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

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.

Being HIV positive and staying on antiretroviral therapy in Africa: A qualitative systematic review and theoretical model

“…Lack of conformity leads to double stigma for HIV-positive key populations: HIV-positive key populations face marked discrimination related to their life-style. MSM, PWID and sex-workers all do not conform to social norms and as a result are morally judged and discriminated against by others [50, 54, 64, 80, 88]. This discrimination is often worse than that experienced by those who are HIV-positive alone [50, 54, 64] and may cause psychological distress [50, 64], compounded by criminalization of MSM and sex-work in several African settings [50, 54, 88].…”

“…MSM, PWID and sex-workers all do not conform to social norms and as a result are morally judged and discriminated against by others [50, 54, 64, 80, 88]. This discrimination is often worse than that experienced by those who are HIV-positive alone [50, 54, 64] and may cause psychological distress [50, 64], compounded by criminalization of MSM and sex-work in several African settings [50, 54, 88]. As a result, key-populations often have very limited support [50, 64, 76, 88] and for PWID, even with excellent support, drug addiction may trump any consideration of health status [56].…”

“…This discrimination is often worse than that experienced by those who are HIV-positive alone [50, 54, 64] and may cause psychological distress [50, 64], compounded by criminalization of MSM and sex-work in several African settings [50, 54, 88]. As a result, key-populations often have very limited support [50, 64, 76, 88] and for PWID, even with excellent support, drug addiction may trump any consideration of health status [56]. Discrimination plays a large role in keeping key populations away from general HIV services [64, 76, 88].…”

Test and Start for People Living With HIV and Who Use Drugs in Low and Middle Income Countries

“…59 Thus, there is a clear need to manage substance use disorders and the barriers to early initiation of anti-retroviral treatment in "Test and Treat" programs for people living with HIV, who use drugs.…”

Improving linkage to HIV care at low-threshold STI/HIV testing sites: An evaluation of the Immediate Staging Pilot Project in Vancouver, British Columbia

“…25 Delays in CD4 testing and receiving results have been shown to hinder early linkage to HIV care and treatment. 26 The ISPP provided CD4 and viral load testing at the time of diagnosis to expedite the process of testing and getting results. However, our evaluation demonstrated that the time to link to care was not significantly improved between those who consented to blood work and those who declined within the intervention group.…”