Residential and inpatient treatment of substance use disorders in Sub-Saharan Africa: a scoping review.

BACKGROUND: With substance use rates increasing in Sub-Saharan Africa (SSA), an understanding of the accessibility and effectiveness of rehabilitative services for people who use alcohol and other drugs (AOD) is critical in the global efforts to diagnose and treat substance use disorders (SUD). This scoping review seeks to address the gaps in knowledge related to the types of research that have been conducted regarding inpatient or residential SUD treatment in SSA, the settings in which the research was conducted, and the study countries. METHODS: A search of three databases, PubMED, Scopus, and African Index Medicus, was conducted for publications related to the treatment of SUD in inpatient or residential settings in SSA. Articles were screened at the title/abstract level and at full text by two reviewers. Articles eligible for inclusion were original research, conducted in SSA, published in English, included populations who received or were currently receiving treatment for SUD in inpatient or residential settings, or documented demand for SUD services. RESULTS: This scoping review included 82 studies originating from 6 countries in SSA. Three themes emerged within the literature: access and demand for inpatient and residential SUD treatment, quality and outcomes of SUD treatment, and descriptions of the services offered and staffing of these facilities. Barriers to access include financial barriers, limited availability of services, and geographic concentration in cities. Women were shown to access residential and inpatient SUD treatment at lower rates than men, and certain racial groups face unique language and financial barriers in accessing services. Studies indicate mixed success of inpatient and residential SUD treatment in sustained SUD remission for patients. CONCLUSION: There are significant gaps in the literature, driven by a lack of longitudinal studies focused on patient outcomes following treatment and the use of a narrow definition of treatment success. Both structural and non-structural barriers, such as stigma and discrimination, are barriers to access. Further research is needed to evaluate approaches to mitigate these barriers and expand access to residential and inpatient SUD treatment.

PrEP initiation and discontinuation among transgender women in the United States: a longitudinal, mixed methods cohort study.

INTRODUCTION: Transgender women in the United States experience high HIV incidence and suboptimal Pre-exposure prophylaxis (PrEP) engagement. We sought to estimate PrEP initiation and discontinuation rates and characterize PrEP discontinuation experiences among a prospective cohort of transgender women. METHODS: Using a sequential, explanatory, mixed-methods design, 1312 transgender women at risk for HIV acquisition were enrolled from March 2018 to August 2020 and followed through July 2022 (median follow-up 24 months; interquartile range 15-36). Cox regression models assessed predictors of initiation and discontinuation. In-depth interviews were conducted among 18 participants, including life history calendars to explore key events and experiences surrounding discontinuations. Qualitative and quantitative data were integrated to generate typologies of discontinuation, inform meta-inferences and facilitate the interpretation of findings. RESULTS: 21.8% (n = 286) of participants reported taking PrEP at one or more study visits while under observation. We observed 139 PrEP initiations over 2127 person-years (6.5 initiations/100 person-years, 95% CI: 5.5-7.7). Predictors of initiation included identifying as Black and PrEP indication. The rate of initiation among those who were PrEP-indicated was 9.6 initiations/100 person-years (132/1372 person-years; 95% CI: 8.1-11.4). We observed 138 PrEP discontinuations over 368 person-years (37.5 discontinuations/100 person-years, 95% CI: 31.7-44.3). Predictors of discontinuation included high school education or less and initiating PrEP for the first time while under observation. Four discontinuation typologies emerged: (1) seroconversion following discontinuation; (2) ongoing HIV acquisition risk following discontinuation; (3) reassessment of HIV/STI prevention strategy following discontinuation; and (4) dynamic PrEP use coinciding with changes in HIV acquisition risk. CONCLUSIONS: PrEP initiation rates were low and discontinuation rates were high. Complex motivations to stop using PrEP did not consistently correspond with HIV acquisition risk reduction. Evidence-based interventions to increase PrEP persistence among transgender women with ongoing acquisition risk and provide HIV prevention support for those who discontinue PrEP are necessary to reduce HIV incidence in this population.

From trauma to transmission: exploring the intersection of adversity, substance use, and HIV risk in women's life histories.

