Patient and provider perspectives on implementation barriers and facilitators of an integrated opioid treatment and HIV care intervention

BACKGROUND: 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). METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.