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, Anna Bowring1, Niklas Luhmann2, Céline Debaulieu3, Stéphanie Derozier2, Sandrine Pont3, Fatima Assouab2, Abdalla Toufik2, Caroline van Gemert1, Paul Dietze1 1Burnet Institute, Melbourne, Australia2Médecins du Monde - France, Paris, France3Médecins du Monde, Dar es Salaam, United Republic of Tanzania
Background – Injecting Drug Use in Tanzania
• Since increased availability of ‘white’ heroin from 1998,1 injecting drug use (IDU) has become a concern in Tanzania
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), 832Nieburg P, Carty L. HIV Prevention among Injection Drug Users in Kenya and Tanzania. Centre forStrategic and International Studies; 2011
• There are currently an estimated 50,000 people who inject drugs (PWID) in Tanzania2
• 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
Background – HIV & HCV in Tanzania
Little progress toward NSP and opioid substitution therapy scale-up• Pilot OST at Muhimbili University Hospital
Background – IDU and Harm Reduction
• 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
RAR ObjectivesAmong PWID & other drug users in Temeke District:
1. Determine HIV and hepatitis C prevalence;
2. Assess knowledge of HIV status and access to HIV care; and
3. Describe risk behaviours.
… to inform an adapted operational response through the MdM F harm reduction program and inform policy ‐in Tanzania
RAR MethodsRAR was structured in 3 phases:
1. Brief qualitative assessment • key informant/drug user interviews, observations, local and national
stakeholder meetings
2. Quantitative survey accompanied with HIV and HCV testing
3. Preliminary response phase I – each participant receiving• information and prevention materials• HIV and HCV test results and referral if required
RAR was structured in three consecutive phases:
1. Brief qualitative assessment • key informants and drug user interviews, ethnographic observations, local
and national stakeholder meetings
2. Quantitative survey accompanied with HIV and HCV testing
3. Preliminary response phase I – each participant receiving• information and prevention materials• HIV and HCV test results and referral if required
RAR 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 consent and consent to undergo HIV and HCV testing
Survey Methods
Survey MethodsSurvey 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 – Orasure OraQuick rapid antibody test HCV (repeated with SD Bioline)
Results – Sample Characteristics267 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
Results – HIV Prevalence
HIV positive Total n % (95% CI) Total 93 34.8 (29.1-40.9) 267Male 69 29.9 (24.0-36.2) 231Female 24 66.7 (49.0-81.4) 36
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
Results – Undiagnosed HIV Prevalence1
Among all PWID• 8 (1.9%) reported a HCV testing history• 2 self-reported positive
Results – HCV Antibody Prevalence
Anti-HCV positive Total n % (95% CI) Total 74 27.7 (22.4-33.5) 267Male 64 27.7 (22.0-34.0) 231Female 10 27.8 (14.2-45.2) 36
1 not accounting for HCV viral clearance
• Awareness of HIV was high – 97%• Awareness of HCV considerably lower – 35%
Results – HIV/HCV Co-Infection1 Prevalence
HIV/anti-HCV positive Total n % (95% CI) Total 45 16.9 (12.6-21.9) 267Male 35 15.2 (10.8-20.4) 231Female 10 27.8 (14.2-45.2) 36
Past month Total HIV Positive
Reused a needle and syringe 134 (77%) 72 (77%)
At last injection …Injected with used syringe 1st cleaned w/ water 111 (42%) 45 (48%)
Shared bottle, spoon, container, or water 45 (17%) 21 (23%)Took solution from a shared container 38 (14%) 22 (24%)
Results – Drug Use Patterns & Risk Behaviours
At last injection … Total HIV PositiveWhere inject …
In camp/maskani 89 (33%) 32 (34%)Who injects with …
With a group in the camp 87 (33%) 34 (37%)
Results – Drug Use Patterns & Risk Behaviours
Results – Drug Use Patterns & Risk Behaviours
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
– Risks in refuelling general HIV epidemic• 54% of undiagnosed HIV+ participants reported
recent unprotected sex– Future HCV burden, especially with co-
infection
RAR Findings & Implications
Advocacy & policy responses:• Needs of PWID and benefits of IDU
harm reduction
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
Acknowledgements• Temeke Harm Reduction Program Team• Research team at MdM:– Céline Debaulieu, Sandrine Pont, Dr Fatima
Assouab, Dr Stella Kilima, Dr Niklas Luhmann, Olivier Cheminat, Stéphanie Derozier, Abdalla Toufik, Edward Kitwala, Salum Mapande, Catherine Shembilu, Wendy Mponzi, Robert Okola, Hadija Juma, Ramadhan Abdalla, Aina Mrope, 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