BACKGROUND: At increased risk for poor health outcomes, physical and/or sexual violence, and onward transmission of HIV, women who use drugs and are living with HIV (WWUDHIV) are vulnerable and in need of services. Understanding the role of trauma across their life history may offer insights into HIV and drug use prevention and opportunities for intervention. We explored trauma and drug use among WWUDHIV in Dar es Salaam, Tanzania. METHODS: We conducted in-depth interviews with 30 WWUDHIV from January-March 2019. Interviewers used semi-structured interview guides and asked questions about the life history as related to drug use. Interviews were audio recorded, transcribed, translated, coded, and life histories charted. We utilized content analysis. RESULTS: Participants described death of family members as traumatic catalysts for drug use. Sexual partners early in their life history were often the point of introduction to drugs and source of HIV acquisition. Death of partners was present across many life histories and was a traumatic event negatively influencing life trajectories, including start of sex work for survival or to support drug use. Sex work in-turn often led to traumatic events including sexual and/or physical violence. HIV diagnosis for many participants followed the start of drug use, frequently occurred during pregnancy or severe illness and was described by most participants as a trauma. Despite this, particularly during pregnancy, HIV diagnosis was a turning point for some participant's desire to engage in drug use treatment. Traumatic events were often cumulative and regularly described as catalysts for poor mental health that could lead to new or increased drug use for coping. CONCLUSIONS: These findings suggest trauma is common in the life history of WWUDHIV and has negative impacts on drug use and HIV vulnerability. Our life history charting highlights the cumulative and cyclical nature of trauma and drug use in this population. This study allows for better understanding of trauma, drug use, and HIV prevention, which offers opportunities for intervention among a group with limited access to services: during adolescence for orphaned youth, following the death of a child or partner, and when vulnerable women engage with the health system (HIV diagnosis, pregnancy, illness).

Virtual Implementation of a Photovoice Project With Youth in Baltimore During the COVID-19 Pandemic.

This article describes the virtual implementation of Photovoice activities conducted as part of a project that sought to gather youths' perspectives on neighborhood and housing conditions, community redevelopment, and health and well-being in Baltimore. We discuss the original in-person design and how activities were implemented virtually, in light of coronavirus disease 2019 (COVID-19) physical distancing guidelines. Challenges to virtual implementation included establishing rapport with youth and families during recruitment and data collection, encouraging active participation during discussion sessions, and varying technological skills among youth. Facilitators of virtual implementation included partnering with a community organization, piloting virtual sessions to assess participant's technology skills, and providing various ways for youth to participate during discussion sessions, engage in group activities, and receive hands-on instruction. This article showcases the ways in which virtual implementation of Photovoice activities can be successfully implemented with youth and provides recommendations for future Photovoice projects that include virtual activities.

Prevalence and predictors of depressive and anxiety symptoms in a sample of women who use drugs in Tanzania: the key role of drug use stigma.

BACKGROUND: Globally, women who use drugs face multiple health vulnerabilities, including poor mental health. Little is known about the mental health burden among women who use drugs in sub-Saharan Africa. This cross-sectional study examined the prevalence and predictors of depressive and anxiety symptoms among a sample of women who use drugs in Dar es Salaam, Tanzania. METHODS: We administered a cross-sectional survey to a non-random sample of 200 women who use drugs in Dar es Salaam between November 2018 and March 2019. We used descriptive statistics to characterize the study sample and fitted separate logistic regression models to assess depressive and anxiety symptoms and their predictors. RESULTS: The percentages of women reporting depressive and anxiety symptoms were 67.5% and 43.7%, respectively. Internalized drug use stigma (AOR = 1.34, 95% CI: 1.03-1.75) and prior attempts to stop heroin use (AOR = 2.99, 95% CI: 1.28-7.00) were associated with depressive symptoms. Enacted drug use stigma from health workers (AOR = 2.02, 95% CI: 1.34-3.04) and anticipated drug use stigma from family (AOR = 1.49, 95% CI: 1.02-2.16) were associated with anxiety symptoms. CONCLUSIONS: Depressive and anxiety symptoms were high among our study sample, with higher reports of symptoms of depression than anxiety. Drug use stigma was a key factor that contributed to elevated symptoms of depression and anxiety.

