HIV clinics in the United States care for large numbers of patients dependent on heroin and prescription opioid analgesics. This chronic and relapsing medical condition may result in reduced quality of life;1 poor adherence to medical recommendations;2 and suboptimal medical outcomes, including increased morbidity and mortality.3,4 Substance abuse treatment can lead to improvements in care, including greater adherence to medical appointments and medication instructions, and improved health status.5,6 Buprenorphine/naloxone (bup/nx), an opioid agonist treatment shown to be as effective as moderate doses of methadone,7-9 can be prescribed by trained physicians with an appropriate Drug Enforcement Agency (DEA) registration and may therefore be offered within the context of an HIV clinic.10 Providing bup/nx within HIV clinical settings has the potential to partially address community-level shortages in treatment capacity6 and to engage patients for whom methadone is not a viable or desirable option.11 In addition, offering drug treatment in an HIV clinical-based setting may reduce stigmatization of drug dependence and drug treatment,12 which may in turn lead to increased willingness to access treatment services. Finally, clinic-based drug treatment is consistent with guidance regarding comprehensive, colocated HIV services,13 and more general recommendations regarding integrated physical and behavioral health care.14-16
Research suggests that outcomes for clinic-based substance abuse treatment are similar to outcomes of treatment in more traditional settings.17 However, historic and legal constraints in the United States have, in general, discouraged physician involvement in substance abuse treatment. Drug treatment remains a relatively small part of the medical school curriculum,18 meaning that few physicians are adequately prepared to undertake office-based care.6,19 The training required for a DEA registration, and mentorship20 and other bup/nx educational opportunities, partially address inadequacies in preparation, however, additional information is needed regarding implementation processes relevant to the programatic and contextual aspects of office-based treatment. Just a small body of literature focuses on these latter considerations;6,15,16,19,21-25 few offer an empirically based or an HIV-focused perspective. In this article, we, therefore, attempt to partially address these gaps in the literature by describing practices utilized in the development and implementation of integrated HIV and bup/nx treatment from programs that participated in the Buprenorphine HIV Evaluation and Support (BHIVES) Collaborative. Our hope is that the information provided may promote effective translation of lessons learned and facilitate integration of bup/nx in other HIV clinical settings.
As described more fully in Weiss, et al,26 from 2004 to 2009, the HIV/AIDS Bureau of the Health Resources and Services Administration (HRSA) funded, through its Special Projects of National Significance (SPNS), the development of demonstration programs that integrated HIV care and bup/nx treatment for opioid dependence at 10 sites across the United States. HRSA also funded an Evaluation and Technical Assistance Center (the “Center”),26,27 which provided evaluation and clinical support to the demonstration programs and oversaw the development and implementation of a mixed-method multisite evaluation. Data from 9 of the 10 sites were included in the multisite evaluation reports, including this article.26
As per funding requirements, all programs developed through the BHIVES Initiative were implemented in clinical settings that (1) provided comprehensive medical and social services; and (2) served a primarily low-income patient population. Programs were required to provide bup/nx treatment on-site; beyond that they were allowed significant autonomy in the staffing and design of their integrated programs, so as to facilitate models of care that were consistent with institutional characteristics and that could be sustained following the grant period. Programs served patients dependent on heroin and/or prescription opioid analgesics and those wanting to, and appropriate for, transfer from methadone treatment.26 As a Ryan White-funded initiative, services were provided regardless of insurance status and ability to pay.
Interview Administration and Data Analysis
To ensure adequate documentation of implementation processes and to promote the translation of research findings into clinical practice,28 the evaluation included 2 visits by Center staff to each site, which were conducted at the start and conclusion of the initiative. The site visits included in-depth individual and group interviews with program staff and administrators. The visit protocol was approved by The New York Academy of Medicine Institutional Review Board, and all interviewees provided signed informed consent.
