The structural and health policy environment for delivering integrated HIV and substance use disorder treatments in Puerto Rico.

BACKGROUND: HIV prevalence in Puerto Rico is nearly twice that of the mainland United States, a level that was substantially fueled by injection drug use. Puerto Rico has a longstanding history of health provision by the public sector that directly affects how HIV and substance use disorder (SUD) treatment services are provided and funded. As part of pre-implementation research for a randomized trial of a community-level intervention to enhance HIV care access for substance users in San Juan, Puerto Rico, we sought to understand the structural and health policy environment for providing HIV and SUD treatments. METHODS: We conducted semi-structured qualitative interviews (n = 8) with government and program administrators in English and Spanish. Data were analyzed to identify dominant and recurrent themes. RESULTS: Participants discussed how lack of integration among medical and mental health service providers, lack of public transportation, and turnover in appointed government officials were barriers to integrated HIV and SUD treatment. Federal funding for support services for HIV patients was a facilitator. The Affordable Care Act has limited impact in Puerto Rico because provisions related to health insurance reform do not apply to U.S. territories. DISCUSSION AND CONCLUSIONS: Implications for intervention design include the need to provide care coordination for services from multiple providers, who are often physically separated and working in different reimbursement systems, and the potential for mobile and patient transportation services to bridge these gaps. Continuous interaction with political leaders is needed to maintain current facilitators. These findings are relevant as the current economic crisis in Puerto Rico affects funding, and may be relevant for other settings with substance use-driven epidemics.

Metabolic syndrome in relation to cardiorespiratory fitness, active and sedentary behavior in HIV+ Hispanics with and without lipodystrophy.

OBJECTIVE: Hispanics in Puerto Rico (PR) have a high prevalence of metabolic syndrome (met-syn), partially explained by low physical activity (PA) and possibly low cardiorespiratory fitness (VO2peak). Met-syn is also associated with lipodystrophy in HIV infected (HIV+) adults taking antiretroviral therapies. However, associations between met-syn, VO2peak, PA, sedentary behavior and lipodystrophy among HIV+ Hispanics have not been adequately reported. We tested the following hypotheses: 1) HIV+ Hispanics with lipodystrophy (HIV-Lipo) would have a higher prevalence of met-syn, lower VO2peak and PA, and higher sedentary behavior compared with those without lipodystrophy (HIV-no-Lipo) and without HIV infection (Non-HIV); and 2) met-syn would be inversely associated with VO2peak and PA, and directly associated with sedentary behavior. METHODS: Ninety Hispanic adults (32 HIV-Lipo, 28 HIV-no-Lipo, 30 Non-HIV) completed measurements of VO2,peak, anthropometry, PA and sedentary behavior with accelerometry, blood pressure, fasting glucose, insulin, and lipids. ANOVA and chi-square tests were used to detect differences between groups, and regression analyses to test associations between variables. RESULTS: More HIV-Lipo (69%) had met-syn compared with HIV-no-Lipo (39%) and Non-HIV (37%) (P = 0.002). Sedentary behavior and PA were not different, but VO2peak differed between all groups: lowest in HIV-Lipo and highest in non-HIV. PA and sedentary behavior were not associated with met-syn, but PA was directly associated with VO2peak (R2 = 0.26, p < 0.01). Also, a lower odds ratio for met-syn was observed with higher VO2peak (0.87; 95% CI: 0.83-0.95). CONCLUSION: Met-syn is related to lipodystrophy in HIV+ Hispanics in PR, and high VO2peak may protect against met-syn in this population.

Physical and leisure activity, body composition, and life satisfaction in HIV-positive Hispanics in Puerto Rico.

Hispanics represent 13% of the U.S. population but account for 19% of the new AIDS cases reported in 2000. The antiretroviral drug therapy used for the treatment of HIV/AIDS may cause lipodystrophy and insulin resistance, among other effects. Physical and leisure activities reduce these effects and improve the emotional and physical well-being of HIV-positive persons. This study describes physical and leisure activities, life satisfaction, depression, and body composition of HIV-positive Hispanics in Puerto Rico and compares body composition, CD4 counts, depression, leisure time, and life satisfaction of participants classified as physically active or inactive. Sixty-eight individuals were evaluated using questionnaires and biophysical measurements. Descriptive statistics and independent t tests were used for data analysis. Physically active participants had higher life satisfaction scores and healthier body composition as compared to those physically inactive. Health professionals must encourage the promotion of a physically active lifestyle among HIV-positive Hispanics.