Reducing Failure-to-Initiate ART among People Who Inject Drugs: the IMAT Strategy

描述（由申请人提供）：从1990年代末开始，注射吸毒，主要是海洛因，在坦桑尼亚达累斯萨拉姆变得普遍，由于与毒品有关的艾滋病毒传播增加，有可能扭转艾滋病毒流行病下降的趋势。坦桑尼亚估计有5万注射毒品者。在达累斯萨拉姆，估计有42%的人感染了艾滋病毒，而在总人口中这一比例为9%。在美国疾病控制中心的支持下，在本研究小组成员的执行下，目前正在坦桑尼亚建立药物辅助治疗服务，特别是美沙酮。迄今为止，在达累斯萨拉姆开设了2个诊所，使1 010名客户接受美沙酮服务。考虑到PWID患者接受美沙酮治疗的速度之快和HIV的高负担，美沙酮诊所为这一关键人群提供了一个独特的机会，可以提供全面的HIV治疗和护理。然而，只有35%的艾滋病毒阳性MAT客户在其艾滋病毒检测后30天内获得CD4结果，只有11%的符合条件的患者在CD4筛查后30天内开始抗逆转录病毒治疗。为了提高这一高危人群的抗逆转录病毒治疗启动率，我们提出了基于pre框架的美沙酮和抗逆转录病毒治疗综合策略（IMAT），该框架包括易感因素、使能因素和强化因素，用于健康规划。IMAT使用：1)有针对性的知识转移，使提供者倾向于及时启动抗逆转录病毒治疗；2)定点CD4计数筛查，使提供者能够启动抗逆转录病毒治疗；3)对加强启动抗逆转录病毒治疗的提供者发出警报和提醒。我们建议在Muhimbili国立医院的美沙酮诊所制定和试点IMAT战略，并在此过程中建立美沙酮和抗逆转录病毒治疗相结合的功能模式，从而提高坦桑尼亚为pwid患者提供服务的效力和效率。本提案的具体目的是：1)通过深度访谈和患者调查描述与美沙酮治疗整合HIV护理和治疗相关的易感、促成和强化因素；2)通过前后研究设计实施和检查IMAT对CD4筛查和ART启动的有效性；3)通过深度访谈、患者满意度和时间运动调查评估IMAT策略的可行性和可接受性。我们的研究小组在撒哈拉以南非洲大陆建立了第一个公共资助的美沙酮项目；然而，在解决艾滋病患者中不成比例的艾滋病毒负担方面仍然存在挑战。使用pre框架，我们的目标是在HIV高流行的美沙酮客户群体中建立一个美沙酮和HIV治疗整合的有效模型。这种设置将使我们能够充分地解决提出的研究问题，而这项研究的结果将有助于为整合提供证据基础，不仅适用于坦桑尼亚的MAT项目，也适用于美国和全世界的MAT项目。

DESCRIPTION (provided by applicant): Starting in the late 1990s, injection drug use, primarily of heroin, has become widespread in Dar es Salaam, Tanzania, threatening to reverse a declining HIV epidemic through increased drug-associated HIV transmission. An estimated 50,000 people who inject drugs (PWID) live in Tanzania. In Dar es Salaam, 42% are estimated to be HIV infected, compared to 9% overall in the general population. Supported by the United States Centers for Disease Control and implemented by the members of this research group, medication assisted treatment services, specifically with methadone, are currently being established in Tanzania. To date, 2 clinics have been opened in Dar es Salaam, enrolling 1,010 clients into methadone services. Given the rapid enrollment of PWID into methadone and high burden of HIV, the methadone clinic provides a unique opportunity to provide comprehensive HIV treatment and care to this key population. However, only 35% of MAT clients who are HIV-positive are receiving CD4 results within 30 days of their HIV test and only 11% of those who are eligible are initiating antiretroviral therapy within 30 days of CD4 screening. To improve ART initiation among this at-risk population, we propose the Integrated Methadone and Antiretroviral Therapy strategy (IMAT) based on the PRECEDE framework of predisposing, enabling, and reinforcing factors for health program planning. IMAT uses 1) targeted knowledge transfer for providers that predispose them to timely ART initiation, 2) point-of-care CD4 count screening for providers that enable ART initiation and 3) alerts and reminders for providers that reinforce ART initiation. We propose to develop and pilot the IMAT strategy in the methadone clinic at Muhimbili National Hospital, and in doing so, we anticipate building a functional model of methadone and ART integration that improves the effectiveness and efficiency of service delivery for PWIDs in Tanzania. The specific aims of this proposal are to: 1) describe predisposing, enabling, and reinforcing factors related to the integration of HIV care and treatment into methadone treatment with in-depth interviews and patient surveys, 2) implement and examine the effectiveness of IMAT on CD4 screening and ART initiation with a pre-post study design, and 3) assess the feasibility and acceptability of the IMAT strategy with in-depth interviews as well as patient satisfaction and time-motion surveys. Our research group has established the first publically funded methadone program on the mainland of sub-Saharan Africa; however, challenges remain in addressing the disproportionate HIV burden amongst PWID. Using the PRECEDE framework, we aim to develop an effective model of methadone and HIV treatment integration among this population of methadone clients with a high HIV prevalence. This setting will enable us to adequately address the proposed study questions, and the results from this research will contribute to the evidence-base for integration that can be applicable to MAT programs not only in Tanzania but also in the United States and throughout the world.