1. Viral Suppression at the First Integrated Methadone and Antiretroviral Therapy Program for People who Inject Drugs in sub-Saharan Africa
Dar es Salaam, Tanzania
Barrot H. Lambdin, PhD, MPH
Senior Epidemiologist & Implementation Scientist
RTI-International, San Francisco, CA

2. Development of Integrated Methadone & Antiretroviral Therapy (IMAT)
Opioid Treatment Program
Launched February 2011
Methadone maintenance
Initially, HIV services partially integrated
Community engagement process to develop fully integrated model
OTP patients
OTP providers
Community engagement meetings
HIV Diagnosis
ART Distribution
Linkage to HIV Care & Tx
Purpose was to identify barriers to timely initiation of ART and perceived benefits/challenges of a fully integrated model of HIV care and methadone

3. Integrated Methadone & Antiretroviral Therapy – Oct 2015
Trained several OTP nurses and clinicians
Point of care diagnostics to determine eligibility
Test & Treat – Jan 2016
Multiple ART Dispensing models
30 day supply from OTP provider
DOT from OTP provider
Co-dispensed with methadone
Off-site ART

4. Methodological Approach
Prospective cohort study:
To assess viral suppression at 6 and 12-months after IMAT implementation
To assess for predictors of viral suppression at 12 months
Routine programmatic and laboratory data: Oct ‘15–Jun ‘17
Outcome: Viral Suppression (<1,000 copies/mL)
ART-related exposures: Dispensing Location, Doses per Day, Dispensing model
Potential Confounders: age, sex, education, CD4 count, time in treatment, HCV, HBV, anxiety, depression, victim of assault
Statistical approach: Logistic regression with robust variances
Model included confounders that were moderately associated (p<0.2) with viral suppression

5. Results 137 clients in HIV care - 135 clients on ART (2 refusals)
Died, 2 (<1%)
Discharged, 1 (<1%)
Defaulted,
6 (4%)
On ART < 12 Mths
20 (15%)
On ART ≥ 12 Mths
106 (78%)

6. Results Characteristics of IMAT Patients on ART for 12 Months
Age, mean (sd)
38 (7)
Female, %
16%
Secondary Education, %
28%
CD4 Count, %
<350, %
39%
≥350-<500, %
24%
≥500, %
37%
HCV antibody +, %
71%
HBV+, %
22%
Depression (past 30 days)
20%
Anxiety (past 30 days)
Victim of Assault
11%

7. Results

8. Number of people who were receiving ART from the methadone clinic and their clinical care and lab monitoring was transferred to the IMAT clinic. Other clients who were receiving ART off-site and their clinical care and monitoring was transferred to the IMAT clinic. Clients who were not on ART and we were able to get them onto ART, and then, there was a new wave of eligible clients after the government allowed us to do test and treat that we were able to get onto ART.

9. Results: Associations with viral suppression
aOR (95% CI)
p-value
ART Dispensing Location
-Off-site ART
1.00 (ref)
-On-site ART
7.01 ( )
0.012
ART Doses per Day
-One
-Two
0.16 ( )
0.022
ART Dispensing Method
-Directly Observed
-Monthly
1.55 ( )
0.620

10. Discussion
High levels of retention & viral suppression among IMAT patients on ART
Success of IMAT driven by early engagement of OTP patients and providers
Limitations: observational data
On-site ART – leverage relationships between OTP providers and clients
Number of doses – possible surrogate for adherence
Future work to develop differentiated models of care for people receiving ART

11. Acknowledgements
Study participants – opioid treatment program patients, providers, program managers and policy makers
Co-authors: Dorothy Mushi, Jessie Mbwambo, Saria Hassan and Alexis Cooke
National Institute of Health (NIDA)
Program Officer: Shoshana Kahana
Technical Collaboration: RTI-International, Muhimbili University of Health and Allied Sciences, Ministry of Health and Social Welfare, National AIDS Control Program