Recognizing the importance of “champions” to the success of any new initiative,29,30 we focus in this article primarily on the final site visit interviews conducted with the site Principle Investigators (PIs)-the individuals with ultimate responsibility for development, promotion, and oversight of the integrated care programs. Additional data, which complemented the PI interviews, came from the other individual and group interviews, discussions with program staff conducted over the full course of the initiative, and written documentation of lessons learned from one of the funded sites (L.B. Bazerman, MS, personal communication, 2010).31
PI interviews ranged from 60 to 90 minutes. They were conducted by 2 Center staff, using semistructured guides (Table 1, for interview topics). Each of the PI interviews was audio recorded, professionally transcribed, and coded according to pre-identified themes, and to themes emerging from the data themselves. The process was consistent with standard analytic methods for qualitative research, which incorporate both inductive and deductive practices.31,32 NVivo (Version 8.0 QSR International, Doncaster, Australia), a software package for qualitative research, was used for maintenance, coding and retrieval of verbatim text. In recognition and respect for respondent expertise, verbatim quotations that illustrate and explicate salient themes are interspersed throughout the narrative. Abbreviated pseudonyms are used to preserve the confidentiality of interviewees while allowing the reader to track quotations from particular individuals.
As summarized in Table 2, BHIVES programs were implemented in hospital-based clinics (n = 6), community health centers (n = 4), and an HIV/AIDS Research Center, with general internal medicine physicians (n = 4), infectious disease (n = 3), psychiatry (n = 1), and family medicine (n = 1) in lead roles. Only 1 site had prior experience providing integrated bup/nx and HIV treatment; all others had a connection to a local bup/nx treatment expert who could serve as a mentor. The majority, but not the total, of patients were receiving HIV care at the participating sites before program enrollment.
Acceptability of Buprenorphine/Naloxone and Integrated Care
“Is it worth it? Absolutely. First and foremost, it expanded our capacity to take care of folks who were previously on the margins of engaging in health care. So, it ended up bringing in folks who haven't been previously engaged in HIV care, and it gave us tools to better take care of the ones who were engaged in some fashion, in our practices already, but not doing well from an addiction standpoint… it also had this spill-over effect of raising our awareness of addiction issues in general.” (Dr. A).
Virtually all staff who participated in the individual and group interviews-including PIs, other providers, and administrative personnel-expressed positive perceptions of integrated HIV and opioid dependence treatment and of bup/nx as a treatment for heroin and other opioid dependence. Although hurdles were identified (described in the Challenges section below), integrated care was perceived as an effective means to expand available treatment slots, facilitate rapid access to services, and provide substance abuse care within a framework consistent with HIV treatment philosophies (including, for example, provision of needed supportive services and a harm reduction approach). Comparing the delivery of substance abuse services before and following the integrated program, one physician commented:
“The medical provider would have had to take more time out of their schedule and then looked up a methadone clinic, or looked up a referral, or paged a substance abuse counselor - or had [the patient] sent to mental health, and then mental health [would have] paged substance abuse. And oftentimes a patient gets frustrated, and they leave. Now they're seeing [the bup/nx coordinator] within the hour. And she's going to be helping them. It may be bup, it may be methadone, it may be detox, but by that day, they are helped.” (Dr. B).
Implicit and explicit comparisons between integrated care and methadone programs were common, with physicians expressing their commitment to clinic-based services, which differed from the seemingly highly regulated and punitive framework of methadone.
Essential contributors to acceptance of the integrated care programs and to the high level of provider satisfaction, included the ease of bup/nx, relative to other prescribed medications-despite concerns and trepidation at the beginning. Ease was likely facilitated by local mentoring relationships required as a condition of the grant, and regular training and support offered through the BHIVES initiative.
“No matter how much you say, Oh my God, that is just so easy. Why are you being so resistant? (physicians) need to have that handholding upfront … they need a body, they need someone who can talk them through it, to get them from switching back into what I call defensive mode: “Oh, this is another drug.” They just need to see it happen and then, day three, these people are normal again. It's like, “Oh my God, they're nice.” (Dr. C).
