title: "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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Pangaea Global AIDS, 436, 14th Street, Suite 920, Oakland, CA 94612, United States. Electronic address: hsaleem1@jhu.edu.
authors.forename: Haneefa T
authors.initials: HT
authors.lastname: Saleem
authors.affiliation: Muhimbili University of Health and Allied Sciences, Department of Psychiatry, P.O. Box 65293, Dar es Salaam, Tanzania.
authors.forename: Dorothy
authors.initials: D
authors.lastname: Mushi
authors.affiliation: Pangaea Global AIDS, 436, 14th Street, Suite 920, Oakland, CA 94612, United States.
authors.forename: Saria
authors.initials: S
authors.lastname: Hassan
authors.affiliation: 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.
authors.forename: R Douglas
authors.initials: RD
authors.lastname: Bruce
authors.affiliation: University of California, Los Angeles, Fielding School of Public Health, Department of Community Health Sciences, United States.
authors.forename: Alexis
authors.initials: A
authors.lastname: Cooke
authors.affiliation: Muhimbili University of Health and Allied Sciences, Department of Psychiatry, P.O. Box 65293, Dar es Salaam, Tanzania.
authors.forename: Jessie
authors.initials: J
authors.lastname: Mbwambo
authors.affiliation: 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.
authors.forename: Barrot H
authors.initials: BH
authors.lastname: Lambdin
mesh_terms: D019380:Anti-HIV Agents / Q000008:administration & dosage*; D018791:CD4 Lymphocyte Count; D005260:Female; D015658:HIV Infections / Q000188:drug therapy*; D007722:Health Knowledge, Attitudes, Practice; D006297:Health Services Accessibility; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D008691:Methadone / Q000008:administration & dosage*; D058850:Opiate Substitution Treatment / Q000379:methods; D019095:Point-of-Care Systems; D057545:Social Stigma; D012944:Social Support; D013636:Tanzania; D013997:Time Factors
chemical_list: D019380:Anti-HIV Agents; D008691:Methadone
keywords: Antiretroviral therapy; Integrated services; Methadone; Qualitative; Tanzania
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