Providing Medication Assisted Treatment (MAT) as an HIV Prevention Intervention: Programmatic Strategies to Maximize Service Utilization in Dar es Salaam, Tanzania

Over the past decade, myriad social and economic factors have fueled a burgeoning population of people who inject heroin in sub-Saharan Africa, creating an urgent need for HIV prevention and treatment services tailored to this marginalized group. While the epidemic in the region remains largely driven through heterosexual risk behavior, a higher probability of disease acquisition per exposure can lead to rapid transmission among people who inject drugs (PWID). Stigma and discrimination isolates PWID from accessing available HIV care services designed for the general population and has contributed to HIV prevalence in PWID up to four times greater than country averages. To address this crisis, a few trailblazing governments with support from international HIV/AIDS funders have begun to develop and in the case of Tanzania, implement, comprehensive national harm reduction services for people who use and inject drugs. This dissertation contributes to the growing body of implementation science literature on medication assisted treatment programs (MAT) for PWID in sub-Saharan Africa. This dissertation takes a three-paper model to identify programmatic and policy strategies to enroll, retain and support patients in MAT programs, focusing on Tanzania. The first paper, a systematic review of the literature on methadone as an HIV prevention intervention, describes evidence-based best practices and applies key findings to make recommendations about service delivery in a limited resource setting. Results suggest that enhanced outreach and increased dosing can help maximize service utilization. The second and third papers delve into the experiences of the first MAT program on mainland sub-Saharan Africa, located at Muhimbili National Hospital in Dar es Salaam, Tanzania. The program has successfully implemented a continuum of harm reduction care, culminating in methadone treatment for PWID. However, monitoring and evaluation data highlight a gender disparity in service utilization, with women comprising less than 10% of clients. Relying on in-depth interviews and observational data collected over three field visits from July 2011 to February 2013, the last two articles look at ongoing service needs for women in treatment and identify strategies to bring more women into care. Results suggest that women face distinct hardship in treatment, needing increased psychosocial support services and economic development interventions to help them heal histories of sexual trauma and regain custody of their children. Additionally, outreach tailored to women can help increase treatment enrollment. Findings from this dissertation have implications for MAT programs in Tanzania and in other areas in the region with similar epidemiological and cultural environments

Providing Medication Assisted Treatment (MAT) as an HIV Prevention Intervention: Programmatic Strategies to Maximize Service Utilization in Dar es Salaam, Tanzania

Over the past decade, myriad social and economic factors have fueled a burgeoning population of people who inject heroin in sub-Saharan Africa, creating an urgent need for HIV prevention and treatment services tailored to this marginalized group. While the epidemic in the region remains largely driven through heterosexual risk behavior, a higher probability of disease acquisition per exposure can lead to rapid transmission among people who inject drugs (PWID). Stigma and discrimination isolates PWID from accessing available HIV care services designed for the general population and has contributed to HIV prevalence in PWID up to four times greater than country averages. To address this crisis, a few trailblazing governments with support from international HIV/AIDS funders have begun to develop and in the case of Tanzania, implement, comprehensive national harm reduction services for people who use and inject drugs. This dissertation contributes to the growing body of implementation science literature on medication assisted treatment programs (MAT) for PWID in sub-Saharan Africa. This dissertation takes a three-paper model to identify programmatic and policy strategies to enroll, retain and support patients in MAT programs, focusing on Tanzania. The first paper, a systematic review of the literature on methadone as an HIV prevention intervention, describes evidence-based best practices and applies key findings to make recommendations about service delivery in a limited resource setting. Results suggest that enhanced outreach and increased dosing can help maximize service utilization. The second and third papers delve into the experiences of the first MAT program on mainland sub-Saharan Africa, located at Muhimbili National Hospital in Dar es Salaam, Tanzania. The program has successfully implemented a continuum of harm reduction care, culminating in methadone treatment for PWID. However, monitoring and evaluation data highlight a gender disparity in service utilization, with women comprising less than 10% of clients. Relying on in-depth interviews and observational data collected over three field visits from July 2011 to February 2013, the last two articles look at ongoing service needs for women in treatment and identify strategies to bring more women into care. Results suggest that women face distinct hardship in treatment, needing increased psychosocial support services and economic development interventions to help them heal histories of sexual trauma and regain custody of their children. Additionally, outreach tailored to women can help increase treatment enrollment. Findings from this dissertation have implications for MAT programs in Tanzania and in other areas in the region with similar epidemiological and cultural environments

Health Care Experiences of Patients with Nonbinary Gender Identities.

