Effective Drugs Policy and Harm Reduction in Tanzania Dr. Jessie Mbwambo – MUHAS Neema Makyao – NACP Amani Msami – DCC Dr. Cassian Nyandindi – MNH/Mwananyamala RRH Sandrine Pont – MdM Dr. Eva Matiko – CDC|PEPFAR

Outline of the presentation What is Harm Reduction, principles, evidence Magnitude & impact of drug use in Tanzania Drug Policy in Tanzania Best practices Achievements Challenges Way forward

What is Harm Reduction? ‘Harm Reduction’ refers to policies, programs and practices that aim primarily to reduce the adverse health, social and economic consequences of the use of legal and illegal psychoactive drugs without necessarily reducing drug consumption. HR benefits users, their families and the community. –HRI ‘Harm Reduction’ refers to public health interventions that seek to reduce the negative consequences of drug use and drug policies. –IDPC The first definition, by Harm Reduction International is more detailed. But the second one, by the International Drug Policy Consortium is broader, including the negative consequences of drug policies. In this definition harm reduction also addresses social exclusion.

Harm reduction principles Harm Reduction International A strong commitment to public health and human rights International Drug Policy Consortium Targeting risks & harms Evidence based & cost effective Rooted in dignity & compassion Acknowledging human rights Challenging policies & practices that maximise harm Transparent, accountable and participatory Harm reduction is a targeted approach that focuses on specific risks and harms. Politicians, policymakers, communities, researchers, frontline workers and people who use drugs should ascertain: What are the specific risks and harms associated with the use of specific psychoactive drugs? What causes those risks and harms? What can be done to reduce these risks and harms?

Support for harm reduction Evidence of paradoxical effect of greater restrictions Evidence of reduction in violence, HIV Opportunity for other health care services UN E4A (Evidence for Action) Series: http://www.who.int/hiv/pub/idu/idupolicybriefs/en/index.html In SE Asia and Eastern Europe, there have been documented evidence if increase in harmful injection practices in response to increase policing activity including capturing for possession of equipment that may be associated with injection practices (syringes and other paraphenalia). Access to safe injection equipment was associated with reduced violence and consistently reduced HIV incidence. Harm reduction services offer a safe opportunity for PWID to access other essential health services that can be integrated e.g. HTC, ART, SRH etc.

Drug use in Tanzania Population size & HIV prevalence –NACP, May 2014 PWUD # 300,000 (200,000-350,000) HIV prevalence 18-25% PWID # 30,000 (20,000-42,500) 30-50% reside in Dar HIV prevalence 36% (22-43%) ♀ PWID: no national consensus on population HIV prevalence in various samples 64-71% High reported sexual risk additional to injection risk HIV prev Natl 5.1% (♀6.2%) Dar 6.9% (♀ 8.2%) Key Populations consensus meeting led by NACP & TACAIDS through support from MEASURE EVALUATION Health Policy Project: Expert meeting with KP stakeholders in Tanzania: Government entities, Academia, Implementing Partners, UN agencies & USG held in April 2014 Delphi process used to estimate populastion size and HIV prevalence Used existing data on KP size estimates through IBBSS and other studies Used global and regional data on size estimates for KP to come up with a local agreed estimates

2013 MOT draft findings

Principles of Effective Drug Policy Assessment of priorities and evidence Human rights Focused on reducing the harmful consequences of use and markets Social inclusion of marginalised groups Build open and constructive relationship between civil society and government Sandrine: supporting text and source http://idpc.net/about/policy-principles African Union Plan of Action on Drug Control 2013-17 calls for the UN comprehensive package of interventions

Drug Policy in Tanzania Tanzania Anti Drug Act no. 9 of 1995Drugs and Prevention of Illicit Traffic in Drugs Act CAP 95 Amendment no.2 of 2012 National Drug Control Policy (awaiting endorsement) National Strategic Framework for HIV/AIDS Prevention for Injecting Drug Users (2012-2016) Policy Guidelines for MAT 2010 Minimum Standards for MAT facilities 2010 National KP communication strategy 2013 Strategy for reduction of stigma and discrimination & impact of HIV on KP (2014 – 2018) NACP with WHO developing M&E for KPs (in progress) The laws and policies on illicit drugs in Tanzania advocate for non-tolerance of drug abuse and trafficking with abstinence being the ultimate goal of all interventions. Possession of small amounts and finding eve trace quantities in body fluids is a criminal offence, as is possession of equipment or paraphernalia that may be for drug use.