Perceived medication effectiveness was also key to satisfaction: virtually all prescribing physicians were able to describe patients-including some whose problems had seemed intractable-that experienced significant improvement in health and functioning, facilitating reengagement with family, school, work, and HIV care. According to 1 physician:
“We've had people who used 2 bundles, 20 bags [of heroin] a day, and get on bup. All of us would say, “Oh my God, they're never going to make it on bup.” But if they're motivated and they get themselves together, they make it.” (Dr. D).
Design of Integrated Care Programs
As noted above, in the United States, only physicians with an appropriate DEA registration are permitted to prescribe bup/nx. Integrated care thus requires, at a minimum, the participation of one physician with a DEA registration. For programs participating in the BHIVES initiative, multiple prescribers were necessary to ensure sufficient coverage: the number varied between 2 and 5 according to patient census and program characteristics. As described in detail below, a nonphysician “bup/nx coordinator” was also considered necessary to provide the counseling, case management, outreach, and other supportive services that facilitate optimal treatment outcomes.
Among participating programs, there was variability in the process for “integration,” ranging from integration at the clinic level (HIV and bup/nx treatment provided by different physicians colocated within a single care setting) to integration at the physician level (HIV and bup/nx treatment both provided by a single physician). The latter model was limited to certain community health centers with full time physician staff. It was considered unrealistic at hospital-based clinics within academic medical centers, where physicians tended toward very focused specializations and were present in the HIV clinic for a limited time each week.
“[For induction], we have to assess the patient, give them the prescription, they go down [to the pharmacy], get the medication, and bring it on up. So on the first days, you're often dealing with 1 or 2 visits, and then that first week, you're dealing with 3-5 visits and then 2 visits after that. So it's just so many visits that it's just hard.” (Dr. E).
“It's just the kind of place where everybody's sort of a subspecialist. So, you want to see a kidney doctor, you can see one in our HIV clinic, you want to see a nutritionist, you want to see a psychiatrist-all these people come right into the HIV clinic. But we don't try to make every doctor become a kidney doctor, a psychiatrist, a neurologist, a substance abuse person.” (Dr. F).
Clinic-level integration implied a “specialist” model of bup/nx treatment, whereby a limited number of physicians oversaw drug treatment for all bup/nx patients. At most sites using a bup/nx specialist model, the specialist was responsible for all phases of bup/nx care. In limited instances, the specialist was only responsible for induction, stabilization, and other relatively challenging phases of treatment, and the primary care provider had responsibility for bup/nx maintenance. Bup/nx physician “specialists” were drawn from psychiatry, addiction medicine, and HIV medicine (including both general internal medicine, infectious disease, and family practice). Some involvement from psychiatry and/or addiction medicine in bup/nx care was seen as advantageous, due to the high prevalence of multisubstance use and complex mental health comorbidities among the patient populations in the participating programs.
The model used least was one that assumed that all physicians would provide bup/nx treatment for their own opioid-dependent patients. Throughout the 5 years of the initiative, diffusion to “all” physicians proved elusive at most sites, despite the fact that the majority of physicians who prescribed bup/nx found it much easier to use than anticipated. It should be noted that patients seemed to be accepting of the specialist model of bup/nx treatment,33 which may reflect the significant role of a bup/nx coordinator in service delivery and care-or, alternatively, lack of perspective regarding alternatives.