PURPOSE: The primary purpose of this study was to characterize the health care experiences of diverse patients with nonbinary gender identities across a range of geographic locations. A secondary aim was to use the qualitative findings to inform recommendations for clinics and providers to create gender-affirming health care environments for nonbinary patients. METHODS: We conducted 3 focus group discussions with 7-9 participants, for a total of 24 unique participants. To be eligible, participants were required to be 18 years of age or older, live in the United States, speak English, have the ability to access Zoom in a private room, have a nonbinary gender identity, and be able to attend one of three scheduled focus groups. RESULTS: Participants reported frequent negative health care experiences, including misgendering, invalidation, and pathologization, even within clinics that signaled alliance with transgender communities. Participants described strategies they use to cope with negative experiences, including health care avoidance, identity concealment, and seeking out providers that are matched in terms of gender minority status and/or race. CONCLUSION: Recommendations for the provision of gender-affirming health care for nonbinary patients include nonbinary-inclusive intake forms and electronic health records, having providers be proactive in eliciting preferred names and pronouns, and requiring education for providers and staff at all levels on the provision of nonbinary-inclusive gender-affirming health care

Generating trust: Programmatic strategies to reach women who inject drugs with harm reduction services in Dar es Salaam, Tanzania

BackgroundStrong evidence supports the effectiveness of methadone-assisted therapy (MAT) to treat opioid dependence, reduce the risk of HIV transmission, and improve HIV related health outcomes among people who inject drugs (PWID). HIV prevalence reaches 71% in women who inject drugs (WWID) in Dar es Salaam, Tanzania; creating an urgent need for access to MAT. Despite the availability and potential benefits of treatment, few women have enrolled in services. This formative research sought to identify programmatic strategies to increase women's participation in outreach and their subsequent enrollment in MAT.MethodsWe conducted twenty-five, in-depth interviews with patients and their providers at a MAT clinic. Open-ended interviews explored enrollment experiences, with a focus on contextual barriers and facilitators unique to women. Ethnographic observations of harm reduction education at outreach sites and the MAT clinic enriched interview data. Trust/mistrust emerged as an overarching theme cross cutting patient and provider accounts of the connective process to enroll PWID in the methadone program. We explore trust and mistrust in relationship to the interrelated themes of family loss, social isolation, vehement discrimination and motivation for treatment.ResultsNarratives delineated both the generation of mistrust against PWID and the generation of mistrust in PWID against outsiders and medical institutions. In order to enroll PWID in treatment, community base organizations engaged outreach strategies to overcome mistrust and connect eligible patients to care, which varied in their success at recruiting women and men. Greater discrimination against WWID pushed them into hiding, away from outreach teams that focus on outdoor areas where men who inject drugs congregate. Building trust through multiple encounters and making a personal connection facilitated entry into care for women. Only PWID were eligible for MAT, due to resource constraints and the higher risk associated with injection drug use. Many women smoke heroin, yet still face high risk of HIV, resulting from low condom use during sex work to fund drug use.ConclusionExpanding outreach times and locations, by women peers, could increase women's enrollment in treatment. Allowing women who smoke heroin to enter the program could prevent onward transmission via sex work and reduce the chance of progressing from the lower risk smoking or sniffing to injection drug use

Data_Sheet_1_“I am still human and worth a life:” a qualitative study of the impacts of a community based, peer-led, treatment support model for young adults living with HIV in Zimbabwe.docx

BackgroundA persistent treatment gap remains between children and adults living with HIV. The Zvandiri program, developed by Africaid, is one of the few models of differentiated service delivery for children, adolescents, and youth that has been shown to improve outcomes along the HIV care continuum, employing Community Adolescent Treatment Supporters (CATS) to offer peer counseling and patient navigation. Our qualitative study provides an in-depth analysis of the feelings and experiences Zimbabwean youth had following an HIV diagnosis, and the ways that CATS facilitated linkage and retention in care.MethodsWe conducted in-depth interviews in Shona with adolescents and young adults who were recently diagnosed with HIV in Zimbabwe. Interviews were audio-recorded, transcribed, and then translated to English. Interviews were coded in Dedoose using a structured a priori codebook. We wrote semi-structured summary memos for each interview. We co-conducted thematic analysis, guided by interpretive phenomenology with a team of Zimbabwean and American experienced qualitative researchers and community partners. We co-developed memos to elaborate and understand key themes across interviews.ResultsMost of our interview participants recounted an immediate sense of loss upon testing HIV positive and a fear that “there was no hope for the future.” CATS played a pivotal role for youth, providing emotional, educational, and logistical support to facilitate treatment initiation, adherence, and persistence in care. The CATS program supported youth through multiple approaches: group sessions, individual meetings, and via text or phone. While CATS offered counseling and comfort to participants, they emphasized the long-term importance of identifying at least one other person in participants’ lives who could know their status and support them around HIV.ConclusionOur findings delineate some of the key concerns that face youth after receiving an HIV diagnosis and the ways that a community-based adherence peer navigation program supported participants to navigate both their feelings and the health care system. Results can inform practice at community-based agencies that are implementing or considering peer youth navigation programs and garner support for policy to fund interventions for youth.</p

