Substance Use Disorders Among Young People Living with HIV in Sub-Saharan Africa: Insights from a Cohort Study in Ghana

Joseph C. Ikewere¹, Rodney Eiger², Brady Heward³, Ruth Owusu-Antwi⁴, Vivien Obilutala-Ugwu⁵, Olasumbo Elizabeth Fabgenle¹, Afolarin Ishola¹, Anthony Kwame Enim¹, John-Paul Omuojine⁵, Charles Martyns-Dickens⁵, Oluwole Jegede⁴, Adeolu Funso Oladunjoye⁷, Dennis Bosomtwe⁶, Ikponmwonso Jude Ogieh⁸, Victory Aghogho Emojiewe⁹, Adetola Emmanuel Babalola¹⁰, Victor Oluwatomiwa Ajekigbe¹¹

ABSTRACT

Background: Substance use disorders are a growing public health concern, especially among adolescents and young people, as they are disproportionately affected. In sub-Saharan Africa, the estimated overall prevalence of substance use disorders is 41.6%. Substance use disorders lead to challenges among young people living with HIV, including reduced adherence to antiretroviral therapy, increased health complications, and increased risk of HIV transmission. Hence, this study aimed to evaluate the patterns and prevalence of substance use disorders among young people living with HIV and their HIV-negative relatives in Ghana.

Methods: This was a cohort observational study where the study participants were organized into two arms: Case and Control. The infected population was recruited from the Komfo Anokye Teaching Hospital (KATH) in Kumasi, Ghana, and their HIV-negative close relatives who are aware of the HIV status of the young people living with HIV. 196 participants were based on convenience recruitment and organized into two groups in equal distribution: young people living with HIV (Case) and HIV-negative relatives (Control). Data was collected between October 22, 2021 and November 14, 2021, using the World Health Organization (WHO)-validated Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) version 3.0. Inferential and descriptive analyses were done using IBM SPSS 27.0, where significance was set as p < 0.05.

Results: Females accounted for 53.57% of the total sample (n = 105) and were between 12 and 24 years old (n = 77; 39.29%). Alcohol was the most reported substance used (n = 46; 23.47%), with 24 controls and 22 cases. Participants in the case group showed high adherence to ART but reported tensions where substance use has impacted their responsibilities. Substance use disorders were found to be generally higher among controls, as they were generally more aware of substance use.

Conclusion: The prevalence of substance use disorders was higher in the HIV-negative close relatives of young people living with HIV. This could be a result of regular counselling received by the young people living with HIV. Efforts should be made to integrate substance use prevention counselling for both young people living with HIV and their close contacts to reduce the burden of substance use disorders.

Keywords: HIV; Substance Use; Ghana; Africa; Psychiatry; ART

1. Introduction

Substance Use Disorder (SUD) is defined by the lack of control over substance abuse, leading to a negative impact on behaviour, emotional reactions and interpersonal relationships. This can be detrimental to health as it can result in poor physical and mental health as well as chronic diseases such as cardiovascular diseases, liver diseases and depression. SUDs are a public health concern and have a significantly higher prevalence in Africa compared to other regions. The estimated overall prevalence of SUDs among adolescents in sub-Saharan Africa is 41.6%, with alcohol and tobacco being the most commonly used substances, reported at prevalence rates of 32.8% and 23.5%, respectively. Despite the serious health risks associated with SUDs, access to appropriate treatment and rehabilitation services remains limited in many parts of sub-Saharan Africa, further exacerbating these issues. This highlights the urgency in the need to address SUDs among young people living with HIV, including reduced adherence to antiretroviral therapy, increased health complications, and increased HIV transmission risk.

Globally, about 40 million people are living with HIV as of 2024, and more than half of this population (26 million) are in the African region. Notably, adolescent girls and young women aged 15-24 years represented 63% of all new HIV infections in 2021. Young people living with HIV (YPLWH) face several challenges, including financial barriers, stigma, discrimination as well as difficulties in disclosure of their status stemming from lack of trust and confidence. Studies show a high prevalence between substance use and YPLWH due to increased distress and other factors.

