Patient and provider perspectives on implementation barriers and facilitators of an integrated opioid treatment and HIV care intervention
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.
KeywordsCare integration Implementation HIV Substance use
people who use drugs
opioid treatment program
Muhimbili National Hospital
integrated methadone and anti-retroviral therapy
consolidated framework for implementation research
care and treatment clinic
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.
PWUD shoulder a disproportionate burden of HIV in Tanzania . HIV prevalence among PWUD living in Tanzania is estimated at 36% compared to 7% in the general population [5, 6]. In an effort to address the high rates of HIV among PWUD in Tanzania, the first publicly-funded OTP on the mainland of sub-Saharan Africa opened in February 2011 at Muhimbili National Hospital (MNH) in Dar es Salaam. The MNH OTP clinic offers methadone maintenance treatment, as well as psychosocial and behavioral therapies, as part of its medication-assisted treatment of opioid use disorder . However, despite daily attendance at the MNH OTP clinic, less than half of treatment-eligible patients initiated ART within 3 months of being deemed eligible for treatment , due partly to delays in CD4 testing, suboptimal systems to monitor patients and link them to care, and siloed health care structures .
To address delays in ART initiation and improve HIV-related clinical outcomes among PWUD attending the MNH OTP clinic, we implemented the Integrated Methadone and Anti-retroviral Therapy (IMAT) intervention at the OTP clinic starting in 2015. At the launch of IMAT implementation, the IMAT intervention included four key components: (1) in-house point-of-care CD4 testing; (2) in-house HIV clinical management by methadone clinic providers trained in comprehensive HIV management, with referrals to the HIV clinic for developing needs; (3) ART delivery through the OTP clinic; and (4) an electronic information system to help providers monitor OTP patients along the continuum of HIV care. At the beginning of 2016, the Tanzanian Ministry of Health and Social Welfare adopted a ‘test and treat’ model for HIV among PWUD at the OTP clinic. Following this change more patients were eligible to initiate onto ART due to the elimination of reliance on a specific CD4 threshold to determine ART eligibility. Since this change occurred after IMAT it has effectively enabled providers at the OTP clinic to operationalize the first ‘test and treat’ model for HIV among PWUD in sub-Saharan Africa. In this paper, qualitative data were collected to examine provider and patient perspectives on the implementation of integrated methadone and HIV services at the Muhimbili OTP clinic.
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.
Characteristics of HIV-positive OST patients interviewed for the study (n = 35)
HIV positive OTP clinic patients not on ART, post IMAT
HIV positive OTP clinic patients not linked to ART before IMAT, now on ART
Interview transcripts were entered into Dedoose (Version 7.0.23) for storage, organization, coding and analysis. The CFIR was used to guide data coding and analysis. Memos were used at each stage of data analysis to saturate analytic categories and facilitate analysis.
The complexity (in terms of time, steps, or difficulty) of the intervention itself
The ability, or lack thereof, to adapt the intervention to the specific clinic context
Improvements or worsening by the intervention, compared to currently existing programs, or having nothing in place of the intervention
Stakeholders’ perceptions of the quality and validity of evidence supporting the belief that the innovation will have desired outcomes
Patient needs and resources
The extent to which the intervention addressed or accounted for patient needs and limited resources
The presence or absence of resources specific to the intervention
The level of compatibility the intervention had with work processes and organizational values
Each interview was coded by the first author (AC), and these codes were used to develop case memos for each construct. Codes related to the construct of patient needs and resources included statements that discussed awareness, or lack of awareness about the needs and resources of those served by the intervention. Codes related to the construct of available resources included statements related to the presence or absence of resources specific to the intervention. Codes for compatibility included statements that discussed the level of compatibility the intervention had with work processes and organizational values. Statements were coded for the construct of complexity if they discussed the complexity of the intervention itself. Codes related to the construct of adaptability included statements regarding the ability, or lack thereof, to adapt the intervention to the specific clinic context. Codes for relative advantage included statements demonstrating that the intervention was better or worse than existing programs, or having nothing in place of the intervention. Lastly, codes for evidence included statements related to providers’ perceptions of the quality and validity of evidence supporting the belief that the innovation will have desired outcomes. Memos contained a summary of all relevant codes for the construct, a rationale for the code and the direct quotations related to the construct. From these memos we were able to assess the construct’s influence on IMAT implementation.
In interviews with patients and providers at the OTP clinic, the complexity of the intervention was not endorsed as a barrier or facilitator to implementation. To some OTP providers, the complexity of the IMAT intervention was beneficial through its clearly defined protocol. However, other providers mentioned some procedures of the intervention that made it more difficult, at least, to initiate ART. For example, some lab services were not fully integrated into the OTP clinic procedures and initially registering patients to receive ARTs was difficult. The complexity of the intervention was not mentioned in interviews with patients. Patients did not mention that they felt burdened by the IMAT intervention protocol, nor did they mention that the intervention procedures were easy to follow.
