Date Published: January 28, 2019
Publisher: BioMed Central
Author(s): Alexis Cooke, Haneefa Saleem, Saria Hassan, Dorothy Mushi, Jessie Mbwambo, Barrot Lambdin.
In Dar es Salaam Tanzania, the first opioid treatment program (OTP) in Sub-Saharan Africa, had very high rates of enrollment of people who use drugs (PWUD) but low rates of antiretroviral therapy (ART) initiation among HIV-positive patients. The integrated methadone and anti-retroviral therapy (IMAT) intervention was developed to integrate HIV services into the OTP clinic. The objective of this paper is to better understand the contextual factors that influence the effectiveness of IMAT implementation using the consolidated framework for implementation research (CFIR).
Semi-structured, in-depth interviews were conducted with 35 HIV-positive OTP patients and 8 OTP providers at the Muhimbili National Hospital OTP clinic 6-months after IMAT implementation. Providers were asked about their reactions to and opinions of the IMAT intervention including its implementation, their role in patient education, intervention procedures, and ART dispensing. Interviews with patients focused on their experiences with the IMAT intervention and adapting to the new protocol. Analysis of interview data was guided by the CFIR.
The CFIR constructs found to be driving forces behind facilitating or impeding IMAT implementation were: intervention characteristics (e.g. complexity, adaptability and evidence related to IMAT), outer setting (e.g. patient needs and resources), and inner setting (e.g. compatibility of IMAT and available resources for IMAT). The most significant barrier to implementation identified in interviews was availability of resources, including workforce limitations and lack of space given patient load. OTP providers and patients felt the design of the IMAT intervention allowed for adaptability to meet the needs of providers and patients.
Understanding the contextual factors that influence implementation is critical to the success of interventions that seek to integrate HIV services into existing programs for key populations such as PWUD. Approximately 4 months after IMAT implementation, the OTP clinic adopted a ‘test-and-treat’ model for HIV-positive PWUD, which significantly impacted clinic workload as well as the care context. In this study we highlight the importance of intervention characteristics and resources, as key facilitators and barriers to implementation, that should be actively integrated into intervention protocols to increase implementation success. Similar interventions in other low-resource settings should address the ways intervention characteristics and contextual factors, such as adaptability, complexity and available resources impact implementation in specific care contexts.
Integrating HIV care and treatment services into opioid treatment programs (OTP) can improve linkages to HIV care and antiretroviral therapy (ART) and optimize HIV treatment benefits for people who use drugs (PWUD) . However, there can be challenges specific to implementing care integration in setting with limited resources. Research indicates that adding or scaling up programs in these settings, can impact clinic efficiency and patient flow and without attention to structural barriers many patients might be lost to follow up [2, 3]. In integrating care services, particularly in setting with limited resources and among vulnerable populations, there is a need to figure out how to deliver and sustain these efforts in ways that are effective, timely and of high quality. Simple translation of interventions, from one care context to another, may not address issues of cultural appropriateness, resource limitations, existing health care structures, or political will.
Semi-structured in-depth interviews were conducted with 35 HIV-positive OTP patients and 8 OTP providers and at the MNH OTP clinic 6-months after IMAT implementation. We interviewed providers at the OTP clinic who were involved with IMAT at the time of data collection, which included 3 nurses, 2 doctors, 1 pharmacist, 1 social worker and 1 administrative person. Providers were asked about their reaction to and opinions of the IMAT intervention including its implementation, their role in patient education, intervention procedures, and ART dispensing.
In this paper we have used the CFIR to understand contextual barriers and facilitators related to implementation of the IMAT intervention. In-depth interviews with patients and providers 6-months post-implementation discussed how intervention characteristics, inner setting and outer setting factors influenced intervention implementation. Understanding the contextual factors that influence implementation is critical to the dissemination, scale-up and adaptation of the IMAT intervention to other settings.
Despite these limitations, assessing determinants of implementation is critical to the replication of efforts in other settings. The CFIR constructs outlined in this paper were found to be driving forces behind facilitating or impeding IMAT implementation. Providers looking to integrate HIV care services into programs providing care for PWUDs in other settings in Sub-Saharan Africa should address intervention characteristics and critical inner and outer setting domains that will impact implementation. Continued use of CFIR in describing implementation of integration programs will allow for comparisons across studies as well as for improving the success of implementing evidence-based interventions.