Olivia Chang, MPH Research and Program Manager Pangaea Global AIDS Hepatitis C and HIV/HCV Co-infection among Methadone Clients in Dar es Salaam, Tanzania: Prevalence and Predictors Olivia Chang, MPH Research and Program Manager Pangaea Global AIDS

Presentation Outline Background Methods Results Conclusions

Emergence of Injection Drug Use in East Africa East Africa became an important hub along international drug trafficking routes from Afghanistan, India and Thailand, in the mid-1980’s to early 1990s. However, it quickly transitioned into a point of consumption, where an estimated 533,000 opiate users live in East Africa. UNODC Data

Drivers of the Epidemic in Tanzania 30,000-50,000 PWID 15,000-20,000 in Dar es Salaam Prevalence Estimates (Dar) PWID General HIV 35%-50% 6.9% HCV 28%-76% 1.5% In Tanzania, injection drug use, primarily of heroin, has become widespread throughout Dar es Salaam, the country’s largest city. Dar es Salaam is also home to Tanzania’s principal maritime port, which handles 95% of the countries international trade. The port serves the landlocked countries of Malawi, Zambia, Democratic Republic of Congo, Burundi, Rwanda and Uganda. Recent estimates indicate 30,000 – 50,000 people who inject drugs in Tanzania. While HIV prevalence is estimated to be 6.9% in Dar es Salaam, and 5.1% in the country overall, prevalence of HIV among people who inject drugs has been estimated at 42-50%.Therefore, injection drug use threatens to become a driver of the HIV epidemic. Prevalence of HCV among a cohort of blood donors in Dar was 1.5% in 2006 (Matee) and seroprevalence in Tanzania is estimated to be 3.2% (95% CI 0.5-8.6), highest in the region (Karoney). Matee: doi:10.1186/1471-2458-6-21 Karoney: doi:10.11604/pamj.2013.14.44.2199 Reported Heroin Use in Tanzania Williams (2009) Nyandindi (2011), Lambdin (2013), Bowring (2013), Matee (2006), TACAIDS (2011), NACP (2014)

Roll-out of Methadone in Dar es Salaam * * Community-based outreach begins (2010) MNH Muhimbili National Hospital MRH Mwananyamala Regional Hospital TRH Temeke Regional Hospital Funded by PEPFAR, the Tanzanian AIDS Prevention Program began providing community-based outreach through mobile units and four CBO storefronts for PWID. In 2010, the Ministry of Health and Social Welfare, in coordination with the Drug Control Commission, began planning to implement methadone maintenance programs in Dar es Salaam, leading to the launch of the first publicly funded methadone clinic on the mainland of Sub-Saharan Africa in February 2011. Scale-up continues with the second and third clinics opening in September 2012 and April 2013. As of July 2014, 1600 Clients have been initiated on methadone maintenance treatment.

Methods: Prevalence and Predictors Study Design: Cross-sectional Data Sources: Routine programmatic and clinical monitoring data Study Population: Clients enrolled in methadone between February 2011 to January 2013 at Muhimbili National Hospital Provider-initiated testing and counseling for HIV and HCV is provided (rapid tests). Linkage to care and treatment for PLHIV; supportive care for PLHCV

Methods: Prevalence and Predictors Covariates: demographics, sexual risk factors, injection risk factors, mental health history, legal/criminal history and history of abuse Outcomes: 1) HCV+ and 2) HIV+/HCV+ Prevalence Estimates: Percentages with 95% confidence intervals Statistical Analysis: Binomial regression to estimate adjusted risk ratios with 95% confidence intervals

Results Methadone clients enrolled: 629 Clients HCV-screened: 494 (79%) Median Age (years) 33 (30,37) Female 7% Median Years of Heroin Use 10 (6, 15) Primary Education or Lower 67%

Results Sexual Risk Behaviors (last 6 months) Multiple Sex Partners 20% No or Inconsistent Condom Use 40% Injection-related Risk Behaviors Ever Practiced Flashblood* 7% Share Needles and/or other Equipment at Last Injection 17% Polysubstance Use (alcohol, cocaine, and/or benzodiazepine) 34% * Practice of injecting oneself with blood from another person who has recently injected heroin.

Results: Prevalence and Predictors of HCV HCV+: 57% (95% CI: 53%-61%) Adjusted Risk Ratios for HCV Seropositivity   Adjusted Risk Ratio (95% CI) p-value Ever Practiced Flashblood 1.27 (1.13, 1.44) <0.001 Share Needles and/or other Equipment at Last Injection 1.35 (1.17, 1.55) Ever Been Arrested 1.21 (1.04, 1.41) PWID had over 30 times higher HCV seroprevalence than clients donating blood at MNH 57% methadone clients vs. 1.5% among blood donors at MNH (Matee: doi:10.1186/1471-2458-6-21)

Results: HIV/HCV Co-infection Overall: 36% (95% CI: 31% – 40%) Total HIV and HCV Screened: 413 (66%)