Economic, social, and clinic influences on opioid treatment program retention in Dar es Salaam, Tanzania: a qualitative study.

BACKGROUND: Medications for opioid use disorder (MOUD) are associated with positive health outcomes. People remaining on MOUD have a reduced likelihood of drug overdose and mortality. Tanzania supports a national opioid treatment program (OTP) offering MOUD, but retention is a continual challenge. To date, most research on MOUD retention in Tanzania and other Sub-Saharan Africa settings has been focused on the individual-level, with little attention to economic, social, and clinic-level factors. METHODS: We qualitatively examined economic, social, and clinic factors that affect retention on MOUD, specifically methadone maintenance therapy, among former and current clients attending an OTP clinic Dar es Salaam, Tanzania. We conducted in-depth interviews with a total of 40 current and former clients receiving MOUD and four focus groups with an additional 35 current clients on MOUD between January and April 2020. We utilized a thematic analysis approach. RESULTS: Daily OTP clinic attendance posed a financial burden to current and former clients and was a barrier to remaining on MOUD. Though treatment is free, clients described struggles to attend clinic, including being able to afford transportation. Female clients were differentially impacted, as sex work was the most common income-generating activity that they participated in, which presented its own set of unique challenges, including barriers to attending during set clinic hours. Drug use stigma acted as a barrier to MOUD and prevented clients from securing a job, rebuilding trust within the community, and accessing transportation to attend the clinic. Being able to rebuild trust with family facilitated remaining on MOUD, as family provided social and financial support. Caretaking responsibilities and familial expectations among female clients conflicted with MOUD adherence. Finally, clinic level factors, such as clinic dispensing hours and punitive consequences for breaking rules, posed barriers to clients on MOUD. CONCLUSION: Social and structural factors, both within (e.g., clinic policies) and outside of (e.g., transportation) the clinic impact MOUD retention. Our findings can inform interventions and policies to address economic and social barriers to MOUD, that can contribute to sustained recovery.

Experiences of Black Women in the United States Along the PrEP Care Continuum: A Scoping Review.

Black women are disproportionately affected by HIV in the U.S. PrEP could decrease the risk of acquiring HIV. This scoping review seeks to understand the experiences of Black women along the PrEP Care Continuum. We searched PubMed, Embase, PsycInfo, and Google Scholar to identify peer-reviewed studies published between July 16, 2012, and December 15, 2021. Articles were included if they discussed PrEP among Black women in the U.S. Two authors screened titles/abstracts and full-text articles. One author extracted and thematically summarized findings (n = 33). Black women reported low levels of PrEP awareness and knowledge, and negative experiences with providers. Women also experienced negative perceptions of PrEP from their social networks, stigma, and mistrust. Future research should focus on helping Black women to overcome PrEP-related barriers. Additionally, future research should further examine barriers to PrEP initiation, adherence, and retention for Black women, as only three studies discussed these aspects of the Continuum.

RESUMEN: Las mujeres negras se ven afectadas de manera desproporcionada por el VIH en los EE. UU. La PrEP podría disminuir el riesgo de contraer el VIH. Esta revisión de alcance busca comprender las experiencias de las mujeres negras a lo largo del continuo de atención de la PrEP. Realizamos búsquedas en PubMed, Embase, PsycInfo y Google Scholar para identificar estudios revisados ​​por pares publicados entre el 16 de julio de 2012 y el 15 de diciembre de 2021. Se incluyeron artículos si discutían la PrEP entre mujeres negras en los EE. UU. Dos autores examinaron títulos/resúmenes y -Artículos de texto. Un autor extrajo y resumió temáticamente los hallazgos (n = 33). Las mujeres negras informaron niveles bajos de conciencia y conocimiento sobre la PrEP y experiencias negativas con los proveedores. Las mujeres también experimentaron percepciones negativas de la PrEP en sus redes sociales, estigma y desconfianza. La investigación futura debería centrarse en ayudar a las mujeres negras a superar las barreras relacionadas con la PrEP. Además, la investigación futura debe examinar más a fondo las barreras para el inicio, la adherencia y la retención de la PrEP para las mujeres negras, ya que solo 3 estudios analizaron estos aspectos del Continuum.

