Barriers and facilitators to implementing electronic patient reported outcome screening for mental illness and substance use disorders at HIV clinics in Alabama: a qualitative study

People living with HIV face disproportionately high rates of mental health issues (MH) and substance use disorders (SUD), which can contribute to reduced antiretroviral treatment (ART) adherence. When left untreated, these psychosocial comorbidities pose an additional threat to the goals of the Ending HIV Epidemic Initiative, which aims to optimize HIV outcomes in states like Alabama, where the rural burden of HIV is among the highest in the nation. Fortunately, electronic patient reported outcome measures (ePROs) are effective in screening for MH and SUD in a wide variety of care settings, facilitating early referrals to evidence-based interventions. In this study, we use the Consolidated Framework for Implementation Research (CFIR) to identify barriers and facilitators to the implementation of depression, anxiety, and SUD ePROs in HIV clinics in Alabama, an Ending the HIV Epidemic Priority Jurisdiction. We interviewed 15 clinical and non-clinical staff at five Ryan White HIV/AIDS Program (RWHP) funded HIV clinics in Alabama. We queried their experiences with an ePRO intervention starting in 2022. We used a rapid analysis technique to explore themes related to the Characteristics of Individuals, Process, Characteristics of Innovation, and Inner Setting domains of CFIR. Two experienced qualitative researchers conducted the semi-structured interviews and iteratively analyzed the transcripts. We identified a variety of barriers and facilitators to implementation of MH and SUD ePROs in HIV clinics that fell under all four included domains. Participants reported significant staff turnover and/or limited staff capacity as primary barriers to consistent implementation. Sites also reported the lack of ongoing training and onboarding at the site level as a barrier that further impeded capacity and understanding. Positively, though, participants also reported that the intervention enhanced patient-provider communication and increased the rate of MH and SUD identification. Having a site champion as the primary point of contact, both internally and externally to the investigation team, was a key facilitator. The champions also increased team motivation and kept the intervention on track. Tablets were key to the intervention, enabling automatic results of ePROs. Despite numerous barriers, such as staff turnover, participants found the intervention to be easy to use, brief, and effective. This success was largely attributed to several facilitating factors, such as the use of tablets and the support of site champions.