This qualitative study sample included 62 participants: 25 health care providers and 37 HIV-positive PWID across the HPTN 074 study sites in three countries (Table 1).
Seventeen providers were clinicians and 8 were SNs. PWID were predominantly male (n=32; 86.5%); female PWID were represented only in Ukraine (5 of 15 participants or 33%), which reflected PWID gender distribution at all three sites . The median age of PWID was 35 years; they were slightly younger in Ukraine and older in Vietnam. On average, over half were unemployed.
Barriers to MAT uptake by PWID living with HIV
Overall, PWID and their health care providers across all sites reported numerous, similar barriers to MAT initiation, although there were some country-specific differences (Table 2).
Complicated entry to MAT program
At all three sites, PWID talked about complicated entry to MAT, combined with a limited number of available treatment slots, and waiting lists to start MAT.
Interviewer (I): How long do the PWID have to wait until they get methadone?
Respondent (R): In case of waiting list, just wait until someone dies. Then the next drug user can automatically fill the vacant position…
I: How long did you wait?
R: About 7 months until they called me.
I: Did that mean some methadone client had died?
R: Yes, I guess so. (PWID, male, 36 y.o., Indonesia)
In Vietnam, PWID talked about multiple procedural barriers and strict admission requirements: local community quotas to enroll in MAT - “only4-5 persons every year” (PWID, male, 37 y.o., Vietnam), need to wait for authorities’ approval of one’s application for MAT, and family presence required for registration at MAT site, which was also the case in Indonesia. According to the respondents, some PWID may want to start MAT, but are unable to meet requirements, not having relatives to accompany them to the MAT site.
Similar to the PWID, most providers in Indonesia and Vietnam described admission requirements: bureaucracy and tedious paperwork, required presence of a family member, and the need to obtain the local authorities’ approval.
I: Which step is the most difficult?
R: The first step, meeting administrative requirements, because not everyone has an ID card and not everyone has a family member. Usually the junkies have already been disowned by their families, and the families do not want to know about their condition anymore. (Counselor/SN, female, Indonesia)
However, according to a provider in Vietnam, the admission procedure was simplified recently, which ironically led to a problem with site capacity mentioned by PWID: MAT facilities have insufficient number of treatment slots to accommodate all the PWID seeking program entry.
The demand on MAT is very high. 270 patients are in the clinic now, exceeding the possible threshold of 150 patients; and the demand for treatment is still high. Current instruction prohibits to receive more patients because it is over the capacity limit to provide services. (SN / physician at ART clinic, Vietnam)
Problematic clinic access
Clinic inaccessibility was a persistent theme in PWID and provider accounts across all sites. Most PWID in Vietnam and some in Indonesia reported daily long trips by motorbike or public transport to their MAT clinic - “about three times transport change” (PWID, male, 37 y.o., Indonesia) - as a huge barrier to clinic access. In addition, PWID in Ukraine and Vietnam talked about inflexible clinic hours, conflict with their working hours, and lines at MAT sites. Many PWID reported that MAT interfered with holding a full-time job.
I can only work on some minor jobs. I spend all the time in the morning for this [MAT], only afternoon is left. It is difficult - someone hires me to do some job nearby, then I try to take time to go; basically, I cannot do any job. (PWID, male, 36 y.o., Vietnam)
Providers across all sites talked about the same bureaucratic and structural barriers to initiation and retention in MAT. They reiterated PWID concerns about the need to visit the MAT site daily, its inconvenient location, and inflexible clinic hours.
MAT should be accessible, literally. A man from Vinogradar shouldn't have to go to somewhere in Svyatoshin - he should come to the clinic near his home and get his pills there, both ART and MAT. Going somewhere, you spend time and money. It all should be close to your place – same as a kindergarten or a school, MAT clinic should be nearby. (Counselor/SN, male, Ukraine)
Most PWID at all sites reported financial burden related with MAT initiation: costly procedures to enter MAT (numerous mandatory examinations) in Indonesia and Ukraine, costly medication (buprenorphine) in Indonesia and Vietnam, and a need to pay for transportation to the clinic and supporting services on-site (parking, cups, tests) in Vietnam.
I: Do you have to pay for Suboxone and the doctor? How much?
R: I pay 100,000 for the doctor, to buy the drugs, 50,000 per strip, Riclona 100,000 per strip, alprazolam 50,000 per strip… I should pay the doctor, then should buy the medicines. I am not a rich person, why don’t I get a net price, not to bear this much! If the goal is to quit drugs, I don’t think this is the way, because my friend can buy the drugs cheaper… (PWID, male, 23 y.o., Indonesia)
Most providers in Indonesia and some in Ukraine and Vietnam also referred to costly procedures to start MAT (mandatory laboratory tests and other examinations) as a barrier for PWID who are often unemployed and have limited financial resources. In Vietnam, where patients or their families have to pay for methadone, providers believed that such financial burden makes patients skip the doses, sometimes for weeks.
Lack of information about MAT
Some PWID in Indonesia and Ukraine mentioned lack of information on available substance use treatment, as well as lack of general understanding of MAT.
I: What methods of available substance use treatment do you know?
R: To be honest, I’ve been injecting for such a long time, I am supposed to know everything, and in the end I do not know anything. Well, I know that there is a detox, but maybe I cannot quite understand what it is... (PWID, female, 35 y.o., Ukraine)
Providers across all sites saw the clients’ lack of information about available treatment as a barrier to MAT initiation; they also noted general lack of understanding of addiction and MAT in society. A provider from Ukraine shared his concerns about negative image of addiction treatment institutions, rooted in the Soviet era.