Data_Sheet_2_“I am still human and worth a life:” a qualitative study of the impacts of a community based, peer-led, treatment support model for young adults living with HIV in Zimbabwe.docx

BackgroundA persistent treatment gap remains between children and adults living with HIV. The Zvandiri program, developed by Africaid, is one of the few models of differentiated service delivery for children, adolescents, and youth that has been shown to improve outcomes along the HIV care continuum, employing Community Adolescent Treatment Supporters (CATS) to offer peer counseling and patient navigation. Our qualitative study provides an in-depth analysis of the feelings and experiences Zimbabwean youth had following an HIV diagnosis, and the ways that CATS facilitated linkage and retention in care.MethodsWe conducted in-depth interviews in Shona with adolescents and young adults who were recently diagnosed with HIV in Zimbabwe. Interviews were audio-recorded, transcribed, and then translated to English. Interviews were coded in Dedoose using a structured a priori codebook. We wrote semi-structured summary memos for each interview. We co-conducted thematic analysis, guided by interpretive phenomenology with a team of Zimbabwean and American experienced qualitative researchers and community partners. We co-developed memos to elaborate and understand key themes across interviews.ResultsMost of our interview participants recounted an immediate sense of loss upon testing HIV positive and a fear that “there was no hope for the future.” CATS played a pivotal role for youth, providing emotional, educational, and logistical support to facilitate treatment initiation, adherence, and persistence in care. The CATS program supported youth through multiple approaches: group sessions, individual meetings, and via text or phone. While CATS offered counseling and comfort to participants, they emphasized the long-term importance of identifying at least one other person in participants’ lives who could know their status and support them around HIV.ConclusionOur findings delineate some of the key concerns that face youth after receiving an HIV diagnosis and the ways that a community-based adherence peer navigation program supported participants to navigate both their feelings and the health care system. Results can inform practice at community-based agencies that are implementing or considering peer youth navigation programs and garner support for policy to fund interventions for youth.</p

Scaling-up health information systems to improve HIV treatment: An assessment of initial patient monitoring systems in Mozambique

IntroductionThe rapid scale-up of HIV care and treatment in resource-limited countries requires concurrent, rapid development of health information systems to support quality service delivery. Mozambique, a country with an 11.5% prevalence of HIV, has developed nation-wide patient monitoring systems (PMS) with standardized reporting tools, utilized by all HIV treatment providers in paper or electronic form. Evaluation of the initial implementation of PMS can inform and strengthen future development as the country moves towards a harmonized, sustainable health information system.ObjectiveThis assessment was conducted in order to 1) characterize data collection and reporting processes and PMS resources available and 2) provide evidence-based recommendations for harmonization and sustainability of PMS.MethodsThis baseline assessment of PMS was conducted with eight non-governmental organizations that supported the Ministry of Health to provide 90% of HIV care and treatment in Mozambique. The study team conducted structured and semi-structured surveys at 18 health facilities located in all 11 provinces. Seventy-nine staff were interviewed. Deductive a priori analytic categories guided analysis.ResultsHealth facilities have implemented paper and electronic monitoring systems with varying success. Where in use, robust electronic PMS facilitate facility-level reporting of required indicators; improve ability to identify patients lost to follow-up; and support facility and patient management. Challenges to implementation of monitoring systems include a lack of national guidelines and norms for patient level HIS, variable system implementation and functionality, and limited human and infrastructure resources to maximize system functionality and information use.ConclusionsThis initial assessment supports the need for national guidelines to harmonize, expand, and strengthen HIV-related health information systems. Recommendations may benefit other countries with similar epidemiologic and resource-constrained environments seeking to improve PMS implementation