Providing Medication Assisted Treatment (MAT) as an HIV Prevention Intervention: Programmatic Strategies to Maximize Service Utilization in Dar es Salaam, Tanzania

Over the past decade, myriad social and economic factors have fueled a burgeoning population of people who inject heroin in sub-Saharan Africa, creating an urgent need for HIV prevention and treatment services tailored to this marginalized group. While the epidemic in the region remains largely driven through heterosexual risk behavior, a higher probability of disease acquisition per exposure can lead to rapid transmission among people who inject drugs (PWID). Stigma and discrimination isolates PWID from accessing available HIV care services designed for the general population and has contributed to HIV prevalence in PWID up to four times greater than country averages. To address this crisis, a few trailblazing governments with support from international HIV/AIDS funders have begun to develop and in the case of Tanzania, implement, comprehensive national harm reduction services for people who use and inject drugs. This dissertation contributes to the growing body of implementation science literature on medication assisted treatment programs (MAT) for PWID in sub-Saharan Africa. This dissertation takes a three-paper model to identify programmatic and policy strategies to enroll, retain and support patients in MAT programs, focusing on Tanzania. The first paper, a systematic review of the literature on methadone as an HIV prevention intervention, describes evidence-based best practices and applies key findings to make recommendations about service delivery in a limited resource setting. Results suggest that enhanced outreach and increased dosing can help maximize service utilization. The second and third papers delve into the experiences of the first MAT program on mainland sub-Saharan Africa, located at Muhimbili National Hospital in Dar es Salaam, Tanzania. The program has successfully implemented a continuum of harm reduction care, culminating in methadone treatment for PWID. However, monitoring and evaluation data highlight a gender disparity in service utilization, with women comprising less than 10% of clients. Relying on in-depth interviews and observational data collected over three field visits from July 2011 to February 2013, the last two articles look at ongoing service needs for women in treatment and identify strategies to bring more women into care. Results suggest that women face distinct hardship in treatment, needing increased psychosocial support services and economic development interventions to help them heal histories of sexual trauma and regain custody of their children. Additionally, outreach tailored to women can help increase treatment enrollment. Findings from this dissertation have implications for MAT programs in Tanzania and in other areas in the region with similar epidemiological and cultural environments