Association of collaborative care intervention features with depression and metabolic outcomes in the INDEPENDENT study: A mixed methods study.

AIMS: The INtegrating DEPrEssioN and Diabetes treatmENT (INDEPENDENT) trial tested a collaborative care model including electronic clinical decision support (CDS) for treating diabetes and depression in India. We aimed to assess which features of this clinically and cost-effective intervention were associated with improvements in diabetes and depression measures. METHODS: Post-hoc analysis of the INDEPENDENT trial data (189 intervention participants) was conducted to determine each intervention feature's effect: 1. Collaborative case reviews between expert psychiatrists and the care team; 2. Patient care-coordinator contacts; and 3. Clinicians' CDS prompt modifications. Primary outcome was baseline-to-12-months improvements in diabetes control, blood pressure, cholesterol, and depression. Implementer interviews revealed barriers and facilitators of intervention success. Joint displays integrated mixed methods' results. RESULTS: High baseline HbA1c≥ 74.9 mmol/mol (9%) was associated with 5.72 fewer care-coordinator contacts than those with better baseline HbA1c (76.8 mmol/mol, 9.18%, p < 0.001). Prompt modification proportions varied from 38.3% (diabetes) to 1.3% (LDL). Interviews found that providers' and participants' visit frequencies were preference dependent. Qualitative data elucidated patient-level factors that influenced number of clinical contacts and prompt modifications explaining their lack of association with clinical outcomes. CONCLUSION: Our mixed methods approach underlines the importance of the complementarity of different intervention features. Qualitative findings further illuminate reasons for variations in fidelity from the core model.

Disparities in diabetes prevalence and management by race and ethnicity in the USA: defining a path forward.

Type 2 diabetes disparities in the USA persist in both the prevalence of disease and diabetes-related complications. We conducted a literature review related to diabetes prevention, management, and complications across racial and ethnic groups in the USA. The objective of this review is to summarise the current understanding of diabetes disparities by examining differences between and within racial and ethnic groups and among young people (aged <18 years). We also examine the pathophysiology of diabetes as it relates to race and ethnic differences. We use a conceptual framework built on the socioecological model to categorise the causes of diabetes disparities across the lifespan looking at factors in five domains of health behaviours and social norms, public awareness, structural racism, economic development, and access to high-quality care. The range of disparities in diabetes prevalence and management in the USA calls for a community-engaged and multidisciplinary approach that must involve community partners, researchers, practitioners, health system administrators, and policy makers. We offer recommendations for each of these groups to help to promote equity in diabetes prevention and care in the USA.

Strengthening Public Health Scholarship in Sudan: The Role of Leadership and Mentorship Development.

A robust public health workforce in Sudan is essential for accelerating progress toward the Sustainable Development Goals, and strengthening public health education is a priority for the Ministries of Health and Higher Education. Faculty at public health training institutions are a critical resource. Globally, development programs for junior to midlevel public health faculty have been well documented. However, most involved direct partnership between a university from the Global North and only one or two universities from the Global South, only one included an explicit focus on creation of a leadership network, and none were launched as fully virtual collaborations. Therefore, we conducted a mixed-method evaluation of the fully virtual Yale-Sudan Program for Research Leadership in Public Health. We used program records, participant feedback, competency assessment, and network analysis to evaluate 1) participant engagement, 2) change in skill, and 3) change in collaboration. The program achieved a 93% graduation rate. All participants would "definitely" recommend the program and described the live virtual sessions as engaging, effective, and accessible. We observed progress toward learning objectives and significant increases in 13 of 14 leadership and mentorship competency domains. Collaboration across Sudanese institutions increased, including an almost doubling in the number of pairs reporting scholarly collaboration. Eight authorship teams are actively working toward peer-reviewed publications. The program engaged scholars and policymakers from across Sudan and the Sudanese diaspora achieved high levels of co-creation and continues despite significant political unrest in the country, serving as a promising model for strengthening of public health education in Sudan.

Toward Reducing Health Information Inequities in the Caribbean: Our Experience Building a Participatory Health Informatics Project.

