The HIV prevalence among people who inject drugs (PWID) in Dar es Salaam, Tanzania, is 42 percent, compared to 7 percent in the general population. In 2011, an opioid treatment program using methadone was established to reduce HIV transmission among this community. Enrollment of PWID into the program surged, but linking and sustaining HIV-positive, eligible patients in antiretroviral therapy faced many obstacles. Since 2014, we have been leading an implementation science initiative to design an innovative strategy for the National Institutes of Health to improve access to HIV treatment among opioid treatment patients in Tanzania.
Collaboratively Building an Integrated Model
To begin, we collected information from opioid treatment patients and opioid treatment providers regarding the barriers and facilitators to antiretroviral therapy delivery and their perspectives with regards to integrating HIV treatment services into the treatment program. We then hosted community engagement meetings with providers, patients, HIV treatment specialists, program directors and stakeholders from the Ministry of Health and Social Welfare to discuss findings from our preliminary data and collaboratively define a model of integrated care.
We found that an overwhelming majority of patients—94 percent—were comfortable with the idea of integrating HIV services into opioid treatment, and providers thought that it could improve HIV treatment access and adherence. On the other hand, stakeholders were concerned about how to offer HIV services within opioid treatment without inadvertently disclosing patients’ HIV status and how to integrate services without overburdening the staff.
The stakeholders decided on a multi-pronged approach, including the following:
- Opt-out HIV screening
- Opioid treatment providers cross-trained in HIV clinical management and monitoring
- Removal of immunologically-based eligibility requirements to receive HIV treatment
- The option of multiple antiretroviral therapy dispensing models based on patients’ needs
- Intensive case management for people who were not achieving viral suppression.
Together, these components were implemented at the end of 2015.
Evaluating the Implementation and Impact of the Integrated Model
Following the implementation of the integrated model, the RTI study team conducted a mixed-methods evaluation, showing that 83 percent of opioid treatment providers had adopted the new implementation strategy. Participants also reported high implementation fidelity. Providers were highly motivated by the idea of centralizing care to meet their patients’ needs and improve their health.
One provider stated, “[People who use drugs] are at an increased risk of getting HIV, so it is [appropriate] for [the OTP clinic] to have HIV services integrated. It is not okay to separate HIV services from this program.”
However, one of the barriers to adoption was the increased workload on providers, especially as a large group of patients were immediately eligible to begin HIV treatment after the removal of eligibility requirements.
At the patient level, 97 percent of eligible opioid treatment patients were receiving HIV treatment after integration, which was a 38 percent increase compared to before the integrated model was implemented. In addition, 93 percent of patients were retained on treatment at the end of the study period, and 83 percent of patients who were receiving their HIV treatment under the integrated model achieved viral suppression within 12 months.
High levels of implementation adoption by providers as well as HIV treatment access and viral suppression by patients were observed following implementation of the integrated model. The success of this initiative could have been driven by early engagement of opioid treatment providers and patients as well as the engagement of the larger community of stakeholders to process information and define an integrated model. Our results demonstrate that high-quality HIV treatment delivery is possible for PWID engaged in opioid treatment in Tanzania, and future efforts should consider integrating evidence-based interventions as needed into opioid treatment programs.
