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Haldane V, Jung AS, De Foo C, Shrestha P, Urdaneta E, Turk E, Gaviria JI, Boadas J, Buse K, Miranda JJ, Strathdee SA, Barratt A, Kazatchkine M, McKee M, Legido-Quigley H. Integrating HIV and substance misuse services: a person-centred approach grounded in human rights. Lancet Psychiatry 2022; 9:676-688. [PMID: 35750060 DOI: 10.1016/s2215-0366(22)00159-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 04/19/2022] [Accepted: 04/19/2022] [Indexed: 12/13/2022]
Abstract
Integrating HIV-related care with treatment for substance use disorder provides an opportunity to better meet the needs of people living with these conditions. People with substance use disorder are rendered especially vulnerable by prevailing policies, structural inequalities, and stigmatisation. In this Series paper we analyse existing literature and empirical evidence from scoping reviews on integration designs for the treatment of HIV and substance use disorder, to understand barriers to and facilitators of care integration and to map ways forward. We discuss how approaches to integration address two core gaps in current models: a failure to consider human rights when incorporating the perspectives of people living with HIV and people who use drugs, and a failure to reflect critically on structural factors that determine risk, vulnerability, health-care seeking, and health equity. We argue that successful integration requires a person-centred approach, which is grounded in human rights, treats both concerns holistically, and reconnects with underlying social, economic, and political inequalities.
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Affiliation(s)
- Victoria Haldane
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Anne-Sophie Jung
- School of Politics and International Studies, University of Leeds, Leeds, UK.
| | - Chuan De Foo
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore; National University Health System, Singapore
| | - Pami Shrestha
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore; National University Health System, Singapore
| | | | - Eva Turk
- Institute for Health and Society, University of Oslo, Oslo, Norway; Medical Faculty, University of Maribor, Maribor, Slovenia
| | - Juan I Gaviria
- Coordinación de Vigilancia Epidemiologica e Infectologia, Hospital del Instituto Ecuatoriano del Seguro Social (IESS) Sur de Quito, Quito, Ecuador
| | - Jesus Boadas
- Centro de Rehabilitación Mental ANSALUD, Santo Domingo, Dominican Republic
| | - Kent Buse
- The George Institute for Global Health, Imperial College London, London, UK
| | - J Jaime Miranda
- Universidad Peruana Cayetano Heredia, Lima, Peru; The George Institute for Global Health, UNSW, Sydney, NSW, Australia
| | | | - Ashley Barratt
- Positive21, London, UK; ReShape/International HIV Partnerships-European Chemsex Forum, London, UK
| | | | - Martin McKee
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Helena Legido-Quigley
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore; National University Health System, Singapore; Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
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Serving the Co-Morbid Mental Health and Substance Use Needs of People with HIV. Community Ment Health J 2021; 57:1328-1339. [PMID: 33387180 DOI: 10.1007/s10597-020-00756-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 12/11/2020] [Indexed: 02/05/2023]
Abstract
People with HIV (PWH) who have mental health disorders (MHD) and substance use disorders (SUD) have lower HIV medication adherence, higher unsuppressed viral loads, and higher mortality rates than those who do not. Individuals who have triple diagnoses (HIV, MHD and SUD) are at an exponential risk for these adverse outcomes. This study explored the barriers and facilitators to accessing and linking PWH with MHD and SUD services. Qualitative interviews with 90 participants were conducted to explore their experiences seeking treatment for MHD and SUD. Results of a thematic analysis found two important barriers to treatment access and utilization: unstable motivation to change and negative experiences with providers. Conversely, an internal drive to heal and rapport with providers facilitated positive treatment experiences. Findings of the study also indicate a need for an integrated treatment model where MHD, SUD, and HIV treatment are available at the same location.
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Grant C, Bergin C, O’Connell S, Cotter J, Ní Cheallaigh C. High-Cost, High-Need Users of Acute Unscheduled HIV Care: A Cross-Sectional Study. Open Forum Infect Dis 2020; 7:ofaa037. [PMID: 32110681 PMCID: PMC7041127 DOI: 10.1093/ofid/ofaa037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 01/30/2020] [Indexed: 11/22/2022] Open
Abstract
Background High-cost, high-need users are defined as patients who accumulate large numbers of emergency department visits and hospital admissions that might have been prevented by relatively inexpensive early interventions and primary care. This phenomenon has not been previously described in HIV-infected individuals. Methods We analyzed the health records of HIV-infected individuals using scheduled or unscheduled inpatient or outpatient health care in St James’s Hospital, Dublin, Ireland, from October 2014 to October 2015. Results Twenty-two of 2063 HIV-infected individuals had a cumulative length of stay >30 days in the study period. These individuals accrued 99 emergency department attendances and 1581 inpatient bed days, with a direct cost to the hospital of >€1 million during the study period. Eighteen of 22 had potentially preventable requirements for unscheduled care. Two of 18 had a late diagnosis of HIV. Sixteen of 18 had not been successfully engaged in outpatient HIV care and presented with consequences of advanced HIV. Fourteen of 16 of those who were not successfully engaged in care had ≥1 barrier to care (addiction, psychiatric disease, and/or homelessness). Conclusions A small number of HIV-infected individuals account for a high volume of acute unscheduled care. Intensive engagement in outpatient care may prevent some of this usage and ensuing costs.
