Background – Injecting Drug Use in Tanzania

1. A critical need to scale up HIV prevention and harm reduction services for people who inject drugs in Tanzania: Results from a HIV and hepatitis C prevalence study in Dar es Salaam, 2011 Mark Stoové1, AnnaBowring1, NiklasLuhmann2, Céline Debaulieu3, Stéphanie Derozier2, Sandrine Pont3, Fatima Assouab2, Abdalla Toufik2, Carolinevan Gemert1, Paul Dietze1 1Burnet Institute, Melbourne, Australia 2Médecins du Monde - France, Paris, France 3Médecins du Monde, Dar es Salaam, United Republic of Tanzania

2. Background – Injecting Drug Use in Tanzania • Since increased availability of ‘white’ heroin from 1998,1injecting drug use (IDU) has become a concern in Tanzania • There are currently an estimated 50,000 people who inject drugs (PWID) in Tanzania2 1 Needle, R. H., et al. (2006). Substance abuse and HIV in sub-Saharan Africa: Introduction to the Special Issue. African Journal of Drug & Alcohol Studies, 5(2), 83 2Nieburg P, Carty L. HIV Prevention among Injection Drug Users in Kenya and Tanzania. Centre for Strategic and International Studies; 2011

3. Background – HIV & HCV in Tanzania • Mainland Tanzania characterised by a generalised HIV epidemic • Few studies of PWID substantially higher HIV prevalence • No hepatitis C (HCV) prevalence estimates among PWID 1 Tanzania Commission for AIDS (TACAIDS), Zanzibar AIDS Commission (ZAC), National Bureau of Statistics (NBS), Office of the Chief Government Statistician (OCGS), and Macro International Inc. (2009) 2Williams, M. L., et al. (2009). HIV seroprevalence in a sample of Tanzanian intravenous drug users. AIDS Education and Prevention, 21(5), 474-483

4. Background – IDU and Harm Reduction • Little progress toward NSP and opioid substitution therapy scale-up • Pilot OST at Muhimbili University Hospital • Médecins du Monde-France (MdM-F) harm reduction program • established in 2010 in Temeke District in Dar es Salaam - poorest of 3 urban districts with highly visible drug use • NSP • HIV & viral hepatitis voluntary counselling and testing (VCT) • HIV care/treatment • Focus on women during program development

5. RAR Objectives Among PWID & other drug users in Temeke District: • Determine HIV and hepatitis C prevalence; • Assess knowledge of HIV status and access to HIV care; and • Describe risk behaviours. … to inform an adapted operational response through the MdM‐F harm reduction program and inform policy in Tanzania

6. RAR Methods RAR was structured in 3 phases: • Brief qualitativeassessment • key informant/drug user interviews, observations, local and national stakeholder meetings • Quantitativesurvey accompanied with HIV and HCV testing • Preliminary responsephase I – each participant receiving • information and prevention materials • HIV and HCV test results and referral if required

7. RAR Methods RAR was structured in three consecutive phases: • Brief qualitativeassessment • key informants and drug user interviews, ethnographic observations, local and national stakeholder meetings • Quantitativesurvey accompanied with HIV and HCV testing • Preliminary responsephase I – each participant receiving • information and prevention materials • HIV and HCV test results and referral if required

8. Survey Methods Recruitment through convenience, snowball and targeted sampling Inclusion criteria: • Injected any drug in past month • Live in Temeke District, speak/understand Swahili, • Signed informed consentand consent to undergo HIV and HCV testing

9. Survey Methods Survey data collection: • Face-to-face, administered by trained interviewers • 70 questions – drug use patterns; injecting & sexual risk behaviours; prevention & Rx service access; HIV/HCV knowledge HIV & HCV rapid testing: • HIV - Determine 1/2 whole blood assay (repeated with SD Bioline) • HCV – OrasureOraQuickrapid antibody test HCV (repeated with SD Bioline)

10. Results – Sample Characteristics 267 PWID recruited: • Demographics: • 231 males (87%); 37 females • Median age 30 years (IQR 26-34 years) • Drug use: • Mean age first inject 24.3 years (SD=5.9 years) • Median injecting duration 5 years (IQR=3-9 years) • Daily injecting of heroin in the past month almost universal (96%) • 81% of PWID first smoked heroin • Median transition time to injecting = 5 yrs; less in newer/younger initiates • Aged ≤25, median transition = 2 yrs

11. Results – HIV Prevalence

12. Results – Undiagnosed HIV Prevalence1 1 no testing history or unsure of HIV status Among all PWID: • 53% no HIV testing history, 76% not tested in past two years • 34% reported not knowing where to access HIV testing

13. Results – HCV Antibody Prevalence Among all PWID • 8 (1.9%) reported a HCV testing history • 2 self-reported positive

14. Results – HIV/HCV Co-Infection1 Prevalence 1not accounting for HCV viral clearance • Awareness of HIV was high – 97% • Awareness of HCV considerably lower – 35%

15. Results – Drug Use Patterns & Risk Behaviours

16. Results – Drug Use Patterns & Risk Behaviours

17. Results – Drug Use Patterns & Risk Behaviours

18. RAR Findings & Implications NSP coverage inadequate, high frequency injecting: • Scale-up NSP distribution • Adapted distribution, including outreach and through peers Undiagnosed HIV & almost no HCV testing • HR services must include HIV/HCV VCT • HIV treatment/referral • HCV education Focus on women • Women only hours/support programs • Engage women involved in transactional sex

19. RAR Findings & Implications Advocacy & policy responses: • Needs of PWID and benefits of IDU harm reduction • Risks in refuelling general HIV epidemic • 54% of undiagnosed HIV+ participants reported recent unprotected sex • Future HCV burden, especially with co-infection

20. Response – Reports From the Field • Field observations of PWID • Improved knowledge of HIV, HCV and risk reduction • Improved hygiene and using sterile syringes whenever possible • Coverage still needs to be improved • Recent graduation of 7 peer educators through MdM • Harm Reduction introduced in almost ‘virgin’ context • Harm Reduction Model accepted by local district authorities • Promotion of the ‘Temeke HR Model’ in other parts of Dar es Salaam and to national authorities

21. Acknowledgements • Temeke Harm Reduction Program Team • Research team at MdM: • Céline Debaulieu, Sandrine Pont, Dr Fatima Assouab, Dr Stella Kilima, Dr NiklasLuhmann, Olivier Cheminat, StéphanieDerozier, AbdallaToufik, Edward Kitwala, SalumMapande, Catherine Shembilu, Wendy Mponzi, Robert Okola, HadijaJuma, RamadhanAbdalla, AinaMrope, Nicolas Abraham • The participants in this study for sharing their experiences, personal information and for giving their time to the study • Tanzanian partners, including the Ministry of Health & Social Welfare and the Temeke Municipal Council