Studies have found numerous factors associated with SUD among YPLWH, such as male sex, employment status, unstable housing, identifiable viral load, and psychiatric symptoms, amongst others. Substance use among this population is also moderated by several variables, including socioeconomic status, criminal justice participation, and mental health disorders. Moreover, the co-occurrence of substance use, mental health challenges, and HIV-related stigma can lead to a cycle of worsening health outcomes, making it even harder for affected individuals to seek support and adhere to treatment.

Ghana is a sub-Saharan African country with a high HIV burden among adolescents and youths. Studying the moderators of SUD among this population is crucial as this age group faces some challenges, such as peer pressure and mental health issues. Hence, this study aims to elucidate the prevalence, patterns and moderators of substance use disorder among a cohort of YPLWH and their HIV-negative close relatives from a Ghanaian clinic. Identifying the patterns and moderators of SUDs in this vulnerable population can result in tailored and more effective interventions, leading to a better HIV treatment outcome.

2. Methods

2.1 STUDY DESIGN

This study was a cohort observational study where the study participants were organized into two arms: Case and Control. The infected population was recruited from the HIV clinic located at the Komfo Anokye Teaching Hospital (KATH) in Kumasi, Ghana. Eligible participants were asked to identify young family members or close associates who were aware of their HIV status. These individuals were invited to participate in the study, during which they were asked if they felt comfortable undergoing HIV testing, sharing their experiences. These individuals were HIV-negative and were believed to have faced psychosocial and/or economic burdens similar to those of the infected group. Their inclusion enabled comparisons regarding exposure to substance use disorder and other factors.

2.2 STUDY POPULATION

The study included young individuals aged 12 to 24 years residing in Kumasi comprising YPLWH and Young People Affected by HIV (YPAH). The YPLWH (case) consisted of individuals aware of their HIV status receiving treatment at the Komfo Anokye Teaching Hospital (KATH) Adolescent and Young Adult HIV Clinic. These participants represented a diverse group, including those infected during adolescence and those infected as infants who had survived with the support of antiretroviral therapies (ART). On the other hand, the YPAH (control) involved family members or close associates of the infected participants who were aware of the HIV-positive status of their peers and were willing to undergo HIV testing and share their experiences. The study team engaged these individuals based on established inclusion and exclusion criteria, followed by obtaining consent for recruitment.

2.3 ELIGIBILITY AND EXCLUSION CRITERIA

2.3.1 Inclusion Criteria

The inclusion criteria were young people aged 12 to 24 years who have been diagnosed and living with HIV infection, as well as close associates or family members who are aware of their HIV status. These individuals were willing to participate in the study, were included in our study. Finally, only participants who fulfilled the aforementioned criteria and showed willingness to provide written consent and, where applicable, assent were involved in our study.

2.3.2 Exclusion Criteria

Our study excluded individuals with advanced medical conditions that impair their cognitive ability to provide informed consent and who showed an unwillingness to participate in the consent process.

2.4 STUDY SITE

The study was conducted at Komfo Anokye Teaching Hospital (KATH) in Kumasi, a 1,200-bed facility and the second-largest teaching hospital in Ghana. The hospital serves approximately 4 million people in the Ashanti Region and is affiliated with the Kwame Nkrumah University of Science and Technology (KNUST). KATH’s HIV clinic provides care to approximately 430 adolescent patients annually and is a referral centre for multiple regions across Ghana.

2.5 DATA INSTRUMENT

Quantitative data was collected between 22nd October 2021 and 14th November 2021 using the WHO-validated Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) version 3.0. The sociodemographic information of the participants, which included the age at study entry, gender, sex orientation, education level, number of siblings, HIV status, and treatment type, was also collected.

The ASSIST version 3.0 is an 8-item standardized tool developed by the WHO to assess substance use over the last 3 months. It is suitable for commonly used substances, including tobacco products, alcohol, cannabis, inhalants, opioids, cocaine and others. The ASSIST tool gathers information from individuals regarding their lifetime substance use, as well as substance use and related issues in the past three months. It can extract various substance use behaviours, including tobacco products, alcohol, cannabis, inhalants, opioids, cocaine and others. The tool categorizes the substance use into one of three categories: ‘low (0-3) or (0-10 for alcohol), ‘moderate (4-26) or (11-26 for alcohol),’ or ‘high’ (27+). These categories guide the appropriate response, ranging from ‘no treatment’ for low risk to ‘brief intervention’ for moderate risk and ‘referral to specialist assessment and treatment’ for high risk. Scoring is calculated by summing the responses to questions 2 through 7, while question 8 is excluded from the specific substance involvement score. However, injecting behaviour (addressed in question 8) is recognized as a significant high-risk activity. It is strongly associated with an increased risk of overdose, dependence, bloodborne infections such as HIV and hepatitis C, and other severe drug-related complications.

