1. United Republic of Tanzania Ministry of Health & Social Welfare HIV Programs Among Key Populations in Tanzania: Presenter: Neema Makyao-NACP-MOHSW 1

2. United Republic of Tanzania Ministry of Health & Social Welfare Outline of the presentation Definition of KP Epidemiology of KP (burden of the disease) Size estimates Services provided and coverage Success and Challenges Way forward 2

3. United Republic of Tanzania Ministry of Health & Social Welfare The KPs Epidemic in context Tanzania HIV epidemic is described as generalized epidemic with pockets of high prevalence among certain sub-populations or geographic regions Others describe it as ‘’mixed epidemic’’ for emphasis on the wide differences in prevalence

4. United Republic of Tanzania Ministry of Health & Social Welfare Definition of key populations KP in Tz are defined to include people who are both extremely vulnerable to and at increased risk of HIV. KP include: PWUD and PWID, MSM and women who practice anal sex, FSW Prisoners.  These are the main group due to nature of their vulnerability 4

5. United Republic of Tanzania Ministry of Health & Social Welfare Key population Groups in Tanzania Other groups deserving special considerations in Tanzanian context include: – Street children – long truck drivers – miners and mining communities – fisher folks and fishing communities – plantation workers – Youth and adolescents – PLHIV as well as sero-discordant couples – Disabled persons (in all forms) – Low income women 5

6. United Republic of Tanzania Ministry of Health & Social Welfare Dynamic Interaction between KPs and the General Population Core HIV Transmitters (KPs) Bridging Population (Clients of KPs) General Populatio n

7. United Republic of Tanzania Ministry of Health & Social Welfare Epidemiology of HIV & STIs in Key Populations in Tanzania National prevalence  HIV: 5.1% among adult population (THMIS 2012) However number of studies have shown that HIV, STIs, TB and HCV in KPs are more than five times higher than the adult general populations. 7

8. United Republic of Tanzania Ministry of Health & Social Welfare Epidemiology of HIV among Key Populations –IBBSS (2010-2013) PWIDs HIV 51.0% in 2011, 15.5% 2013 ( RDS Dar) PWUDs HIV 22% community data (Dar) FSW HIV 31.4 ( 2010) and 14.2-37.5% (2013) (7 Regions) MSM HIV 22% (2013) (Dar) and 42% in 2010. Generally HCV,HBV, HSV2 and syphilis are high into all the studies 8

9. United Republic of Tanzania Ministry of Health & Social Welfare

10. MOT The 2013 MOT study shows that the majority of new infections in Tz are occurring:  in stable heterosexual relationships (38.8%),  casual heterosexual sex (28.9%),  clients of sex workers (8.7%),  partners of people engaged in casual sex (7.6%) and MSM (6.8%).  These five groups constitute 91% of all new infections.

11. United Republic of Tanzania Ministry of Health & Social Welfare Size Estimates For Key Populations The three surveys included size estimate through multiplier method with FSWs, MSM & PWIDs. Drug Users mapping and size estimates (UCSF & DCC-PEPFAR) in five regions. MOHSW planning to do programmatic mapping and size estimates of KPs in 10 regions (November 2014-GF) to guide service provision for KPs eg GF funds for KPs and PEPFAR RFA in 5 regions. 11

12. United Republic of Tanzania Ministry of Health & Social Welfare Size Estimates cont……….. NACP & TACAIDS through support from MEASURE EVALUATION: Expert meeting with KP stakeholders, UN agencies & USG April 2014 Delphi process used to estimate 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 12

13. United Republic of Tanzania Ministry of Health & Social Welfare Final Size Estimates for Tz… PWIDs  Approximately 300,000 PWUDs (range 200,000- 350,000) in Tanzania PWID about 30,000 (range 20,000 - 42,500) MSM  Point estimate for MSM population size was 49,000 (range 41,000-71,000)  FSW Estimated there are 155,500 FSW in mainland Tanzania, with a range of 128,610 to 198,050. 13

14. United Republic of Tanzania Ministry of Health & Social Welfare Policy Guidelines for HIV Services KP Comprehensive HIV & Health Services Delivery 2014 with PSI&EH under USAID support KP HCW Comprehensive training manual (facilitate delivery of KP friendly services)-EH under USAID support National KP communication strategy –PSI NACP with WHO developing M&E for KPs (in progress) 14

15. United Republic of Tanzania Ministry of Health & Social Welfare Policy Guidelines for HIV Services National Strategic Framework for HIV/AIDS Prevention for Injecting Drug Users (2012-2016) A clinical guide for Medically Assisted Treatment for Opioid Dependence: Guide for Screening and Brief Intervention for Substance Abuse Disorders Outreach Service Guide for HIV prevention among Drug Using Populations Policy Guidelines for MAT 15

16. United Republic of Tanzania Ministry of Health & Social Welfare What are we doing? Leadership Leadership by NACP and TACAIDS KP sub committee actively engaged Planning and technical assistance Guideline development Training manual and training of health care workers and police Resource mobilizations Multi-partner engagement Key stakeholder consultations Stakeholder Validation