Role and Responsibilities of the Buprenorphine/Naloxone Coordinator
All the sites participating in the BHIVES initiative felt that they had “complicated” patients, with significant comorbidities and multiple psychosocial issues. This perception was supported by the assessment data collected through baseline and follow-up surveys, which indicated high rates of poverty, incarceration, homelessness, multisubstance use, and mental health disorders.34 To address these significant patient needs, each site developed systems within which a nonphysician provider, referred to here as a “bup/nx coordinator” offered counseling and case management services, and acted as liaison between the HIV provider, the bup/nx provider, and the patient. At some sites, the bup/nx coordinator also did outreach and case finding; at other sites, a separate outreach worker was hired. Bup/nx coordinators were the “face” and the “glue” of the program to providers, staff, and patients alike. They were also helpful in responding to urgent requests during and outside of regular office hours. Physicians were consistent in acknowledging that, given their HIV and bup/nx caseloads, they would be unable to provide the level of supportive services that the bup/nx coordinators were offering and that was deemed necessary to patients, particularly at the start of bup/nx treatment.
“And for our patients, you know, maybe their biggest priority is trying to stay dry at night [sleeping] under [a] bridge or maybe they're hungry. And that's just got to take precedence over them keeping their appointment with me. And so our substance abuse counselor views that as part of her role … I think they really benefit from closer follow-up than I could give them, like phone contacts and those sorts of things, and in person with their counselor, and addressing some of the mental health issues that I just can't get to in a 25-minute visit.” (Dr. A).
Within the BHIVES initiative, bup/nx coordinators came from a range of disciplines and had a variety of credentials, including: licensed practical nurse, registered nurse, nurse practitioner, certified substance abuse counselor, health educator, and pharmacist. The variety reflected a combination of site-level priorities and pre-existing staffing configurations and skills, as several sites successfully transitioned current staff into the coordinator role. Experience with a substance using population was considered essential; beyond that, most of the physicians interviewed emphasized interpersonal, organizational, and intellectual skills rather than a specific profession or training:
“They have to have some familiarity with the drug. But I think what they really have to have is the ability to listen to the patients, to talk to the patients and then the willingness to go out and find people where they're at.” (Dr. G).
“It's more like somebody to … stay on top of what's going on with the patients and then to actually work with them-that has the experience and training to know how to work with substance abusers and counsel them individually and run a group, for example. I think those are, by far, the more important components of the job.” (Dr. F).
As described previously, the range of job responsibilities incorporated into the bup/nx coordinator position undoubtedly extended beyond any particular field, thereby precluding a “natural fit” with respect to training or credentials. A significant minority of respondents felt that a clinical background (nursing or pharmacy) was necessary to assess withdrawal symptoms before and during induction, for adjustments to bup/nx doses, and to assist with somatic complaints. It was also suggested that having a nurse in the coordinator position gave the role and the service the credibility, from the perspective of both patients and other providers, desirable at the start of a new program. Finally, there was a concern that policies at some HIV clinics would require individuals with significant involvement in bup/nx induction to hold a nursing or pharmacy degree, due to the clinical aspects of the work. It should be noted that independent of credentials, bpn/nx coordinators were closely supervised by prescribing physicians and mental health professions and received training on a range of topics including chemical dependency, motivational interviewing, criminal justice, pain management and addiction, and prescription and street drug use.
Challenges to Integrated Treatment
“Successful treatment is not just, ‘Oh, you're not using heroin anymore.’ Successful treatment is that you've gotten a job, and you've gotten housing again, and you're back with your husband, and you're taking your antiretrovirals, and you're taking your antidepressants. Because the opioid-negative urine is just an indication that they're not using drugs. But then the rest of their lives can be a total mess and then they're just going to cycle back into drug use.” (Dr. H).
Physicians interviewed had vast experience providing HIV treatment or psychiatric care to substance users and had commonly addressed substance use and its implications in consultations with patients before the start of the program. Very few, however, had previously attempted to treat drug use directly. Providers found that there was a group of patients for whom integrated care was clearly not effective. Patients with special needs, including those with the most chaotic lives and those with cognitive impairments, were generally thought to be better suited to methadone programs. Most commonly, preference for referral to methadone was attributed to program services rather than to the medication itself. According to one physician:
“Somebody's got uncontrolled schizophrenia, opiates, benzos, homeless and about to be incarcerated-I would say they don't necessarily need the pharmacology of [methadone], they just need the structure of a program that I can't provide.” (Dr. I).
