Integration of buprenorphine into a multi-component harm reduction program fro people who inject drugs in Kampala, Uganda

摘要 自2008年以来，撒哈拉以南非洲国家的注射毒品使用迅速增加， 海洛因和可卡因[1-11]导致艾滋病毒和丙型肝炎病毒感染的高流行率，特别是在坦桑尼亚， 肯尼亚[1，12，13]。乌干达最近估计注射毒品的人数也有所增加[14-16] 在坎帕拉大约有4000人[17]。据估计，乌干达艾滋病毒感染者中的艾滋病毒流行率约为 17%在多项研究中[14，17]，海洛因是最常见的注射药物。尽管风险很大， 采取干预措施，减少与注射毒品使用和与毒品有关的性风险相关的危害， 开始在该地区开发和实施。大多数研究人员认为， 需要采取措施减少艾滋病毒感染者的感染，包括： 注射器交换计划（SEP）;频繁的艾滋病毒检测和与艾滋病毒护理的联系;抗逆转录病毒治疗 感染后开始治疗，以通过抑制病毒降低进一步传播的风险;药物辅助 治疗;心理社会支持和暴露前和暴露后预防[22-24]。在所提出的应用中， 我们将与乌干达减少危害网络和马凯雷雷大学公共卫生学院合作， 制定、完善和试行一项针对PWID的艾滋病毒预防综合干预措施，以确保其可行性和可接受性 在坎帕拉的两个减少伤害中心（DIC）。我们将使用实施科学的方法， 干预研究综合框架（CFIR），以制定干预措施， 利用各发展中国家的资源切实可行地执行和维持这些战略。干预将使用社交网络 艾滋病毒/丙型肝炎病毒检测将PWID纳入DIC。参与者将获得一小笔艾滋病毒感染津贴， HCV检测，注射海洛因的人将被提供纳洛酮，丁丙诺啡，一个自我指导的计算机- 基于药物治疗计划，CBT 4CBT，并将完成一个简短的采访，以确定其他PWID和 获得优惠券，招募他们进行艾滋病毒/丙型肝炎病毒检测。参与者还将获得一系列服务 已经在DIC提供的药物，包括注射器和其他安全注射用品，PrEP和避孕套。最后， 那些艾滋病毒呈阳性的人将被分配一名同伴导航员，他将把他们与护理联系起来，并确保继续 艾滋病毒诊所的就诊率和抗逆转录病毒疗法的坚持率。拟议项目的具体目标包括：1） 在乌干达坎帕拉为艾滋病感染者制定艾滋病毒预防综合干预措施， 干预研究框架; 2）通过使用 CFIR框架，以确定执行和扩大的障碍并找到解决方案; 3）评估可行性， 可接受性和初步承诺的干预与6个月的试点测试。我们将收集定量 执行成果，包括接受艾滋病毒/丙型肝炎病毒检测的人数、注射器的使用情况， 纳洛酮、丁丙诺啡的摄取和保留以及CBT 4CBT的摄取，并在基线时进行调查 和3个月的试点参与者，以衡量注射和性风险行为的变化前后， 接收干预组件。

ABSTRACT Since 2008, countries in Sub Saharan Africa have seen rapid increases in injection drug use including injection of heroin and cocaine [1-11] resulting in high prevalence of HIV and HCV infection, particularly in Tanzania and Kenya [1, 12, 13]. Uganda also has seen an increase in people who inject drugs [14-16] with recent estimates at approximately 4000 in Kampala [17]. HIV prevalence among PWID in Uganda is estimated to be around 17% in multiple studies [14, 17], with heroin being the most commonly injected drug. Despite the serious risk, interventions to reduce the harms associated with injection drug use and drug related sexual risk are just beginning to be developed and implemented in the region. Most researchers argue that a combination of approaches are needed to reduce HIV infection among PWID including: provision of clean syringes through syringe exchange programs (SEPs); frequent HIV testing and linkage to HIV care; antiretroviral therapy initiation after infection to reduce risk of onward transmission through viral suppression; medication assisted therapy; psychosocial support and pre- and post-exposure prophylaxis [22-24]. In the proposed application, we will collaborate with the Uganda Harm Reduction Network and Makerere University School of Public Health to develop, refine and pilot for feasibility and acceptability a combination HIV prevention intervention for PWID in two harm reduction Drop In Centers (DICs) in Kampala. We will use implementation science methods, the Consolidated Framework for Intervention Research (CFIR), to develop the intervention so that it can be feasibly implemented and sustained using the resources in DICs. The intervention will use social network HIV/HCV testing to bring PWID into the DICs. Participants will be given a small stipend for receiving HIV and HCV testing, and those who inject heroin will be offered naloxone, buprenorphine, a self-directed computer- based drug treatment program, CBT4CBT, and will complete a short interview to identify other PWID and receive coupons to recruit them for HIV/HCV testing. Participants will also be offered an array of services already offered in the DICs including syringes and other safe injection supplies, PrEP, and condoms. Finally, those who are HIV positive will be assigned a peer navigator who will link them into care and ensure continued attendance to HIV clinics and ART adherence. Specific aims of the proposed project include the following: 1) To develop a combination HIV prevention intervention for PWID in Kampala Uganda, using the Consolidated Framework for Intervention Research; 2) To refine the intervention through implementation cycles using the CFIR framework to identify barriers and find solutions to implementation and scale-up; 3) To assess feasibility, acceptability and initial promise of the intervention with a 6-month pilot test. We will collect quantitative implementation outcomes including the numbers of people tested for HIV/HCV, uptake of syringes and Naloxone, uptake and retention on buprenorphine, and uptake of CBT4CBT and conduct surveys at baseline and 3-months with pilot participants to measure changes in injection and sexual risk behaviors before and after receiving intervention components.