So I can say that there are points where we have to diverge from the IMAT principles but it is explainable. There are a few of us so things have to be done in that way. The tests are run in the afternoon and the nurses prioritize patients, let’s say those who had lower CD4 counts were given priority when we were using the CD4 count category for initiating treatment.
I come for ART when they are finished. Some people were not taking their medications properly so it was concluded that they will be taking their medications here. Those who are doing well are given their medications to take at home. [My partner and I] are doing well and we are taking our medications at home. We ask them for a refill when they are finished.
This patient highlighted the importance of the intervention allowing patients to take the medications at home or through DOT based on their preference.
It is not only one client, I remember so many clients. There were so many patients who were running [running away and leaving care] and so there was a delay in getting their blood samples for CD4 counts. This program has made it easy for us; we take the blood samples directly from the clients. We will do the other baseline investigations if the CD4 counts are found to be very low and we would call the doctor to start that specific client on therapy. The procedures used to take so long in the past and there were no special doctors for that group of clients. It is easier now because I can just call the doctor because there is a specific doctor for that and he can start the therapy [there is a specific doctor at the OTP clinic who initiates ART].
I have an advantage on my health. My health has improved so much because I get all treatment at the same place. I am thankful for the providers because they are monitoring us closely. There are no disturbances when you get services at the same place.
I didn’t know if there would be any part of Africa that would provide the integrated services…I was aware of it after seeing it right here in our place. It opened up my mind and helped me understand better on how we can improve the MAT services and the ART services.
After participating in IMAT, patients also commented on improvements in their health. However, in interviews patients did not discuss their perceptions of the quality and validity of evidence against or in support of the IMAT intervention.
Patient needs and resources
I think the HIV services are better in the IMAT program. It has helped us to follow them up closely, we can tell if a client is not adhering to therapy and we have been able to establish the directly observed therapy. We observe them as they take [ART medication]. IMAT has enabled us to monitor them closely and start them on directly observed therapy if they are found with poor adherence.
It is as I have told, how can I take methadone and the ARTs at the same time without taking food? I will fall down because both of the medications are strong. I am asking them to forgive me because you may hear that I have left their medications and have gone [patient left medications at the clinic and went home].
Available clinic resources
We, pharmacists, have no counselling rooms, we have no special room in which we can call clients and counsel them. We just end up feeling sad as we see patients deteriorating. We have no private room in which we can ask the patient why he is not taking his medications.
I feel good because there are no circles in getting the medications. There are so many things to do in other hospitals. In here they just test you and start you on ARTs right away. Our doctor collects the medications for us. You just find your medications with him on your appointments.
There is no gap because everybody has their own role to play. As a social worker, I know my roles at the clinic, the doctor knows his roles too. There are points in which I must consult the doctor or the nurse on duty. We can discuss about what to do about certain issues that may arise. We maintain confidentiality because it is very important. We can disclose some issues to the team members as we all work in the interest of the clients.
That is the first important thing that I want to say. It is very good that HIV services are integrated with methadone therapy. I just go to room number 11 for my medications and put them in my pocket. We have more confidentiality since the services have been integrated. The nurse goes to collect our medications for us. She comes here with the medications and we take them slowly. I am very happy with this system. It is a very good thing that HIV services have been integrated with methadone services.
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.
Assessing context is important when evaluating interventions because it takes into account the fact that implementation outcomes neither exist nor arise in a vacuum. Context refers to the set of circumstances or unique factors that surround a particular implementation effort, and which must be accounted for in data interpretation . Doing so allows us to assess whether intervention success or failure is related to problems with the protocol, or to the intervention occurring in a context without adequate resources, support, and the systems necessary for success. This is in alignment with implementation science literature that posits a clinic’s capacity to conduct an intervention does not necessarily reflect whether the intervention itself is effective or ineffective, but rather whether the intervention is implemented effectively and as intended in a particular context . As applied to this study, we see differences between patients and providers, related to how context impacted intervention implementation. While the IMAT intervention was able to address patient needs in terms of ART initiation, more contextual factors such as food insecurity and transportation exist outside of the clinic’s purview, but still impact patient treatment and care. While these contextual factors may not impact the number of clients initiating ART it will certainly impact their medication adherence and therefore rates of viral load suppression which is a critical determinant of HIV related morbidity and mortality. Similar interventions might be able to facilitate implementation and create a more supportive environment through the expansion of services, allowing care to be located closer to where patients live (thus minimizing travel burden) and linking patients to relevant services, such as food assistance programs.