Even for patients considered to be appropriate for integrated care, physicians and bup/nx coordinators interviewed emphasized that bup/nx was not a “magic bullet” and that outcomes fluctuated over time.
“When I just started off on this, I was under the impression that we would do our outreach, enroll patients, they get the intervention, and stay in the intervention or not, and that would be that. When in fact, what's happened, is reflective of the dynamic nature of addiction. People are in care, they're out of care, they're doing well, they're having a little relapse and I need to track them down.” (Dr. A).
Multisubstance use and the multiple psychosocial issues that had been masked by opioid dependence were among the greatest challenges faced by providers, limiting the effectiveness of available services.
“Treating the substance abuse is basically just opening the [door] to all the other sorts of problems that are going on with these folks. We've unmasked probably 3 cases of bipolar disorder that I recall that were wild.” (Dr. C).
Multisubstance use was the norm among BHIVES patients,34,35 and the absence of readily available and effective treatments for cocaine and other stimulants resulted in significant frustration for providers. Most programs attempted to partially address multisubstance use through the integrated program, either with counseling or by requiring more frequent visits for bup/nx prescriptions when continuing drug use was evident. Some programs referred patients with persistent cocaine or stimulant use to community-based drug treatment programs or self-help groups.
Staff and Collaborator Preconceptions
Although physicians and staff of the integrated programs were, as noted above, enthusiastic about program success, buy-in from other providers was necessary for identification and referral of an expanded patient pool. Physician referral of appropriate bup/nx treatment candidates was, however, variable. According to those interviewed, some colleagues were wary of addressing substance use at all, feeling that it was outside of their realm of expertise and responsibility. Others were willing to refer patients dependent on heroin to bup/nx treatment, but were hesitant to address problematic use of prescribed opioids, which could have been treated with bup/nx, as well. Provider ambivalence toward abuse of prescribed opioids was considered particularly difficult to affect, given both the predominance of harm reduction approaches within HIV prevention and care, and the years of provider experience observing often painful HIV deaths-with prescribed opioids providing valuable relief from suffering. An additional barrier to treatment for problematic prescribed opioid use was inadequate knowledge on the part of physicians regarding the relative advantage of bup/nx in cases of opioid dependence.36
At multiple sites, buy-in and support from administrative and other clinic staff was also a concern. There was evidence at some sites that substance-abuse services were stigmatized, despite recognition of widespread drug use among the patient population.
“We had this precipitated withdrawal, [and] we brought the patient back to this area we call the treatment room where we have a few stretchers … and this nurse, and I never would have expected it, but before we brought the patient back she said, ‘I just hate dealing with these kinds of patients.’ She works in the treatment room of the HIV clinic, she sees a lot of- but as soon as she heard it was somebody in withdrawal. And that sort of struck me that, if we were asking existing staff, if we came to them and said, ‘Hey, we got this new exciting thing, but you need to put in some effort on it’ I don't know exactly how well it would go over” (Dr. F).
Some sites also needed to do significant education with the community-based drug treatment providers to whom they regularly referred patients. For example, some residential drug treatment programs had not wanted to accept patients on bup/nx believing this violated their ‘drug-free’ policy.
Variable Approaches to Care
Finally, reconciliation of the perceived philosophical inconsistencies between HIV and addiction medicine practices represented an ongoing challenge.37 As noted at the outset, the majority of physicians participating in the BHIVES Initiative articulated approaches to care, whether it be harm reduction or patient-centered, that emphasized patient autonomy and a non-judgmental acceptance of a range of patient behaviors. Although they recognized that there are tradeoffs between practices that seek to optimize adherence and those that seek to optimize engagement and self-management, they tended toward the latter interests:
“We use these models [of chronic disease to teach] about patient management and education. It's important [for patients] to be able to manage their chronic illness. Like, why would [bup/nx] be different? So, that's our framework, and I think a lot of people don't have that framework, don't want that framework in their setting.” (Dr. D)
Standard practices of clinic-based opioid treatment, including urine toxicologies, medication reviews and medication contracts, were utilized, but-in aggregate-not at the frequency recommended in bup/nx guidelines.36,38 It should be noted that in certain locations, however, they came to be highly valued, and their use and impact extended significantly beyond the bup/nx program. In these locations, providers were able to see (and frame) these practices as non-punitive and as offering opportunities for initiating conversation, rather that dictating particular expectations.