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Affiliation(s)
| | - Colm Bergin
- St James’s Hospital, Dublin, Ireland
- Trinity College, Dublin, Ireland
| | | | | | - Clíona Ní Cheallaigh
- St James’s Hospital, Dublin, Ireland
- Trinity College, Dublin, Ireland
- Correspondence: Clíona Ní Cheallaigh, MB, MRCP, PhD, Department of Clinical Medicine, Trinity Centre for Health Sciences, St James’s Hospital, Dublin 8, Ireland ()
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Abstract
OBJECTIVE We sought to identify optimal strategies for integrating HIV- and opioid use disorder-(OUD) screening and treatment in diverse settings. DESIGN Systematic review. METHODS We searched Ovid MEDLINE, PubMed, Embase, PsycINFO and preidentified websites. Studies were included if they were published in English on or after 2002 through May 2017, and evaluated interventions that integrated, at an organizational level, screening and/or treatment for HIV and OUD in any care setting in any country. RESULTS Twenty-nine articles met criteria for inclusion, including 23 unique studies: six took place in HIV care settings, 12 in opioid treatment settings, and five elsewhere. Eight involved screening strategies, 22 involved treatment strategies, and seven involved strategies that encompassed screening and treatment. Randomized controlled studies demonstrated low-to-moderate risk of bias and observational studies demonstrated fair to good quality. Studies in HIV care settings (n = 6) identified HIV-related and OUD-related clinical benefits with the use of buprenorphine/naloxone for OUD. No studies in HIV care settings focused on screening for OUD. Studies in opioid treatment settings (n = 12) identified improving HIV screening uptake and clinical benefits with antiretroviral therapy when provided on-site. Counseling intensity for OUD medication adherence or HIV-related risk reduction was not associated with clinical benefits. CONCLUSION Screening for HIV can be effectively delivered in opioid treatment settings, yet there is a need to identify optimal OUD screening strategies in HIV care settings. Strategies integrating the provision of medications for HIV and for OUD should be expanded and should not be contingent on resources available for behavioral interventions. REGISTRATION A protocol for record eligibility was developed a priori and was registered in the PROSPERO database of systematic reviews (registration number CRD42017069314).
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Hassan S, Cooke A, Saleem H, Mushi D, Mbwambo J, Lambdin BH. Evaluating the Integrated Methadone and Anti-Retroviral Therapy Strategy in Tanzania Using the RE-AIM Framework. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16050728. [PMID: 30823440 PMCID: PMC6427450 DOI: 10.3390/ijerph16050728] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 02/14/2019] [Accepted: 02/22/2019] [Indexed: 01/03/2023]
Abstract
There are an estimated 50,000 people who inject drugs in Tanzania, with an HIV prevalence in this population of 42%. The Integrated Methadone and Anti-Retroviral Therapy (IMAT) strategy was developed to integrate HIV services into an opioid treatment program (OTP) in sub-Saharan Africa and increase anti-retroviral therapy (ART) initiation rates. In this paper, we evaluate the IMAT strategy using an implementation science framework to inform future care integration efforts in the region. IMAT centralized HIV services into an OTP clinic in Dar Es Salaam, Tanzania: HIV diagnosis, ART initiation, monitoring and follow up. A mixed-methods, concurrent design, was used for evaluation: quantitative programmatic data and semi-structured interviews with providers and clients addressed 4 out of 5 components of the RE-AIM framework: reach, effectiveness, adoption, implementation. Results showed high reach: 98% of HIV-positive clients received HIV services; effectiveness: 90-day ART initiation rate doubled, from 41% pre-IMAT to 87% post-IMAT (p < 0.001); proportion of HIV-positive eligible clients on ART increased from 71% pre-IMAT to 98% post-IMAT (p < 0.001). There was high adoption and implementation protocol fidelity. Qualitative results informed barriers and facilitators of RE-AIM components. In conclusion, we successfully integrated HIV care into an OTP clinic in sub-Saharan Africa with increased rates of ART initiation. The IMAT strategy represents an effective care integration model to improve HIV care delivery for OTP clients.
