Table 2 Themes and subthemes that addressed barriers to and facilitators of engagement in care for HIV+ substance users

Linkage to care

 Barriers to linkage to care

  Denial of HIV diagnosis

8

“When I first found out, I was in denial like crazy. I wasn’t trying to hear it, you know, because I’m saying how can I, how could it be me….Yes, I used more often, it’s like that’s all I lived for was to get high”—female, age 47

  Inevitability of death from HIV

11

“For me, I actually tried to run away again and I didn’t see [my doctor] for a while. I ran back into the streets because I found out, oh I had the bug of life, you know, my death is coming soon and everything. I wanted to escape, I ran away from home again…It did nothing for me, the shit was in me, it’s going to take me eventually”—male, age 33

 Facilitators of linkage to care

  Illness/disease progression

8

“…they told me what my CD4 count was. And they said I was AIDS defined. And the doctor asked me did I want to die. I told him, no, I didn’t want to die… And that’s when I decided to get on the meds. From them telling me that I could die from it”—male, age 55

Retention in care

 Prioritization of drug use over HIV treatment

13

“When I drugged I ain’t gonna take my medicine right… I don’t want to do anything but get high. The way I was using, when I use, I would use”—female, age 51

 Forgetting to take medication

10

“… when I’m high, I’ll forget. That’s put as simple as I can… I’m chasing the drug. I’m not thinking about my health.”—male, age 28

 Side effects of medication

6

“…He would give me the medicine but I wouldn’t take it. And I was thinking like I knew a lot of people that had HIV too… when they wasn’t taking the medicine, they was fine, but as soon as they started taking the medicine, like they were dying like flies. So I figured I ain’t taking that medicine. I ain’t messing with that.”—female, age 42

Reengagement in care

 Illness/disease progression

8

“…, but I tried my best in spite of that to stay somewhat compliant with those pills, you know. I didn’t want to get sick, so I took them”—male, age 48

 Ritual associated with medication

9

“At one point it used to make miss doses because I would be getting high. You know if I’m getting high, I wouldn’t think about taking my medication but now, you know, it’s like a program. Every time I eat a meal in the daytime and the evening time, I take my medication along with my meal so. As long as I eat two meals a day, I’m going to take my medication”—male, age 59

 Positive provider-patient relationship

15

“… if there was something that she didn’t like that I’ve done, as far as taking my medication, she would argue with me and I wouldn’t have no problem with her doing that because she was right and I was wrong. That made me feel like she cared. So that’s how it was with me”—female, age 54