“What we've done is had everybody do prescription contracts so that they know in advance, this is the policy, they're not being singled out, everybody does this, it's just part of safely prescribing this medication. And so we really haven't had very many refusals at all… Most people-I like to ask them-so what do you think this is going to show? And most people will just tell you straight up, amazing enough, and it's really opening this wonderful door for discussing what's' going on in their lives and how they're doing clinically from an addiction standpoint. One person, for example, was negative for their prescribed opiate and positive for cocaine. I confronted him with this, and he said, ‘Ever since I lost my job-I had been so good, but I relapsed on cocaine and I'm supplementing my income by selling my oxycodone.’ And obviously he didn't get his oxycodone refilled that day, but we were able to connect him with a social worker who was able to help him get resources that he qualified for, and plug him in for other things, and set up appointments with our substance abuse counselor to talk about cocaine, which was his more pressing issue.” (Dr. A).
“It's at least weekly initially, and then we move them out to 2 weeks and then monthly. So it's kind of a rollout. But it's a contingency management sort of approach. And I think that if you just give somebody a bottle of bupenorphine and don't have some kind of constraints with it initially, I think you're going to lose some. We lost a lot of people very early when we first did that, and we had to regroup and rethink.” (Dr. C).
Similarly, physicians noted that they learned that bup/nx need not be provided on an emergency or unconditional basis.
“In the beginning, we did coddle people a lot more…. The person would come in and say if I didn't start them on treatment today they were going to use heroin …. At some point, we realized, “What are we doing here? This is treatment. This is not crisis management, this is treatment. If you want treatment, come back for treatment. If you want a fix, we're not in that business.” …It took us a while to figure out what was going on and figure out how to address this and get this more widespread approach to bup not being an emergency, and really being thoughtful like other primary care illnesses.” (Dr. D).
In this article, we describe findings from qualitative interviews with physicians who served as site level PI's in BHIVES, an initiative that focused on integrating bup/nx treatment for opioid dependence into HIV care. Interviews were conducted by program evaluators in the final year of the initiative, to identify lessons learned that could facilitate the diffusion of integrated care to other HIV clinical sites. Interviewees reported that bup/nx represents a valued option for their opioid-dependent patients. Integrated care proved feasible and program design could be tailored, so as to be consistent with pre-existing setting and staff characteristics. A licensed and registered physician prescriber is required for integrated care, with at least one back-up prescriber to ensure adequate coverage. Based on the experience of programs participating in BHIVES, the prescriber's role may vary, ranging from the provision of integrated care for his or her own patients to a specialty service available to all clinic patients who are appropriate. Physicians participating in BHIVES programs reported that bup/nx treatment was easier than they anticipated.
At most sites, physicians that were not part of the grant-funded program were slow to take on bup/nx treatment; this hesitancy should be accounted for in program planning and design. The relatively slow diffusion of bup/nx may be attributed to limited need or continued reluctance on the part of many doctors to assume any responsibility for drug treatment. It may also be an artifact of the BHIVES sample, which included a large number of clinics with part time (as little as half a day per week) physician staff and specialized models of care.
