Research Paper
“Can’t you initiate me here?”: Challenges to timely initiation on antiretroviral therapy among methadone clients in Dar es Salaam, Tanzania

https://doi.org/10.1016/j.drugpo.2015.12.009Get rights and content

Highlights

  • •

    We explored challenges to ART initiation among methadone clients in Tanzania.

  • •

    Health system factors, stigma, and limited social support hinder ART initiation.

  • •

    On-site CD4 testing, HIV providers and peer support could enable ART initiation.

Abstract

Background

Despite dramatic improvement in antiretroviral therapy (ART) access globally, people living with HIV who inject drugs continue to face barriers that limit their access to treatment. This paper explores barriers and facilitators to ART initiation among clients attending a methadone clinic in Dar es Salaam, Tanzania.

Methods

We interviewed 12 providers and 20 clients living with HIV at the Muhimbili National Hospital methadone clinic between January and February 2015. We purposively sampled clients based on sex and ART status and providers based on job function. To analyze interview transcripts, we adopted a content analysis approach.

Results

Participants identified several factors that hindered timely ART initiation for clients at the methadone clinic. These included delays in CD4 testing and receiving CD4 test results; off-site HIV clinics; stigma operating at the individual, social and institutional levels; insufficient knowledge of the benefits of early ART initiation among clients; treatment breakdown at the clinic level possibly due to limited staff; and initiating ART only once one feels physically ill. Participants perceived social support as a buffer against stigma and facilitator of HIV treatment. Some clients also reported that persistent monitoring and follow-up on their HIV care and treatment by methadone clinic providers led them to initiate ART.

Conclusion

Health system factors, stigma and limited social support pose challenges for methadone clients living with HIV to initiate ART. Our findings suggest that on-site point-of-care CD4 testing, a peer support system, and trained HIV treatment specialists who are able to counsel HIV-positive clients and initiate them on ART at the methadone clinic could help reduce barriers to timely ART initiation for methadone clients.

Section snippets

Background

Recent evidence highlighting the individual and public health benefits of expanded access to antiretroviral therapy (ART) has galvanized efforts to increase the number of people accessing treatment (Cohen et al., 2011, Kitahata et al., 2009, Sterne et al., 2009). Despite dramatic improvement in ART access globally, people living with HIV who inject drugs are less likely to receive ART compared with non-drug users as they consistently face barriers that limit the availability and accessibility

Study setting

This research was conducted at the Muhimbili National Hospital methadone clinic in Dar es Salaam between January and February 2015. As part of routine care, the clinic offers provider initiated HIV testing and counseling at enrollment for all clients followed by ongoing HIV testing every six months (see Table 1 on the HIV care and treatment management of methadone clients). Clients who test positive for HIV have blood drawn at the methadone clinic for CD4 testing and are screened for pulmonary

Characteristics of the sample population

Among the methadone clients interviewed, 10 were women and 10 were men. Five out of the 10 women were on ART at the time of the interview compared to six out of the 10 men. In our sample, the median time enrolled in methadone treatment was 3 years. The median time on ART among those receiving ART at the time of our interviews was 1 year, 4 months.

Six of the 12 providers at the methadone clinic interviewed were doctors; two were nurses providing HIV-related services to clients; two were

Discussion

This study examined barriers and facilitators to ART initiation among women and men receiving methadone-assisted treatment at the Muhimbili National Hospital methadone clinic in Dar es Salaam, Tanzania. We interviewed 20 methadone clients living with HIV, women and men, and 12 providers based at the methadone clinic. Our research illuminates the need to implement strategies to overcome systemic barriers, stigmatization, and limited social support that hinder timely ART initiation.

Integration of

Acknowledgements

We would like to thank all research participants and our research assistants. This research was supported by the National Institutes of Health, National Institute on Drug Abuse (Grant No. 1R34DA037787).

Conflict of interest: The authors declare no conflict of interest.

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