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

描述(申请人提供)：从20世纪90年代末开始，注射吸毒，主要是海洛因，在坦桑尼亚的达累斯萨拉姆变得普遍，有可能通过增加与毒品有关的艾滋病毒传播来扭转艾滋病毒流行的下降趋势。据估计，坦桑尼亚有5万人注射毒品(PWID)。在达累斯萨拉姆，估计有42%的人感染了艾滋病毒，而总人口的这一比例为9%。由美国疾病控制中心支持并由该研究小组成员实施的药物辅助治疗服务，特别是美沙酮辅助治疗服务，目前正在坦桑尼亚建立。到目前为止，已在达累斯萨拉姆开设了2家诊所，为1010名患者招募了美沙酮服务。鉴于美沙酮的快速招募和艾滋病毒的高负担，美沙酮诊所提供了一个独特的机会，为这一关键人群提供全面的艾滋病毒治疗和护理。然而，在艾滋病毒检测呈阳性的MAT客户中，只有35%的人在艾滋病毒检测后30天内收到了CD4结果，而符合条件的患者中，只有11%的人在CD4筛查后30天内开始抗逆转录病毒治疗。为了在高危人群中改善抗逆转录病毒疗法的启动，我们提出了美沙酮和抗逆转录病毒综合治疗策略(IMAT)，该策略基于健康计划规划的易感因素、使能因素和强化因素的前述框架。IMAT使用1)有针对性的知识传授给那些使他们能够及时接受抗逆转录病毒治疗的提供者，2)对支持抗逆转录病毒治疗启动的提供者进行护理点CD4计数筛查，以及3)向加强抗逆转录病毒治疗启蒙的提供者发出警报和提醒。我们建议在穆亨比利国立医院的美沙酮诊所开发和试行IMAT战略，通过这样做，我们预计将建立一个美沙酮和抗逆转录病毒治疗相结合的功能模式，以提高坦桑尼亚为残疾人提供服务的效力和效率。这项建议的具体目的是：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整合到美沙酮治疗中有关的易感因素、促成因素和强化因素；2)通过研究前设计，实施和检查IMAT在CD4筛查和ART启动方面的有效性；3)通过深入访谈以及患者满意度和时间动态调查，评估IMAT战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由公共资金资助的美沙酮计划；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。利用前面的框架，我们的目标是在这一艾滋病毒流行率较高的美沙酮客户群体中开发一种有效的美沙酮和艾滋病毒治疗整合模式。这一背景将使我们能够充分解决拟议的研究问题，这项研究的结果将有助于整合的证据基础，不仅适用于坦桑尼亚的MAT计划，也适用于美国和全世界的MAT计划。

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.