2.6 STUDY PROCEDURES

The case group was first recruited during routine HIV clinic visits at KATH. Medical records were reviewed to identify eligible participants. Once eligibility was confirmed, participants were asked to identify two family members or close associates for potential recruitment. After obtaining consent, participants completed the questionnaire for 20–30 minutes. The control group, close associates or family members nominated by the infected participants were approached and informed about the study. After consenting, they underwent HIV testing to confirm their negative status. Eligible individuals, such as the infected group, completed the survey. In cases where the first nominee declined or tested positive, the second nominee was considered for recruitment. For participants aged 12, assent and parental consent were obtained, covering the exact details. Recruitment and engagement occurred during routine clinic visits, with materials available in English and optionally translated into Twi. A unique number was assigned to each participant for easy identification throughout the study period.

2.7 SAMPLE SIZE AND SAMPLING

A mixed sampling approach was employed. Purposive sampling was the main method used to select the study participants.

2.8 STATISTICAL ANALYSIS

The data were first scored and cleaned with Microsoft Excel and analysed using IBM SPSS v. 27.0 (IBM Corp, Version 25.0, and Armonk, NY, USA). Descriptive statistics summarized the demographic and outcome measures. A regression model was developed to test several potential moderators, such as age, gender, socioeconomic status, and HIV-related factors, to see how they affect the relationship between risk factors and the severity of SUD. The analysis looked at the main effects of these moderators and how they interacted with the primary predictors, providing a clearer understanding of how these factors influence SUD outcomes in this group. The results revealed which variables significantly changed the strength or direction of the relationship between the predictors.

2.9 ETHICAL CONSIDERATIONS

Ethical approval with reference No: KATH IRB/RR/096/21 was obtained from the Institutional Review Board at KATH. All participants provided informed consent or assent where applicable. The study adhered to ethical guidelines, ensuring confidentiality and offering support services for participants diagnosed with HIV during the study process.

3. Results

A total of 196 respondents participated in the study. Table 1 presents the background characteristics of the study respondents.

Assessing the ARV medication intake among the cases, Lamivudine (3TC) was reported as the most frequently used (24%). The next most frequently used were Dolutegravir (DTG), used in 20 cases (10.2%), and Tenofovir Disoproxil Fumarate (TDF), used in 15 cases (7.65%). Zidovudine (AZT), Abacavir (ABC) and Efavirenz (EFV) were reported to be used in 11 cases (5.61%), 4 cases (5.61%), and 4 cases (2.04%). Only 3 cases (1.53%) reported the use of Lopinavir/ritonavir (LPV/r). Most respondents (92 cases, 93.88%) reported adhering to their ARV medication.

Table 2 shows the lifetime substance use among respondents. Alcohol was the most (46 (23.47%)) reported substance being used with 24 controls and 22 cases. For tobacco, hallucinogens and opioids, 8 (4.08%) positive responses were each reported. Of the 8 positive responses, 7 (87.5%) were in the control group, and 1 (12.5%) were in the case group. None of the respondents in the case group reported taking cocaine or inhalant, although 7 (100) respondents in control reported usage.

The frequency of substance usage among respondents during the previous three months is shown in Table 3. For tobacco use, all the respondents (7 (100%)) in the control group reported having never taken tobacco in the last three months, while one case group participant (12.5% of total tobacco users) reported monthly use. For alcohol use, 18 (39.13%) respondents reported consuming alcohol once or twice, with an even share between the control and case groups. Regarding sedative use, 8 (88.89%) respondents had not used sedatives in the last 3 months, with 7 (87.5%) and 1 (12.5%) respondents in the control and case groups, respectively.

