealthy alcohol use. That a tension exists regarding how to best integrate services is not surprising. On one hand, Infectious Disease and HIV-specialty trained physicians, who increasingly serve as the primary care physician for HIV-infected patients, have an existing relationship with the patient and are managing other treatments. However, prior multi-site studies indicate that HIV providers are often unaware of their patient’s alcohol use and often do not discuss it, even with patients with higher levels of drinking [29, 30, 78]. Moreover, only 65 % of HIV providers reported high comfort with discussing substance use . Thus, it is likely that team-based approaches as structured in the integrated stepped care model, which do not rely on HIV providers to deliver treatment for unhealthy alcohol use, are likely to be an important strategy for effectively addressing unhealthy alcohol use. This model is consistent with others developed to treat other substance use disorders (i.e. buprenorphine for opioid use disorders in HIV clinics) [79–81] and supports the integration of social workers, Psychologists and Addition Psychiatrists into HIV clinics. If effectiveness of integrated stepped care for unhealthy alcohol use in HIV clinics is demonstrated, future studies should focus on determining the optimal role of HIV providers, based on their knowledge and self-efficacy, for delivering such treatments. In addition, the extent to which such an intervention should target other health behaviors, such as drug use or sexual risk behaviors, warrants investigation.
The results of this study should be interpreted in the context of its limitations. First, the providers represented a convenience sample of individuals involved with an ongoing randomized controlled trial. Our results may not reflect the opinions of other providers involved with the randomized controlled trial or apply to other VA-based providers more generally. Second, our interview guides were not piloted in advance of our study. In retrospect, given the expressed need to address alcohol along with other drug use and HIV prevention, we would have asked Addiction Psychiatrists further about their comfort prescribing pharmacotherapy for other substances (i.e. tobacco, opioids, cocaine) using an integrated model and how they might address HIV risk behaviors and prevention. Third, these findings may not transfer universally to other HIV clinical settings, particularly settings where Psychologists and Addiction Psychiatrists are less available. The goal of the STEP Trials is to evaluate the effectiveness of integrated care from Psychologist and Addiction Psychiatrists, along with Social Workers. If effectiveness is demonstrated, issues of generalizability of this and the main study’s findings to other HIV clinical settings will be carefully considered. Fourth, this qualitative study was conducted during the 1st year of implementation of integrated stepped care in the context of a randomized controlled trial. Whether these findings will apply at later stages is unclear; though this study does provide important insights to inform planning phases and initial implementation of integrated stepped care models. Fifth, given our small sample size, we are unable to determine whether we had reached thematic saturation. Regardless, this study provides meaningful data given its focus on implementation of a novel model of care for unhealthy alcohol use in HIV clinics based on a robust deductive approach to data analysis, which revealed consistency in findings within and across different groups of providers. Sixth, our study may have been subject to social desirability bias given the proportion of interviewers relative to interventionists; however, we felt that the diverse perspectives of the interviewers served to enhance the richness of the conversation and data collection.
In conclusion, our study represents an important step in identifying key considerations based upon the CFIR constructs when implementing an integrated stepped care model for unhealthy alcohol use in HIV clinics. We found that implementation of this model may be facilitated by tools to help providers enhance patient motivation, close alignment with organizational values and existing models of care, and optimization of provider self-efficacy and roles. Future efforts aimed at obtaining the perspectives of additional providers, as well as patients and HIV providers will be important for developing a comprehensive understanding of factors impacting implementation of integrated stepped care for unhealthy alcohol use in HIV clinics. In addition, consideration of alternative models involving various providers completing the primary components of the intervention, will be important for informing the development of successful interventions.
EJE participated in all aspects of this study, including writing the HIC protocol, leading the data analysis and writing the first draft of the manuscript. NBH and SAM contributed to design of the data collection tools, participated in data collection and analysis. CD contributed to the design of the data collection tools and data analysis. LEF participated in data collection. PGOC and ECW participated in data analysis. DAF participated in all aspects of this study, including conceiving the study design, leading the data collection, and revising of the manuscript. All authors made substantial contributions to the revising of the manuscript. All authors read and approved the final manuscript.
The authors declare that they have no competing interests.
This work was generously supported by grants from the National Institute on Alcohol Abuse and Alcoholism (NIAAA) (1U01AA020795, 2K05 AA16928) and the National Institute on Drug Abuse (NIDA) (K12DA033312-02). Dr. Williams is supported by a Career Development Award from VA Health Services Research & Development (CDA 12-276) and is an investigator with the Implementation Research Institute (IRI) at the George Warren Brown School of Social Work at Washington University in St. Louis. IRI is supported through an award from the National Institute of Mental Health (R25 MH080916-01A2) and the Department of Veterans Affairs, Health Services Research & Development Service, Quality Enhancement Research Initiative (QUERI). Neither NIH nor the VA had a role in the study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the article for publication. Dr. Kendall Bryant, a NIAAA employee and scientific collaborator on the project, participated in the analysis and interpretation of data; in the writing of the report; and in the decision to submit the article for publication.
Earlier versions of this work were presented as poster presentations at the 38th Annual Research Society on Alcoholism Scientific Meeting on June 24, 2015 in San Antonio, Texas and the 8th Annual Conference on the Science of Dissemination and Implementation on December 15, 2015 in Washington, D.C.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
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