HIV Stigma, HIV status disclosure, and ART adherence in the context of an integrated opioid use disorder and HIV treatment setting in Dar es Salaam, Tanzania.

Little is known about social factors, including stigma, that affect antiretroviral therapy (ART) adherence among people enrolled in opioid use disorder treatment (OUDT) in the context of integrated OUDT and HIV treatment models. We qualitatively examined the relationship between HIV stigma, HIV status disclosure, and ART adherence among clients living with HIV at an OUDT clinic with integrated HIV services in Tanzania. We conducted in-depth interviews with 25 clients receiving HIV care at an OUDT clinic in Dar es Salaam, Tanzania between January and April 2020. HIV stigma, particularly anticipated stigma, and HIV status disclosure were key factors that affected ART adherence. Participants feared non-voluntary HIV status disclosure to and HIV stigma from their peers enrolled in OUDT. Most participants reported concealing their HIV status from peers at the OUDT clinic and not associating with other clients living with HIV at the clinic. Reducing HIV stigma and enhancing clinic structures and procedures to maintain privacy and confidentiality are essential to mitigating the effects of stigma on ART adherence.

Behavioral Determinants of Routine Health Information System Data Use in Senegal: A Qualitative Inquiry Based on the Integrated Behavioral Model.

Routine health information system (RHIS) data are essential in driving decision making and planning in health systems as well as health programs. However, despite their importance, these data are underutilized, and the underlying individual-level facilitators and barriers to use remain understudied. In this research, we applied the Integrated Behavior Model (IBM) to examine how attitudes toward RHIS data, perceived norms concerning RHIS data use, and the ability to use RHIS data influence the demand and use of RHIS data among stakeholders in Senegal. Using data from interviews with respondents working at national levels of malaria, HIV, and TB control programs in Senegal, we used a framework analysis approach to apply the IBM behavioral constructs and identify their linkages to RHIS data use. We found that attitudes about the quality, availability, and relevance of RHIS data for decision making were important in driving data use among respondents. Institutional expectations, organizational protocols, policies, and practices around RHIS data ultimately shape social norms around the use of the data. Although we found that perceived ability and self-efficacy to use RHIS data were not barriers to RHIS data use among stakeholders at the strategic levels of their respective organizations, these were reported to be barriers at lower levels of the health system. Low perceived control of the RHIS data production process ultimately reduced RHIS data use for decision making among the strategic-level respondents. We recommend context-specific reexamination of existing RHIS interventions with a renewed emphasis on behavioral aspects of data use. The IBM can help guide practitioners, policy makers, and academics to address multiple socioecological factors that influence data use behavior when recommending RHIS and data use solutions.

Revisiting revitalization: exploring how structural determinants moderate pathways between neighborhood change and health.

Vacant housing can produce many issues that affect residents' quality of life, especially in historically segregated communities of color. To address these challenges, local governments invest in strategic, place-based revitalization initiatives focused on the regeneration of vacant housing. Yet, the outcomes of these efforts remain contested. To maximize health benefits of revitalization investments, a more nuanced understanding of pathways between neighborhood changes and residents' responses, adaptations, and ability to thrive is necessary, though, remains largely absent in the literature. Using the Vacants to Value initiative in Baltimore, MD as a case study, we explore (1) how health manifests among certain groups in the context of vacant housing revitalization; (2) how vacant housing and its regeneration engender social and cultural environmental change i.e., gentrification; and (3) what structural determinants (cultural norms, policies, institutions, and practices) contribute to the distribution of material resources and benefits of revitalization. Results suggest that vacant housing revitalization requires more than just physical remedies to maximize health. Our findings demonstrate how vacant housing revitalization influences the physical environment, social environment, and structural determinants of material resources and community engagement that can ultimately impact residents' physical, mental, and social health. This study recommends that because housing disparities are rooted in structural inequalities, how policies, practices, and processes moderate pathways for residents to adapt and benefit from neighborhood changes is consequential for health and health equity. Establishing shared governance structures is a promising approach to foster equitable decision-making and outcomes. Going forward in urban regeneration, pathways to retain and strengthen the social environment while revitalizing the physical environment may be promising to achieve healthy communities.