Table 4 shows the frequency of respondents’ urge and desire to take substances. For tobacco use, 26 (92.86%) respondents reported that they never had the urge to use. Amongst them, 10 (38.46%) were from the control group. Within the case group, 2 (100%) respondents reported having the urge once or twice. Regarding alcohol, 17 (62.96%) respondents reported not having the urge to use it, with the case group accounting for 7 (58.82%). Of those who felt the urge, 8 (29.63%) reported experiencing it once or twice. Among the respondents, 1 (3.57%) reported having the urge once or twice, and another 1 (3.57%) weekly, all from the case group. Overall, across all the substances, almost all the respondents under the control group who responded reported never feeling the desire or urge to use.

The health, social, legal or financial problems caused by substance use among the respondents are presented in Table 5. In the case group, 4 (30.77%) respondents reported that they had gotten into a health, social, legal or financial problem once or twice as a result of alcohol use. Among the respondents who used substances, 2 (12.50%) participants in the case group reported that once or twice, they had gotten into a problem. All participants in the control group who responded to this question reported that they had never gotten into any problem as a result of any substance use.

Table 6 represents the impact of drug use on participants’ ability to fulfil their usual responsibilities in the last three months. Only 1 (4.17%) respondent reported that tobacco intake had impeded him from fulfilling his usual responsibility once or twice in the last three months. Among the respondents who use substances, 2 (7.41%) respondents reported that their use of alcohol has impeded them from fulfilling their responsibilities once or twice in the last three months. 24 (95.83%) respondents, with 8 (34.78%) from the control and 15 (65.22%) respondents from the case group, reported that their use of cannabis has never stopped them from fulfilling their responsibilities.

Table 7 presents the frequency with which users’ relatives and friends have expressed concerns over their substance use. In the past 3 months, 1 (12.50%) of the tobacco respondents reported a show of concern. While 8 (80.00%) respondents who use cannabis reported that their relatives or friends have never shown concern, 1 (10.00%) reported a show of concern, and another 1 (10.00%) reported a show of concern but not in the last three months. Cocaine, amphetamine and other substances showed uniform responses, with 100.00% of both groups reporting no expressed concerns.

Participant attempts to control, cut down or stop using substances in the last three months are shown in Table 8. For tobacco, only 1 (12.50%) of the respondents reported attempts to control, cut down, or stop substance use in the last three months. For amphetamine, inhalants, sedatives, hallucinogens, and opioids, 6 (42.86%), 11 (39.29%), 2 (22.22%), 1 (12.50%) and 1 (12.5%) respondents all in the case group reported that they have never attempted to control, cut down, or stop substance use in the last three months.

4. Discussion

This study explores important insights into substance use disorders amongst young people living with HIV in Kumasi, Ghana. The findings from the study evaluate the prevalence of substance use disorders and identify specific factors associated with this challenge. Most of our participants were females, which is different from Ludwig et al.’s study, which had a higher number of male respondents. There was an almost equal distribution between the sociodemographic characteristics among the cases and the control. The mean age of 16.50 years in the case group is close to the 15.53 years found in the HIV/STD high-risk group found in incarcerated adolescents in Florida.

In this present study, there was a higher prevalence of substance use among the control group. However, the study conducted by Stephanie et al. showed that those living with HIV had higher substance use prevalence. Concurrent with the findings from this study, the prevalence of substance use among the case group was relatively low. Multiple studies have reported alcohol to be the most frequently abused substance, which is also consistent with our findings, which report that about one in four adolescents (23.47%) have a lifetime history of alcohol use. Interestingly, most of the respondents in the control group engaged in alcohol, tobacco and sedative use. This may be because individuals with HIV are likely to receive more counselling and education from regular clinic appointments and, hence, may take more precautions. This may also be corroborated by their lack of urge to use substances and their reported adherence to ARV medications.

The prevalence of substance use in the preceding three months was higher for alcohol consumption when compared to tobacco or sedative use. Also, participants who engaged in substance use amongst those living with HIV reported higher signs of addiction as they reported being unable to fulfil essential responsibilities, although, generally, most of the respondents reported little difficulty with completing their daily activities.

This is consistent with the findings from Starks et al., who reported similar patterns of drug use and associations with mental health amongst adolescents and young adults with HIV. While our study focused only on quantitative analyses, the study by Starks et al. goes ahead and includes qualitative descriptions.

