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

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

Knowledge, attitudes and perceptions of students on sexual health needs of sexual and gender minority individuals in a South African University of Kwa-Zulu Natal: A mixed methods study

There is scant literature available in South Africa that explores the knowledge, attitudes and perceptions of student nursing trainees and other healthcare workers who deliver sexual health services to sexual and gender minority (SGM) communities with unique health needs. An online, mixed-method, questionnaire-based survey was employed to conveniently sample 39/78 (50%) final-year Bachelor of Nursing students from the University of Kwa-Zulu Natal to understand their knowledge, attitudes and perceptions. Descriptive statistics were applied for quantitative results and thematic analysis was used for free-text qualitative data. Results suggested that over 67% of the participants lack the skills and knowledge to obtain a comprehensive history salient to the health needs of SGM populations. Students reported that social upbringing and religious beliefs impact the care they render, with many showing favourable attitudes toward the SGM community. Overall, students reported no content related to SGMs in the current nursing curriculum, however, students were receptive, highlighting the need to be clinically competent to provide relevant healthcare for SGM to meet their sexual health needs. It thus require that students must be trained and have included the SGM content in their curriculum to meet the sexual health needs of SGM population to enable non discriminatory, equitable health provision. being informed and having the necessary skills and knowledge obtained during training in the health institutions of higher learning can address the issues of greatest concern related to the HIV health needs of SGM populations

Entre Nosotras: a qualitative study of a peer-led PrEP project for transgender latinas.

BACKGROUND: Uptake of HIV pre-exposure prophylaxis (PrEP) remains low among transgender people as compared to other subgroups, despite high rates of HIV acquisition. In California, Latinx people comprise 40% of the population and Latina transgender women experience some of the highest burden of HIV of any subgroup, indicating a critical need for appropriate services. With funding from the California HIV/AIDS Research Programs, this academic-community partnership developed, implemented, and evaluated a PrEP project that co-located HIV services with gender affirming care in a Federally Qualified Heath Center (FQHC). Trans and Latinx staff led intervention adaptation and activities. METHODS: This paper engages qualitative methods to describe how a PrEP demonstration project- Triunfo- successfully engaged Spanish-speaking transgender Latinas in services. We conducted 13 in-depth interviews with project participants and five interviews with providers and clinic staff. Interviews were conducted in Spanish or English. We conducted six months of ethnographic observation of intervention activities and recorded field notes. We conducted thematic analysis. RESULTS: Beneficial elements of the intervention centered around three intertwined themes: creating trusted space, providing comprehensive patient navigation, and offering social support entre nosotras (between us women/girls). The combination of these factors contributed to the interventions success supporting participants to initiate and persist on PrEP, many of whom had previously never received healthcare. Participants shared past experiences with transphobia and concerns around discrimination in a healthcare setting. Developing trust proved foundational to making participants feel welcome and en casa/ at home in the healthcare setting, which began from the moment participants entered the clinic and continued throughout their interactions with staff and providers. A gender affirming, bilingual clinician and peer health educators (PHE) played a critical part in intervention development, participant recruitment, and patient navigation. CONCLUSIONS: Our research adds nuance to the existing literature on peer support services and navigation by profiling the multifaced roles that PHE served for participants. PHE proved instrumental to empowering participants to overcome structural and other barriers to healthcare, successfully engaging a group who previously avoided healthcare in clinical settings