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

描述（由申请人提供）：从20世纪90年代末开始，注射毒品，主要是海洛因，在坦桑尼亚达累斯萨拉姆已经变得普遍，通过增加与毒品相关的艾滋病毒传播，有可能扭转艾滋病毒流行的下降趋势。据估计，坦桑尼亚有5万名注射毒品者。在达累斯萨拉姆，估计有42%的人感染了艾滋病毒，而一般人口的总感染率为9%。在美国疾病控制中心的支持下，并由该研究小组成员实施，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，为1 010名病人提供美沙酮服务。鉴于PWID迅速登记到美沙酮和艾滋病毒的高负担，美沙酮诊所提供了一个独特的机会，提供全面的艾滋病毒治疗和护理，这一关键人群。然而，只有35%的艾滋病毒阳性的MAT客户在艾滋病毒检测后30天内获得CD 4结果，只有11%的合格客户在CD 4筛查后30天内开始抗逆转录病毒治疗。 为了提高ART启动在这一高危人群中，我们提出了综合美沙酮和抗逆转录病毒治疗策略（IMAT）的基础上PRECEDE框架的易感性，使能和加强因素的健康计划规划。IMAT使用1）针对容易使他们及时启动ART的提供者的有针对性的知识转移，2）针对能够启动ART的提供者的护理点CD 4计数筛查，以及3）针对加强ART启动的提供者的警报和提醒。我们建议在Muhimbili国家医院的美沙酮诊所制定和试点IMAT战略，在这样做的过程中，我们预计将建立一个美沙酮和ART整合的功能模型，以提高坦桑尼亚PWID服务的有效性和效率。这项建议的具体目标是：1）通过深入访谈和患者调查，描述与将艾滋病毒护理和治疗纳入美沙酮治疗相关的诱发因素、促进因素和强化因素，2）通过前后研究设计，实施并检查IMAT对CD 4筛查和ART启动的有效性，（3）通过深入访谈、患者满意度调查和时间-动作调查评估IMAT策略的可行性和可接受性。我们的研究小组已经在撒哈拉以南非洲大陆建立了第一个由医疗机构资助的美沙酮计划;然而，在解决PWID中不成比例的艾滋病毒负担方面仍然存在挑战。使用PRECEDE框架，我们的目标是开发一个有效的模式，美沙酮和艾滋病毒治疗的整合在这一人群中的美沙酮客户与艾滋病毒的高流行率。这种设置将使我们能够充分解决提出的研究问题，从这项研究的结果将有助于整合，不仅适用于在坦桑尼亚，而且在美国和世界各地的MAT程序的证据基础。

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.