The COVID-19 pandemic has universally inflicted challenges in healthcare service delivery and uptake, yet some population groups were disproportionately affected. This particularly includes key populations at risk of HIV such as people who inject drugs (PWID) who are enrolled in the Opioid Substitution Therapy (OST) program. To adhere to COVID-19 mitigation measures, e.g. physical distancing, avoiding overcrowding, stay-at-home orders, and countrywide lockdown, OST clinics worldwide have reduced their service delivery hours and curtailed other treatment support services. 1 Consequently, this could contribute to methadone overdose, withdrawal, discontinuation and dropout from daily methadone dosing, and general health problems. 2, 3 Moreover, personal life circumstances inflicted by the pandemic such as loss of employment, food security and housing could potentially contribute to relapse into opioid drug use. 4, 5 thus elevating their vulnerability to human immunodeficiency virus (HIV) and Hepatitis C virus.
In this context, COVID-19 led us to seek alternative patient-centred approaches such as telehealth services to facilitate access to healthcare for these vulnerable, marginalized populations. Telehealth provides an effective and secure approach for consulting healthcare professionals to gauge a deeper understanding of the symptoms of diseases, prevention and treatment measures, psychological problems, and other related issues. 6 However, while implemented in other countries, this emergency service delivery modality experienced some challenges in facilitating healthcare access.7, 8 As OST requires daily attendance in clinics with limited provisions for take-home doses to a selected group of clients, the COVID-19 situation considerably threatened the continuity of the treatment for those receiving daily treatment. To minimize these barriers within the local context, the Department of Narcotics Control (DNC), under the Ministry of Home Affairs (MoHFW), Government of Bangladesh (GoB) considerably relaxed the guidelines to expand take-home doses of methadone from OST clinics, allowed telehealth services for the delivery of healthcare and education, and allowed clinicians to provide prescriptions remotely.
Lack of computer or eHealth literacy was cited as the most pressing obstacle to rendering telehealth. The insufficiency of high-speed bandwidth, application design issues, and basic interoperability remain as challenges in delivering telehealth services. The lack of appropriate equipment was cited as another challenge. 9 Due to a lack of exposure and training in the new technology, limitations emerge in providing telehealth services efficiently. Another major obstacle was resistance to change and being familiarized with newer modalities, which were exacerbated by the expensive technology. 9
However, telehealth services for OST may widen already-existing inequity gaps among PWID with restricted access to technology, lack of digital literacy, financial constraints, and other social difficulties that limit their capacity to seek healthcare online. Despite the promise of innovative therapies and delivery methods to reach populations facing healthcare access barriers, privileged patients with the necessary resources benefit from telehealth services. 10
The existing evidence in the literature regarding telehealth services among marginalized, vulnerable population such as ex-PWID under OST and other key populations remains scattered and currently lacks synthesis. No such literature has been found in the Bangladeshi context focused on the key population, specifically PWID enrolled in OST programmes. Therefore, this article aims to describe the current status of telehealth services in OST clinics in Bangladesh, as well as its challenges and future prospects. It is hoped that these insights, if incorporated into the telehealth service delivery modality, can help leverage the benefits of telehealth.
OST programme in Bangladesh
Opioid Substitution Therapy (OST) has been pioneered by the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) in Bangladesh. At present, icddr,b, and Save the Children Bangladesh render services to a total of 3200 PWID under the OST programme. OST is recommended by WHO and UNAIDS to contain the transmission of HIV among PWID. 11 The idea behind this process is to substitute the injectable opioid with an oral opioid alternative, which frees PWID from the risk of injection sharing, 12 thus preventing HIV and AIDS transmission. According to a report published in 2016, there are a total of 14 countries in Asia and 87 OST programs around the world, 13
icddr,b operates three stand-alone OST clinics, two in the capital city of Dhaka (at Tejgaon and Doyagonj) and one in Narayngonj district adjacent to Dhaka, providing OST services to a total of 600 PWID. While Tejgaon is an ancillary part of a government-operated drug treatment centre, the other clinics are part of community-based harm reduction service centers for PWID.
Existing services at OST clinic
OST clinics are primarily aimed at providing methadone to PWID in a medically supervised condition where doctors, nurses, counsellors and consultant psychiatrists are available. In addition to methadone provision, the clinics provided free general medical services with lab investigations and medicines, urine testing for illicit substance use (opioids, sedatives, methamphetamine), individual, group or family counselling sessions, complicated case referrals to hospitals, NGOs, etc.
General medical treatment is provided by a registered physician along with free over-the-counter medications. Also, HIV testing services (HTS) are available, and there is a system in place to refer people to care and support who are diagnosed as HIV positive, i.e. at government ART centers. Counselling officers also provide individual counselling sessions and operate weekly group discussion meetings as part of a behavior change communication strategy.
COVID-19 scenario in Bangladesh
Bangladesh reported its first case on 8th March 2020 from Narayanganj, where one of our OST clinics is situated. The first COVID-related death occurred on 18th March 2020. The cumulative caseload on 31st March 2021 was 61,1295. 14 Since then, the Government of Bangladesh declared a partial lockdown of the cities, particularly Dhaka, by shutting down public transport, marketplace, public and private schools, and offices on 26th March 2020. Only the emergency services like hospitals, pharmacies, fire brigades, food stores, etc. were exempted from the lockdown.
The below Fig. 1 is highlighting the infection trends and stay-at-home regulations implemented by the Government are shown from January 2020 to March 2021. 15
Challenges imposed by COVID-19 on OST and its pathway to telehealth
The ongoing lockdown constituted a major threat for OST clients who depend on daily doses of methadone, an opioid substance that induces physical and psychological dependence. The odds of treatment interruption, dropout, concurrent drug use, and overdose-related mortality among OST clients were all made more likely by the lockdown circumstances and It was necessary to use a different type of intervention strategy. The routine programme data revealed high rates of treatment retention indicator of 98% (147/149) before intervention but it came down 29% (43/149) during the initial stages of the pandemic. Therefore, there was a consensus between the government and programme implementers to relax the stringent guidelines of the methadone take-home dose, thus allowing flexibility in the services to ensure treatment retention. But in addition to giving out take-home doses, doctor consultations were also required to address subsequent dose adjustments, withdrawal management, and unexpected clinical situations like missed or vomited doses in order to fine-tune the methadone dosages.
Another major challenge faced by the OST programme during the COVID-19 pandemic was the disruption of the regular clinic activities, particularly the general medical treatment provided by the clinic physician. The OST clients, who were all ex-PWID, generally had a prolonged history of substance use, practised risky injecting and sexual behaviour and had various medical issues warranting medical attention due to their volatile lifestyle. Along with syndemic infections like HIV, HCV, HBV, and TB; general medical conditions emerged such as diarrhoea, anorexia, nausea, vomiting, generalized fatigue, weight loss, common cold, cough, etc. Severe clinical conditions were also reported such as COPD, leg ulcers, Deep Vein Thrombosis (DVT), etc. that requires specialized treatment, appropriate referrals and follow-up. Programmatic experiences indicated the constant demand for medical advice by the OST clients, even for simpler complaints. If their demands are unmet, there is chance of treatment discontinuation or dropout. To alleviate this issue, icddr,b OST clinics started to provide medical advice, basic health education, COVID-19-related information and medical prescriptions to the OST clients, adopting the concept of telehealth.
Telehealth
“The term telehealth denotes the delivery of healthcare services, where distance is a critical factor, by all healthcare professionals using information and communication technologies for the exchange of valid information for the diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of health care providers, all in the interest of advancing the health of individuals and their communities”. 16