Facilitators and barriers to implementation of low barrier care in HIV care systems in the southern United States

Abstract

With antiretroviral therapy effective in both treating and preventing HIV infection, ending the HIV epidemic in the US is now possible. However, navigating the organization of the majority of HIV care in the US is often impossible for populations living unhoused and experiencing untreated severe mental health and/or substance use conditions, contributing to their poor care engagement and viral suppression. One effective intervention for this population is utilization of low barrier care (LBC), or incentivized, walk-in HIV care with wrap-around services and few rules or administrative requirements for services. Yet while public health entities have a rare opportunity through new federal resources to adopt and implement LBC in their jurisdictions, few have chosen to do, including none in the southern US where HIV incidence and poor viral suppression are pronounced. To explore perceptions of LBC as an intervention and potential facilitators and barriers to its implementation in the southern US we used the Consolidated Framework for Implementation Research to guide a team-based, framework-guided rapid qualitative analysis of data from 25 focus groups and 2 key informant interviews with members of 5 southern HIV care systems. Participants overwhelmingly agreed that LBC would address the needs of a large proportion of persons virally unsuppressed and at risk for transmitting HIV in their jurisdictions. By starting small and building upon existing infrastructure they believed it would be possible to implement LBC, but lack of funding, clinical capacity, HIV-related stigma and policies restricting eligibility for services and use of incentives could inhibit successful implementation.