Exploring barriers and potential solutions before implementing a scale-up strategy to expand methadone coverage among people who inject drugs in Tajikistan

Abstract

Introduction: The Eastern European and Central Asian region has the most rapidly growing HIV epidemic worldwide, concentrated among people who inject drugs (PWID). Scaling up opioid agonist therapies (OAT) is a highly effective primary and secondary HIV prevention strategy, yet coverage remains low (2.7 %) among the 18,000 PWID injecting opioids in Tajikistan. Methods: As part of a pre-implementation activity before using the blended NIATx implementation strategy, we focused on the first NIATx principle, to understand and involve the customer by exploring the barriers and facilitators to OAT scale-up (i.e. greater methadone program entry and retention resulting in more people on methadone). From October to December 2023, recipients (i.e., PWID) were assessed across all 14 OAT sites in 12 cities in 28 focus groups, stratified by those on (N = 120) and not on (N = 108) methadone. Nominal group technique (NGT) was selected as a rapid, inclusive and mixed methods strategy to identify and prioritize the most important barriers and facilitators. Barriers and solutions were categorized to guide implementation targeting individual (i.e., patients/providers), organizational (i.e., clinic) and policy (e.g., laws/regulations) factors. Results: The three highest-ranking barriers nationally to scaling up methadone were similar for both groups: 1) organizational factors like logistical inconvenience and demands on patients (transport, schedule, daily dosing); 2) policy factors like requirements to be listed in the national OAT registry which can restrict access to a driver's license and employment; and 3) individual and societal factors like widespread disinformation about methadone. The three highest-ranking solutions included: 1) changing policies to allow take-home dosing (both groups); 2) expanding the number of sites where methadone could be dispensed (e.g., primary healthcare clinics and pharmacies); and 3) widely disseminating reliable information about methadone to PWID and other stakeholders like governmental organizations and police. For those not on methadone, site expansion was the second highest solution, while for those not on methadone, disseminating accurate information was second highest. Conclusion: This pre-implementation study provides important insights into implementation strategies that might be considered to scale-up methadone that targets recipients (patients, providers, and family), organizations and policies.