Precision medicine seeks to leverage technology to improve the health for all individuals. Successful health information systems rely fundamentally on the integration and sharing of data from a range of disparate sources. In many settings, basic infrastructure inequities exist that limit the usefulness of health information systems. We discuss the work of the Yale Transdisciplinary Collaborative Center for Health Disparities focused on Precision Medicine, which aims to improve the health of people in the Caribbean and Caribbean diaspora by leveraging precision medicine approaches. We describe a participatory informatics approach to sharing data as a potential mechanism to reducing inequities in the existing data infrastructure.

Evaluating the Integrated Methadone and Anti-Retroviral Therapy Strategy in Tanzania Using the RE-AIM Framework.

There are an estimated 50,000 people who inject drugs in Tanzania, with an HIV prevalence in this population of 42%. The Integrated Methadone and Anti-Retroviral Therapy (IMAT) strategy was developed to integrate HIV services into an opioid treatment program (OTP) in sub-Saharan Africa and increase anti-retroviral therapy (ART) initiation rates. In this paper, we evaluate the IMAT strategy using an implementation science framework to inform future care integration efforts in the region. IMAT centralized HIV services into an OTP clinic in Dar Es Salaam, Tanzania: HIV diagnosis, ART initiation, monitoring and follow up. A mixed-methods, concurrent design, was used for evaluation: quantitative programmatic data and semi-structured interviews with providers and clients addressed 4 out of 5 components of the RE-AIM framework: reach, effectiveness, adoption, implementation. Results showed high reach: 98% of HIV-positive clients received HIV services; effectiveness: 90-day ART initiation rate doubled, from 41% pre-IMAT to 87% post-IMAT (p < 0.001); proportion of HIV-positive eligible clients on ART increased from 71% pre-IMAT to 98% post-IMAT (p < 0.001). There was high adoption and implementation protocol fidelity. Qualitative results informed barriers and facilitators of RE-AIM components. In conclusion, we successfully integrated HIV care into an OTP clinic in sub-Saharan Africa with increased rates of ART initiation. The IMAT strategy represents an effective care integration model to improve HIV care delivery for OTP clients.

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.

Convenience without disclosure: a formative research study of a proposed integrated methadone and antiretroviral therapy service delivery model in Dar es Salaam, Tanzania.

BACKGROUND: Though timely initiation of antiretroviral therapy (ART) is a vital component of effective HIV prevention, care and treatment, people who inject drugs are less likely to receive ART than their non-drug using counterparts. In an effort to increase access to ART for people who inject drugs, we examined perceived benefits, challenges, and recommendations for implementing an integrated methadone and ART service delivery model at an opioid treatment program (OTP) clinic in Dar es Salaam, Tanzania. METHODS: We conducted in-depth interviews with 12 providers and 20 HIV-positive patients at the Muhimbili National Hospital OTP clinic in early 2015. We used thematic content analysis to examine patient and provider perspectives of an integrated model. RESULTS: Respondents perceived that offering on-site CD4 testing and HIV clinical management at the OTP clinic would improve the timeliness and efficiency of the ART eligibility process, make HIV clinical care more convenient, mitigate stigma and discrimination in HIV care and treatment settings, and improve patient monitoring and ART adherence. However, perceived challenges included overburdened OTP clinic staff and limited space at the clinic to accommodate additional services. Limited privacy at the OTP clinic and its contribution to fear among HIV-positive patients of being stigmatized by their peers at the clinic was a common theme expressed particularly by patients, and often corroborated by providers. Co-dispensing ART and methadone at the clinic's pharmacy window was viewed as a potential deterrent for patients. Providers felt that an electronic health information system would help them better monitor patients' progress, but that this system would need to be integrated into existing health information systems. To address these potential barriers to implementing an integrated model, respondents recommended increasing OTP provider and clinic capacity, offering flexible ART dispensing options, ensuring privacy with ART dispensing, and harmonizing any new electronic health information systems with existing systems. CONCLUSIONS: An integrated methadone and ART service delivery model at the MNH OTP clinic could improve access to HIV care and treatment for OTP patients. However, specific implementation strategies must ensure that OTP providers are not overburdened and confidentiality of patients is maintained.

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

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.