5. Limitations of the Study

While the study provides valuable insights into the complex relationships between substance use disorders, HIV, and various demographic, behavioural, and lifestyle factors, it is essential to acknowledge that the findings do not apply to the specific context and demographics of the study participants. For instance, the focus on young people living with HIV in Ghana is not representative of other Sub-Saharan African countries with different cultural, socioeconomic, and healthcare contexts.

The study relied on self-reported data, which may introduce bias and inaccuracies, such as under-reporting of substance use and over-reporting their adherence to treatment. This shows the negative impact that can be caused with engaging in substance misuse as also consistent with the epidemiological analysis of substance use disorders by Onaoluwapo et al. Interestingly, most of the participants who engaged in cannabis use did not have their relatives’ raising highbrows compared to those who engaged in tobacco. This may be because participants who smoke cannabis may tend to be more secretive with their dealings when compared to tobacco which is more socially acceptable.

Overall, one of the strengths of this study is the identification of controls within the study population, which helped provide detailed comparison models. Our utilization of data from a single centre may limit generalization, although the reports from our study have been consistent with those of previous studies. The findings from our study have critical implications for substance use in adolescent care, especially for those living with HIV. In addition, targeted interventions should be provided in terms of prevention, early recognition and prompt treatment of people with addiction especially the young people who are more at risk of substance use disorder.

6. Recommendations

Conduct longitudinal studies to examine the temporal relationships between substance use disorders, HIV, and other variables. Design and implement intervention studies to evaluate the effectiveness of various strategies in preventing and treating substance use disorders among young people living with HIV. Conduct qualitative research to gain a deeper understanding of the experiences and perspectives of young people living with HIV.

Some policy interventions, such as the implementation of integrated care models, address both HIV and substance use disorders simultaneously. Increase screening and diagnosis of substance use disorders among young people living with HIV. The use of evidence-based interventions, such as cognitive-behavioural therapy and medication-assisted treatment, to address substance use disorders.

The introduction of stigma reduction interventions and the social and structural barriers that prevent young people living with HIV from accessing interventions that address substance use among YPLWH. Collaboration among stakeholders—healthcare providers, educators, policymakers, and community leaders—is essential to create sustainable, evidence-based solutions. By addressing substance use holistically, we can improve the overall well-being of YPLWH and pave the way for a healthier future. Finally, by investing in tailored interventions, we can improve health outcomes, enhance quality of life, and promote the long-term well-being of this vulnerable population.

7. Conclusion

This study revealed that the prevalence of substance use, particularly alcohol, is significant, with 23.47% of participants reporting lifetime alcohol use. Interestingly, the control group reported higher substance use, possibly due to HIV-positive participants receiving more counselling and education during clinic visits. Targeted interventions focusing on addiction control are crucial for at-risk groups. Future research should expand to diverse settings to deepen understanding and inform more effective strategies to manage SUDs among adolescents living with HIV. There should also be a call to action for tailored interventions.

8. Acknowledgments

Ethics approval and consent to participate: The Komfo Anokye Teaching Hospital Institutional Review Board approved this study. Tel: +233 3220 00617. Email address: [email protected] or [email protected]. (Ethical approval with reference No: KATH IRB/RR/096/21 was obtained from the Institutional Review Board at KATH).

Consent for publication: Not applicable

Availability of data and materials: The dataset analysed during the current study is available in the supplemental section.

Competing interests: The authors declare that they have no competing interests.

Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the REACH Program, grant no. 5H79TI081358-02 from SAMHSA in 2021. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services, nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. government. The authors alone are responsible for the content and writing of this paper.