17. United Republic of Tanzania Ministry of Health & Social Welfare KP Coordination KP HIV services are provided by HIV IPs, NGOs and CSOs and coordinated by MOHSW through NACP and TACAIDS. KP subcommittee under Prevention TWG DCC coordinate supply, demand & harm reduction components for PWUDs PWIDs, MSM & FSWs interventions are as per WHO/UNAIDS/USG recommended package of HIV services for KPs 17

18. United Republic of Tanzania Ministry of Health & Social Welfare KP interventions Peer led behavior change communications all KPs Promotion and distribution of condoms and non silicon lubricants Provision of mobile HTC, STI, FP, TB and care and treatment services and linkage to care and treatment Community outreach programmes (linkage and referrals) 18

19. United Republic of Tanzania Ministry of Health & Social Welfare KP Interventions…… Medically Assisted Therapy Needle Syringe Programmes ART TB, STI screening and treatment Peer education Psychosocial therapy Other mental health services and other medical services provided as well e.g. wound care for PWIDs Economic strengthening activities &occupational therapy Wellness centres/ drop in centres Escorted referrals to Health care services 19

20. United Republic of Tanzania Ministry of Health & Social Welfare Monitoring and Evaluation of KP programs KP M&E plan currently being developed (output, outcome, impact indicators) Harmonize M&E Tools for KPs to collect routine data to monitor program implementation Routine Data Quality Assessment will also be done Integrated Bio-Behaviour Surveillance Survey to track Outcome and Impact indicators (baseline done)

21. United Republic of Tanzania Ministry of Health & Social Welfare Coverage of KP services …….. Under PEPFAR-CDC support, Tanzania implemented comprehensive package of Health services to PWIDs in Dar es Salaam since 2011. Cumulatively enrolled 2000 PWIDs into MAT from 3 Health Facilities in Dar: (2011-Sept 2014) (including LTF & deaths). PWUDs reached from 2007 -2014 - 31,316 through community programs with 4 CSOs. 21

22. United Republic of Tanzania Ministry of Health & Social Welfare Coverage of KP services.......... Through PEPFAR-USAID programs for MSM and FSW a total number of 98,421 KP reached through comprehensive services since 2010-June 2014.  Services are provided under: PSI-10 regions, AMREF-3, PASADA 1, NACOPHA-6 and ICAP-1, FHI 360 lake zone, Dar Makambako and Tunduma  MdM and its affiliated CSOs-1  Water Reeds-Southern Highlands-3 regions (testing campaign) From July, 2011 MdM distributed a total number of 662,520 syringes and needles and reached 12,705 PWUDs.

23. United Republic of Tanzania Ministry of Health & Social Welfare Achievements Developed KP Comprehensive service provision through technical and financial support of PEPFAR under USAID and WHO Developed training manual for HCW on stigma reduction to KPs (curriculum, facilitator guide, participants manual and teaching slides) Piloted the manual into three regions (Njombe, Iringa and Shinyanga) (250 HWC) and trained National TOTs (30)

24. United Republic of Tanzania Ministry of Health & Social Welfare Achievements National Subcommittee for coordination of KP Harm reduction services to PWUDs increase retention and health seeking behavior Increase in the uptake of HIV services eg HTC services Increase in HIV identified KPs enrolled in CTC Evidence based information (IBBSS and size estimates) 24

25. United Republic of Tanzania Ministry of Health & Social Welfare Challenges Continuous supply of reagents for testing of HCV, HBV and urine testing (avoid overdose still on drugs) Methadone is not available for all drug users Inadequate funding for KPs Pervasive Stigma, discrimination, and violence against KPs Low condom usage (with non-pp of FSW and MSM) 25

26. United Republic of Tanzania Ministry of Health & Social Welfare Challenges Continuum of care is difficult for KPs due to late presentation to health services and linking HIV positive KPs to CTC is still low Law prohibiting possession of needle/syringe is a barrier to NSP Repressive laws push clients into hiding hence barrier to accessing care

27. United Republic of Tanzania Ministry of Health & Social Welfare Next step Scale up services to reach more KP due to burden of diseases and scale into other geographical areas eg MAT scale up prepared Advocate for elimination of all forms of abuses towards KPs Build capacity for implementation and coordination of the KP program Mobilize more resources to support and scale up KP programs eg MAT scale up

28. United Republic of Tanzania Ministry of Health & Social Welfare Next step…… Strengthen the M&E system for quality data on KPs, track KP sizes, and quality improvement of programs Generate strategic information for policy decision making and programing Support LGAs to map and plan for comprehensive response according to needs (PWID/PWUD population size and risk behaviors)

29. United Republic of Tanzania Ministry of Health & Social Welfare 29 THANK YOU

30. United Republic of Tanzania Ministry of Health & Social Welfare THANK YOU!