Designated staff to conduct outreach, counseling, and case management, particularly for patients with complicated psychosocial issues and co-occurring disorders, was considered to be necessary for program retention and treatment success. For programs participating in BHIVES, grant funds were used to support staff positions to undertake these responsibilities.39 However, social workers, substance abuse counselors, health educators, case managers, and outreach workers, already employed in HIV clinics, might be able to do this work as well, particularly where volume is relatively low. The credentials of a bup/nx coordinator were considered secondary to personal characteristics, including familiarity with substance abuse issues; accessibility; communication skills; and ability to coordinate the patient's medical, psychosocial, and drug treatment services.
There are several limitations to the findings presented here. A relatively small number of programs were funded through the BHIVES initiative, and the majority of them were implemented in academic medical centers. The service delivery model in academic medical centers, with limited clinic time per physician, differs from that in other settings, which reduces the generalizability of findings. In addition, program services and activities, ranging from physician training to salary coverage for the bup/nx coordinator, were grant funded. Implementation of similar models without outside funding would likely yield different reported experiences. The fact that the participating sites successfully competed for grant funding for this service also suggests that there may be differences between the BHIVES sites and other HIV clinical sites, both with respect to motivation and baseline competencies. Finally, descriptions included here are based primarily on self-report elicited in semistructured qualitative interviews, with site level PI's. The perspectives of PI's as innovation “champions,”30 although highly informative, are not necessarily representative of others involved in the initiative or their colleagues that opted not to participate. Given the significant responsibility of the bup/nx coordinators, a careful analysis of their responses to interview questions may elucidate differing opinions regarding integration ease and bup/nx effectiveness from those reported here. In addition, the extent to which the interview format was appropriate for gathering all the data required and/or that interview responses suffered from social desirability and recall bias is unknown. Despite these limitations, this report represents the most comprehensive description of practices for integrating bup/nx into HIV care to date. In addition, (1) the multisite perspective, (2) the ongoing communication between evaluation and site staff over the full course of the initiative,26 and (3) the utilization of qualitative rather than survey data, facilitate a level of detail generally absent in research on barriers and facilitators to practice innovations. Although qualitative methods are often considered to be less reliable than quantitative approaches, when carried out using a systematic methodologies for data collection and analysis, they are very well suited to research focused on complex processes and that focus on perceptions and attitudes. Qualitative methods are appropriate for the “lessons learned” focus of this article, as they allow detailed descriptions of concerns and solutions, rather than mere counts.
The experience of the BHIVES initiative suggests that the integration of bup/nx treatment into HIV clinical settings is feasible and considered a valued addition to the range of services already being provided. Integration necessitates a number of programatic considerations including mechanisms for full-time coverage, for communication, and for the supportive services needed by patients. Processes for implementing those mechanisms and form of integration may be flexible, which allows for the development of integrated care in diverse HIV clinic settings.
We would like to express our appreciation to all the providers and staff who graciously agreed to host evaluation site visits and to participate in the individual and group interviews. We greatly appreciate their time, thoughtful responses, and candor. We are particularly grateful to the staff of the Miriam Hospital Center for sharing their own “lessons learned” document with us. We would also like to thank Evaluation Center and HRSA staff who participated in site visits and conducted interviews, Bruce Schackman, Marc Gourevitch, Patrick O'Connor, Jonathon Gass, and Michael Botsko (Evaluation Center), and Lois Eldred, Adan Cajina, Pamela Belton, and Katherine McElroy (HRSA). Finally, we would like to thank the reviewers for their insightful comments on an earlier draft of this article.
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APPENDIX 1: BHIVES COLLABORATIVE
The CORE Center (Chicago, IL), El Rio Santa Cruz Neighborhood Health Center (Tucson, AZ), Johns Hopkins University (Baltimore, MD), Miriam Hospital (Providence, RI), Montefiore Medical Center (Bronx, NY), OASIS, (Oakland, CA), Oregon Health Sciences University (Portland, OR), University of California San Francisco Positive Health Program at San Francisco General Hospital (San Francisco, CA), University of Miami Medical School (Miami, FL), Yale University School of Medicine (New Haven, CT), and The New York Academy of Medicine (New York, NY).