Convenience without disclosure: a formative research study of a proposed integrated methadone and antiretroviral therapy service delivery model in Dar es Salaam, Tanzania

Alexis Cooke, Haneefa Saleem, Dorothy Mushi, Jessie Mbwambo, Saria Hassan, Barrot H. Lambdin

Though timely initiation of antiretroviral therapy (ART) is a vital component of effective HIV prevention, care and treatment, people who inject drugs are less likely to receive ART than their non-drug using counterparts. In an effort to increase access to ART for people who inject drugs, we examined perceived benefits, challenges, and recommendations for implementing an integrated methadone and ART service delivery model at an opioid treatment program (OTP) clinic in Dar es Salaam, Tanzania. We conducted in-depth interviews with 12 providers and 20 HIV-positive patients at the Muhimbili National Hospital OTP clinic in early 2015. We used thematic content analysis to examine patient and provider perspectives of an integrated model. Respondents perceived that offering on-site CD4 testing and HIV clinical management at the OTP clinic would improve the timeliness and efficiency of the ART eligibility process, make HIV clinical care more convenient, mitigate stigma and discrimination in HIV care and treatment settings, and improve patient monitoring and ART adherence. However, perceived challenges included overburdened OTP clinic staff and limited space at the clinic to accommodate additional services. Limited privacy at the OTP clinic and its contribution to fear among HIV-positive patients of being stigmatized by their peers at the clinic was a common theme expressed particularly by patients, and often corroborated by providers. Co-dispensing ART and methadone at the clinic's pharmacy window was viewed as a potential deterrent for patients. Providers felt that an electronic health information system would help them better monitor patients' progress, but that this system would need to be integrated into existing health information systems. To address these potential barriers to implementing an integrated model, respondents recommended increasing OTP provider and clinic capacity, offering flexible ART dispensing options, ensuring privacy with ART dispensing, and harmonizing any new electronic health information systems with existing systems. An integrated methadone and ART service delivery model at the MNH OTP clinic could improve access to HIV care and treatment for OTP patients. However, specific implementation strategies must ensure that OTP providers are not overburdened and confidentiality of patients is maintained.