Results: HIV/HCV Co-infection Overall: 36% (95% CI: 31% – 40%) Among HIV+: 86% (95% CI: 81%-91%) Total HIV and HCV Screened: 413 (66%)

Results: Predictors of HIV/HCV Co-infection Adjusted Risk Ratios for HIV/HCV Co-infection   Adjusted Risk Ratio (95% CI) p-value Female 1.81 (1.60, 2.04) <0.001 Ever Practiced Flashblood 1.41 (1.25, 1.59) Share Needles and/or other Equipment at Last Injection 1.36 (1.21, 1.53)

Results: Predictors of HIV/HCV Co-infection Adjusted Risk Ratios for HIV/HCV Co-infection   Adjusted Risk Ratio (95% CI) p-value Female 1.81 (1.60, 2.04) <0.001 Ever Practiced Flashblood 1.41 (1.25, 1.59) Share Needles and/or other Equipment at Last Injection 1.36 (1.21, 1.53)

Conclusions Risky injection practices drive transmission. PWID, particularly women, have a disproportionate burden of disease and are also harder to reach. Current coverage is inadequate, scale-up of harm reduction is urgently needed. This is not new, we know that risky injection practices, such as sharing needles, drives transmission of HIV and HCV. Unique to East Africa, flashblood puts PWID at even higher risk of bloodborne infections. In Dar es Salaam, approximately 85% of women who inject drugs also engage in sex work. Experiences of violence drive women out of shared venues, creating insular, hidden communities away from men which further complicates the delivery of risk reduction services and hampers the willingness of women to access services. While the program has steadily increased the number of PWID reached, 1,600 accounts for only 10% of the estimated 15-20 thousand PWID in Dar es Salaam. Current coverage through needle and syringe exchange and methadone maintenance treatment programs is inadequate and needs scale-up. In the era of revolutionary HCV treatments, we must apply lessons learned from HIV treatment programs and scale-up of ART. Barriers to increasing access to treatment for HCV include high costs, perceived complexity of regimens, concerns of non-adherence, side effects, and treatment duration. These are not so different from the early challenges to HIV treatment programs. Similar to HIV, we must ensure strong political will, affordable and equal access to treatment, simplification of drug regimens, de-centralization of services, integration into other health settings, and high quality monitoring and evaluation systems. And, we must achieve all of these, while concurrently addressing the unique needs of PWID.

How do we Respond? Systems: At the root, system-level interventions and improvements are needed for programs to adopt evidence-based practices, maximize sustainability of efforts; and improve decision-making processes for program improvement. Strengthened monitoring and evaluation systems, proper training of health care workers, and decentralized and integrative services are pivotal to reaching this key population. Essential to all these components is advocacy to catalyze change and make systems work better for those they are intended to serve. We must achieve all of these, while concurrently addressing the unique needs of PWID.

Testing and counseling How do we Respond? Care for PWID HCV VL Monitoring Hep A/B immunization Reach female PWID Scale-up NSP and OST Testing and counseling Condom distribution IEC & BCC Systems: At the root, system-level interventions and improvements are needed for programs to adopt evidence-based practices, maximize sustainability of efforts; and improve decision-making processes for program improvement. Strengthened monitoring and evaluation systems, proper training of health care workers, and decentralized and integrative services are pivotal to reaching this key population. Essential to all these components is advocacy to catalyze change and make systems work better for those they are intended to serve. We must achieve all of these, while concurrently addressing the unique needs of PWID.

Testing and counseling How do we Respond? Care for PWID Research/ Policy Affordable and equal access to tx HCV VL Monitoring Hep A/B immunization Simplify/optimize tx regimen Reach female PWID Drug interaction studies Scale-up NSP and OST Testing and counseling Condom distribution IEC & BCC Genotyping Prevalence Estimates Systems: At the root, system-level interventions and improvements are needed for programs to adopt evidence-based practices, maximize sustainability of efforts; and improve decision-making processes for program improvement. Strengthened monitoring and evaluation systems, proper training of health care workers, and decentralized and integrative services are pivotal to reaching this key population. Essential to all these components is advocacy to catalyze change and make systems work better for those they are intended to serve. We must achieve all of these, while concurrently addressing the unique needs of PWID.

How do we Respond? Affordable and equal access to tx HCV VL Monitoring Care for PWID Research/ Policy Affordable and equal access to tx HCV VL Monitoring Hep A/B immunization Simplify/optimize tx regimen Reach female PWID Drug interaction studies Scale-up NSP and OST Testing and counseling Condom distribution IEC & BCC Genotyping Prevalence Estimates Systems: At the root, system-level interventions and improvements are needed for programs to adopt evidence-based practices, maximize sustainability of efforts; and improve decision-making processes for program improvement. Strengthened monitoring and evaluation systems, proper training of health care workers, and decentralized and integrative services are pivotal to reaching this key population. Essential to all these components is advocacy to catalyze change and make systems work better for those they are intended to serve. We must achieve all of these, while concurrently addressing the unique needs of PWID. Strengthen M&E systems Train Health Care Workers Decentralize and Integrate Services Advocacy Systems

Acknowledgements