Of course, for many of them [PWID], it is very difficult to make a decision, because they do not know anything about available range of services they could get. For many, the image of drug treatment clinic since Soviet times is some punitive institution, where he will be tied to a bed and experience some incredible tortures… (Narcologist, male, Ukraine)
Negative opinion of methadone treatment
PWID across all sites expressed negative opinion of MAT and specifically of treatment with methadone. Such opinion was overwhelmingly pronounced in Ukraine where PWID associated methadone with lack of freedom and life-long treatment. Many Ukrainian and Vietnamese PWID considered methadone a free drug rather than medication - “they substitute one drug with another” (PWID, male, 39 y.o., Ukraine). Others, especially in Indonesia and Vietnam, believed that “it is better to use drugs than methadone” (PWID, male, 39 y.o., Vietnam). Most PWID in Ukraine would prefer buprenorphine to methadone due to beliefs that buprenorphine is less toxic and that quitting methadone was impossible once you started it.
MAT is like a double-edged sword. Some people think that MAT was invented to simply eliminate injecting drug users… A person who uses methadone for some time, especially methadone, - he turns into a vegetable, especially with high dosage. He only goes to MAT and back home, nothing else... (PWID, male, 33 y.o., Ukraine)
Providers in Ukraine confirmed that PWID had misconceptions about methadone; they cited their patients who perceived methadone treatment as “chemicals that destroy my body” (Counselor/SN, female, Ukraine), “point of no return” and having “one foot in a grave” (Counselor/SN, male, Ukraine). Both physicians and counselors in Ukraine believed that many PWID would join MAT if free buprenorphine was available.
Social stigma towards PWID
Across all sites, PWID talked about stigma and social devaluation of people who use drugs; in their opinion, such stigma was more common in community than at health care facilities. In addition, according to PWID in Indonesia and Vietnam, people in community do not differentiate between active drug users and MAT patients, so joining MAT means that you confirm that you are “drug user”. Similarly, providers in Indonesia and Ukraine reported social stigma towards both PWID and addiction treatment.
It turns out that if you are a drug addict, then in any case you are a thief, a villain, or something like that… (PWID, male, 33 y.o., Ukraine)
Unlike other participants, one PWID in Vietnam recognized that people in his community were very supportive of his MAT initiation, “Everyone is happy for me, they come and talk with me” (PWID, male, 36 y.o., Vietnam). Such support motivated this person to retain in treatment.
Other barriers related to drug use
Ukrainian PWID often talked about their drug dependence and drug use, which takes up all their time, saying they were so accustomed to a drug user’s life. PWID in Ukraine and Vietnam also mentioned using other substances when on MAT, as a barrier to adherence.
Basically, I would be happy not to use drugs, but 20 years of use – well, I've already forgotten how it is, (to live) without drugs... (PWID, male, 37 y.o., Ukraine)
I: So you took methadone for two years and left the program. Why do people quit MAT, what are their reasons?
R: They quit because they still “play” with drugs, and they think that using both drug and medication, they are not going to have craving anymore, but actually taking both, it is even more craving. It fights against each other; therefore, they have to quit methadone - it is better to use only drugs. (PWID, male, 39 y.o., Vietnam)
In Ukraine, providers saw drug use related barriers somewhat differently: they believed that PWID “cannot imagine life without drugs” because they “want to be under the influence” (Counselor/SN, male, Ukraine). For them, drug dependence and lack of motivation for treatment were equivalent. Providers (but not PWID) in Ukraine felt that some PWID might not start addiction treatment because of “lack of will” (ID physician, female, Ukraine) and laziness; they perceived that PWID prioritized drug use over caring for their health and hence were less motivated to take up ART and MAT. In providers’ opinion, PWID would initiate MAT only in a critical situation, “When they are broke and have no money for the drugs, then they come to us.” (Narcologist, male, Ukraine)
Problems with drug interactions
As the study participants were PWID living with HIV, some in Ukraine and Vietnam who were on ART explained their reluctance to start MAT by fear of interaction between ART and methadone.
R: While taking methadone, also taking ART, the medication is resistant.
I: What does it mean?
R: For example, I take the dose of 100 mg; it is reduced to 50 only. (PWID, male, 42 y.o., Vietnam)
PWID and providers across all sites reported far fewer facilitators than barriers to substance use treatment uptake (Table 3). As in the case of barriers, PWID and providers across study sites described similar facilitators to initiate MAT.
Internal motivation for a life change
Internal motivation for a life change was the main facilitating factor for quitting drug use and starting MAT reported by PWID in Indonesia and Ukraine; they felt tired of drug use and expressed a will “to live a normal life” (PWID, male, 38 y.o., Indonesia) without drugs. Similarly, providers in Ukraine and Vietnam spoke about PWID being tired of a drug user’s life, considering their internal will for a life change as a motivator to MAT initiation.
I: What was your personal reason to start MAT?
R: First, I was already tired of such a life that I had (laughs). It is in the first place. I already wanted to change it, make it at least a little better. Plus, I want to have kids, I want to live a normal life. Not to exist, but to live a life. (PWID, male, 42 y.o., Vietnam)
According to PWID across all sites, social support, and particularly MAT information and motivation from peers and providers facilitated their treatment uptake. Support and opinion of friends/peers was important for PWID in Indonesia and Vietnam, as well as support (Indonesia) and even pressure (Ukraine) from the family.
In my case, a pregnancy of my wife drove me to the drug treatment program. Also, I was curious about benefit of methadone because I heard a little from my friends. Finally, my family encouraged me to join [MAT]. I felt guilty looking at my wife and child who did not eat sufficiently. When I joined methadone, I realized that I could earn legal money for them. (PWID, male, 36 y.o., Indonesia)
Similarly, providers in Indonesia and Vietnam believed that MAT information and motivation from peers and providers was helpful, as well as information provided by local community-based organizations in Ukraine. Across all sites, providers considered the family influence important for PWID engagement in MAT.