Guidelines for HIV/Health Services Outreach Service Guide for HIV Prevention among Drug Using Populations 2010 Guide for Screening and Brief Intervention for Substance Abuse Disorders 2010 A clinical guide for Medically Assisted Treatment for Opioid Dependence 2010 Advocacy Communication and Social Mobilization Strategy on HIV/AIDS Prevention for PWID, 2013-16 KP Comprehensive HIV & Health Services Delivery 2014 KP HCW Comprehensive training manual 2014 Cross-cutting strategic documents also supportive of PWID interventions: NMSF 2013/24-2017/18 HSHSP III (2013)

Developed set of national PWUD/PWID policies and guidelines, led by Drug Control Commission collaborating with MOH. Launched in 2010 National Strategic Framework approved January 2012 National Guidelines for Comprehensive Package approved September 2014

Comprehensive package for PWID Aligned with WHO/UNAIDS/UNODC standards nine elements: NSP OST & other drug dependence treatment HTC ART STI prevention & treatment Condoms IEC Viral Hepatitis vaccination, diagnosis & treatment TB prevention, diagnosis & treatment

Best Practices New strategies and guidelines aligned with the harm-reduction approach recommended by UN Allows access and support for treatment as needed Strong support at highest level of government translates to other levels Emerging success in treatment and recovery encourages others to access treatment Initial partner-led efforts gaining government support

Achievements 44,443 PWUD reached by CBOs (2007- 9/2014) 6,154 PWID accessing NSP ~990,000 distributed (July 2011-Sep 14) 2,000 on MAT (Feb 2011-Sep 2014) ~98% tested & received HIV results @ MAT (many more through outreach!) 178 on ART & MAT 927 diagnosed and treated for TB (incl. 5 MDR) 5,054 Police trained plus 29,806 members of community policing initiative TAPP providing services through community CSOs: 4 CSOs have been providing services in Dar since 2007-2014 Total PWUD reached from September 2007 – June 2014 are 29,806/Sept 2014 are 31,316 MAT ~2,000 MAT MNH HIV - Testing 98% of 870, MAT clients tested once every 6 months (ask MAT Temeke and Mwananyamala) MAT MNH TB - diagnosed and DOT 10.2% of 879 (5 MDR Tb) (ask MAT Temeke and Mwananyamala) TAPP Police trained – 54 high ranking police officers and 230 community police plus the country Coordinator for Law Enforcement Against HIV and AIDS Network ART 86 MNH; 16 TMK; 76 MNY TB diagnosed and treated 39 Mwananyamala; 9 TMK MdM: 2011-Temeke Dar es Salaam Mkikute + MdM DIC PWID 6,154 Outreach all PWUD: 13,127 (July2011-Sep 14) Syringes 987, 607 HIV Testing 2195 TB diagnosed and treated 108 (27 Jan-Sep 2014) Police trained 2,300 in 2013 2,729 in 2014= 5,000

Challenges Law prohibiting possession of needle/syringe is a barrier to NSP Repressive laws push clients into hiding hence barrier to accessing care e.g. possession of minimal amounts, trace amount in body fluids  criminal offence Positive steps in collaboration with police but sustained response requires integrating HR in the law & mainstream training Fundamental problem of unemployment continues post recovery Resource allocation to for coverage of services

Way Forward Aim to reform drug law to accommodate minimum health standards and create enabling environment for health-seeking behavior among PWUD Support LGAs to map and plan for comprehensive response according to needs (PWID/PWUD population size and risk behaviors) Innovative livelihood options as primary prevention and rehabilitation (multi-sector involvement) Publicly recognize and reward positive actions Recovery and reform from criminality Law enforcement supporting access to care National MAT scale-up plan to treat 25,000 PWUD by 2018

Thank you!