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Affiliation(s)
- Saria Hassan
- Yale School of Medicine, Yale University, New Haven, CT 06511, USA.
| | - Alexis Cooke
- San Francisco Department of Psychiatry, University of California, San Francisco, CA 94118, USA.
| | - Haneefa Saleem
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA.
| | - Dorothy Mushi
- Department of Psychiatry, Muhimbili University of Health and Allied Sciences, Dar-Es-Salaam 11000, Tanzania.
| | - Jessie Mbwambo
- Department of Psychiatry, Muhimbili University of Health and Allied Sciences, Dar-Es-Salaam 11000, Tanzania.
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Tran BX, Nguyen LH, Nong VM, Nguyen CT, Phan HTT, Latkin CA. Behavioral and quality-of-life outcomes in different service models for methadone maintenance treatment in Vietnam. Harm Reduct J 2016; 13:4. [PMID: 26837193 PMCID: PMC4736621 DOI: 10.1186/s12954-016-0091-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2015] [Accepted: 01/14/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Integrating HIV/AIDS and methadone maintenance treatment (MMT) services with existing health care delivery system is critical in sustaining efforts to fight HIV/AIDS in large injection-driven epidemics. However, efficiency of different integrative service models is unknown. This study assessed behavioral and health-related quality-of-life (HRQOL) outcomes of MMT in four service delivery models and explored factors associated with these outcomes of interest. METHODS A cross-sectional survey was conducted in two HIV epicenters in Vietnam: Hanoi and Nam Dinh Province. All patients in five selected MMT clinics were invited to participate, and 1016 were interviewed (80-90% response rate). RESULTS Respondents had a mean age of 35.8, taken MMT for average 16.5 months and 3.3% on MMT for 36-60 months. The MMT integrated with rural district health center (DHC) has the highest prevalence of concurrent drug use (11.3%). The percentage of condom use (last sexual intercourse) with primary and casual partners was lowest in the MMT at urban DHCs. Patients at the rural DHC reported very high proportions of pain/discomfort (37.8%), anxiety/depression (43.1%), and mobility (13.3%). In regression models, poorer HRQOL outcomes were found in MMT models in the rural areas or without general health care, and among those patients who were HIV positive, reported concurrent drug use, and had higher numbers of previous drug rehabilitation episodes. Mobility and anxiety/depression are factors that increased the likelihood of concurrent drug use among MMT patients. CONCLUSIONS Outcomes of MMT were diverse across different integrative service models. Policies on rapid expansion of the MMT program in Vietnam should also emphasize on the integration with comprehensive health care services including psychological supports for patients.
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Affiliation(s)
- Bach Xuan Tran
- Institute for Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, Vietnam. .,Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Long Hoang Nguyen
- Institute for Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, Vietnam.,School of Medicine and Pharmacy, Vietnam National University, Hanoi, Vietnam
| | - Vuong Minh Nong
- Institute for Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, Vietnam
| | - Cuong Tat Nguyen
- Institute for Global Health Innovations, Duy Tan University, Da Nang, Vietnam
| | | | - Carl A Latkin
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Saleem HT, Mushi D, Hassan S, Bruce RD, Cooke A, Mbwambo J, Lambdin BH. "Can't you initiate me here?": Challenges to timely initiation on antiretroviral therapy among methadone clients in Dar es Salaam, Tanzania. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2015; 30:59-65. [PMID: 26831364 DOI: 10.1016/j.drugpo.2015.12.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Revised: 11/11/2015] [Accepted: 12/10/2015] [Indexed: 01/10/2023]
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.
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Affiliation(s)
- Haneefa T Saleem
- Pangaea Global AIDS, 436, 14th Street, Suite 920, Oakland, CA 94612, United States.
| | - Dorothy Mushi
- Muhimbili University of Health and Allied Sciences, Department of Psychiatry, P.O. Box 65293, Dar es Salaam, Tanzania
| | - Saria Hassan
- Pangaea Global AIDS, 436, 14th Street, Suite 920, Oakland, CA 94612, United States
| | - R Douglas Bruce
- Pangaea Global AIDS, 436, 14th Street, Suite 920, Oakland, CA 94612, United States; Cornell Scott-Hill Health Center, 428 Columbus Avenue, New Haven, CT 06519, United States; Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510, United States
| | - Alexis Cooke
- University of California, Los Angeles, Fielding School of Public Health, Department of Community Health Sciences, United States
| | - Jessie Mbwambo
- Muhimbili University of Health and Allied Sciences, Department of Psychiatry, P.O. Box 65293, Dar es Salaam, Tanzania
| | - Barrot H Lambdin
- RTI International, 351 California Street, Suite 500, San Francisco, CA 94104, United States; University of California San Francisco, San Francisco, CA, United States; University of Washington, Seattle, WA, United States
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