Facilitators of IMAT implementation included the CFIR domains of adaptability, relative advantage and evidence. These are all attributes of the intervention that were directly addressed by stakeholders (OTP patients, OTP providers, Local NGOs delivering HIV care services, HIV experts) at the time of intervention design . This group identified ART initiation as a problem that could be addressed by integration of services. Furthermore, they highlighted the importance of designing an intervention that allowed for adaptability to meet the needs of providers (e.g. flexibility) and patients (e.g. confidentiality) as critical to the success of a complex intervention. The post-IMAT interviews confirmed that incorporating these stakeholders’ views provided for key facilitators for implementation. While not part of the intent of IMAT, interviews with patients and providers also suggest that integrating HIV care at the OTP clinic helped to improve retention as well. In looking to implement a similar integration program in other settings, it is important to incorporate stakeholder priorities in the intervention design to facilitate implementation.
The most significant barrier to implementation identified in interviews centered on contextual factors related to available resources. For some providers, lack of available resources (e.g. space) significantly hindered implementation and intervention delivery. While the shift to a ‘test and treat model’ was not explicitly discussed in interviews, it did result in increasing the number of OTP patients eligible for ART initiation. While providers discussed challenges related to available resources this was not a barrier endorsed in patient interviews. In interviews, IMAT patients felt they were able to easily receive services, which may indicate that IMAT patients are not acutely awareness of limitations in clinic resources or that providers were able to manage them without impacting their clinical care. In limited resource settings, prior service integration efforts in other health sectors have also shown the importance of policy-level efforts to improve the efficiency in resource utilization (providers and financial) of integration efforts . These issues of available resources and compatibility will need to be addressed at the policy and service-delivery level, especially in context of a ‘test and treat’ model to ensure the sustainability and scalability of IMAT as well as other integration of service efforts.
In provider interviews we observed a discrepancy in comments about compatibility compared to comments made about available resources. While providers felt it was easy for them to incorporate intervention procedures into existing workflows and systems at the clinic, they also indicated that the level of resources (e.g. workforce, space and lab equipment) dedicated to implementation had an overall negative influence on implementation. The strain on resources may also been seen as a sign of successful implementation. Following the shift to a ‘test and treat model’, there was a sudden increase in the number of patients to manage. Had IMAT not been compatible with the OTP clinic, we might observe patients dropping out or leaving care thus not straining clinic resources in this way. This suggests that there may be tension between the compatibility of an intervention for a particular setting, and the necessary tools and resources needed to implement the intervention effectively. Having an adaptable intervention will allow for modifications to the intervention that will allow for increased compatibility for the available resources.
Though this study did not examine individual outcomes following IMAT implementation, we should note that OTP providers conducted over 100 CD4 tests within the first 3 months of IMAT implementation. Nearly 40 clients were seen by HIV care and treatment-trained clinicians for ART initiation at the MAT clinic. Following this the OTP clinic adopted a ‘test and treat’ model for HIV among PWUD at the OPT clinic, thus eliminating reliance on CD4 testing to determine ART eligibility and increasing workload demands .
There are limitations of this study. We were not able to the domain of process in this study due to lack of available data. Multi-site comparisons of intervention delivery may be a key component in understanding and assessing how implementation is carried out, as well as potential intervention barriers that occurred as a result of the implementation process. It is possible that the exclusion of this construct limits perspectives of implementation barriers and facilitators. We only interviewed patients currently enrolled and providers working at the MNH methadone clinic. Patients who have defaulted or who were not currently enrolled in care for other reasons may have very different perspectives around these issues. Thus, patient interview data may be biased in only collecting the experiences of those who have been successful in treatment. In addition, data for this study were collected in one setting, raising questions around generalizability.
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.
AC analyzed interview data using thematic context analysis. Manuscript preparation was divided between AC, HS and SH. Feedback and editing was provided by DM JM and BL, who contributed greatly to manuscript development. All authors read and approved the final manuscript.
We would like to thank all research participants and our research assistants.
The authors declare that they have no competing interests.
Availability of data and materials
The data generated and/or analyzed during the current study are not publicly available to protect the privacy of the patients and providers at MNH but are available from the corresponding author on reasonable request.
Consent for publication
Ethics approval and consent to participate
This study received ethical approval from the Tanzanian National Institute for Medical Research, Muhimbili University of Health and Allied Sciences, and Ethical and Independent (E&I) Review Services in the United States.
This research was supported by the National Institutes of Health, National Institute on Drug Abuse: Grant number 1R34DA037787. The preparation of this manuscript was supported by the National Institutes of Health, National Institute on Drug Abuse fellowship grant: Grant number T32 DA007250. SH supported by the National Institues of Health, National Heart, Blood, and Lung Institute: Grant number 1K12HL138037. Publication made possible in part by support from the UCSF Open Access Publishing Fund. These funding sources had no role in the analysis or interpretation of the data, writing of the manuscript, or the decision to submit the paper for publication. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.
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