References

1. Furlanetto Junior ML. Treatment and the current concept of relapse in substance use disorder. Int J Clin Images Med Rev 2022;1. Accessed December 16, 2024. https://ijcimr.org/ijcimr-v1-1035/
2. Dayal P, Vishakha V, Thakur N. Review on effect of drug abuse on health. V Pub J Nurs Med Res 2023:25-26.
3. Stein DJ, Seedat S, Herman A, et al. Lifetime prevalence of psychiatric disorders in South Africa. Br J Psychiatry 2008;192:112-117.
4. Olawole-Isaac A, Ogundipe O, Amoo EO, Adeloye DO. Substance use among adolescents in sub-Saharan Africa: A systematic review and meta analysis. South Afr J Child Health 2020;14:121-127.
5. Amin P, Douaihy A. Substance use disorders in people living with human immunodeficiency virus/AIDS. Nurs Clin North Am 2018;53:57-75.
6. World Health Organization. WHO HIV and AIDS statistics. Available from: https://www.who.int/media/does/created-source/hq/hiv-hepatitis-and-stis-library/j0482-who-ias-hiv-statistics_aw-1_final_v5.pdf?fsrvn=61639578_3
7. Murewanhema G, Musuka G, Moyo P, Moyo E, Dzinamarira T. HIV and adolescent girls and young women in sub-Saharan Africa: A call for expedited action to reduce new infections. IJID Reg 2022;5:30-32.
8. Soomar SM, Qamar W, Azizullah Z, Ali TS. Challenges in healthcare access for young people living with HIV: A review. J Glob Health Econ Policy 2023;3. Accessed December 17, 2024. https://joghep.scholasticahq.com/article/117353-challenges-in-healthcare-access-for-young-people-living-with-hiv-a-review
9. Gameral KE, Brown L, Kahler CW, et al. Prevalence and correlates of substance use among youth living with HIV in clinical settings. Drug Alcohol Depend 2016;169:11-18.
10. Nyongesa MK, Mwangi P, Kinuthia M, et al. Alcohol and illicit drug use among young people living with HIV compared to their uninfected peers from the Kenyan coast: Prevalence and risk indicators. Subst Abuse Treat Prev Policy 2021;16:86.
11. Nugent NR, Brown LK, Belzer M, et al. Youth living with HIV and problem substance use: Elevated distress is associated with nonadherence and sexual risk. J Int Assoc Physicians AIDS Care 2010;9:113-115.
12. Morawej Z, Nyundo A, Kinyaga A, et al. Prevalence and factors associated with substance use among HIV-positive youth attending HIV care and treatment centers in Dodoma, Tanzania. AIDS Res Ther 2022;19:65.
13. Williams PL, Leister E, Chernoff M, et al. Substance use and its association with psychiatric symptoms in perinatally HIV-infected and HIV-affected adolescents. AIDS Behav 2010;14:1072-1081.
14. Ikewere J, Eiger R, Heward B, et al. Opioid use among young people living with HIV: A review. Psychiatry Res Commun 2024.
15. Abedin NFZ, Jaafar Z, Husain S, Abdullah R. The validity of ASSIST as a measurement of learning approach among MDAB students. Procedia Soc Behav Sci 2013;90:549-557. doi:10.1016/j.sbspro.2013.07.125
16. Ludwig A, Monico LB, Gryczynski J, et al. Drug and sexual HIV-risk behaviors among adolescents and young adults with opioid use disorder. J Subst Abuse Treat 2021;130:108477.
17. Rowe CL, Wang W, Greenbaum P, Liddle HA. Predicting HIV/STD risk level and substance use disorders among incarcerated adolescents. J Psychoactive Drugs 2008;40:503-512.
18. Stephanie S, Stephen MA, Michael TY, Silvia SM. Patterns of drug use and HIV infection among adolescents in a nationally representative sample. Physiol Behav 2018;176(1):139-148.
19. Morawej Z, Nyundo A, Kinyaga A, et al. Prevalence and factors associated with substance use among HIV-positive youth attending HIV care and treatment centers in Dodoma, Tanzania. AIDS Res Ther 2022;19(1):1-9. doi:10.1186/s12981-022-00485-w
20. Cook RL, Comer DM, Wiesenfeld HC, et al. Alcohol and drug use and related disorders: An underrecognized health issue among adolescents and young adults attending sexually transmitted disease clinics. Sex Transm Dis 2006;33.
21. Necho M, Belete A, Getachew Y. The prevalence and factors associated with alcohol use disorder among people living with HIV/AIDS in Africa: A systematic review and meta-analysis. Subst Abuse Treat Prev Policy 2020;15:1-15.
22. Kanekar AS. HIV/AIDS counseling skills and strategies: Can testing and counseling curb the epidemic? Int J Prev Med 2011;2:10-14.
23. Edelman EJ, Dziura J, Esserman D, et al. Working with HIV clinics to adopt addiction treatment using implementation facilitation (WHAT-IF?): Rationale and preliminary findings from a hybrid type 3 effectiveness-implementation trial. Contemp Clin Trials 2020;98:106156.