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, Anna Bowring1, Niklas Luhmann2, Céline Debaulieu3, Stéphanie Derozier2, Sandrine Pont3, Fatima Assouab2, Abdalla Toufik2, Caroline van Gemert1, Paul Dietze1
1Burnet Institute, Melbourne, Australia
2Médecins du Monde - France, Paris, France
3Médecins du Monde, Dar es Salaam, United Republic of Tanzania
Thanks you – Today I will be presenting the findings from the quantitative phase of a rapid assessment and response of the harm reduction needs of people who inject drugs in Dar es Salaam, Tanzania.

2. 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
There are currently an estimated 50,000 people who inject drugs (PWID) in Tanzania2
Although heroin has been around in East Africa since the mid 1980s it wasn’t until the late 1990s that injecting drug use emerged as a concern in Tanzania, as the availability of white heroin led to the transitioning from smoking to injecting.
Most recent estimates suggest there are currently approximately 50,000 people who inject drugs in the country.
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
Mainland Tanzania is characterised by a generalised HIV epidemic spread mostly through heterosexual transmission. However, the few studies of PWID in Tanzania suggest HIV prevalence in this population is substantially higher than found in the general population, particularly among women where prevalence estimates have been as high as 65%, with high risk injecting and sexual risk practices reported.
There are currently no prevalence estimates for hepatitis C among PWID in Tanzania.
A limited number of cross-sectional studies have measured HIV prevalence in small samples of PWID in Tanzania; in Dar es Salaam, estimates are as high as 64% among women 28% among men, and 42% overall.
A study of used syringes 57% tested positive for HIV.
In Zanzibar, estimates of HIV prevalence in PWID range from 12-26%.
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),

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
Harm reduction interventions in Tanzania are scarce and there has been little progress towards the scale-up of NSP or opioid substitution therapy beyond a recent pilot OST program at Muhimbili University Hospital and the recently established Harm Reduction Program developed by Medicins Du Monde.
This program was established in 2010 in Temeke District, the poorest of 3 urban districts of Dar es Salaam and an area with highly visible drug use.
The program consists of NSP services delivered through a fixed site and through outreach, HIV and viral hepatitis VCT, and HIV treatment and care services.
The program was developed with a special focus on meeting the service needs of women and was developed with the involvement of peers and the local community.
To inform this program MdM designed and conducted the rapid assessment and response that I will report on today. Our team and the Burnet Institute provided technical and analysis support for this study.

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
The objectives of the study were to:
Determine HIV and hepatitis C prevalence;
Assess knowledge of HIV status and access to HIV care; and
Describe risk behaviours …
… among PWID & other drug users in Temeke District:
And consistent with the basic tenets of a rapid assessment and response, it was also designed to inform an adapted operational response through the MdM harm reduction program and inform broader policy in Tanzania.

6. RAR Methods RAR was structured in 3 phases:
Brief qualitative assessment
key informant/drug user interviews, observations, local and national stakeholder meetings
Quantitative survey accompanied with HIV and HCV testing
Preliminary response phase I – each participant receiving
information and prevention materials
HIV and HCV test results and referral if required
The rapid assessment and response consisted of 3 phases:
First, a brief qualitative phase was used to inform sampling strategies and questions for a quantitative survey phase that was accompanied by HIV and HCV testing.
A preliminary response phase included the provision of information and prevention materials to participants and HIV and hepatitis C testing results and referral to care if needed.

7. RAR Methods RAR was structured in three consecutive phases:
Brief qualitative assessment
key informants and drug user interviews, ethnographic observations, local and national stakeholder meetings
Quantitative survey accompanied with HIV and HCV testing
Preliminary response phase I – each participant receiving
information and prevention materials
HIV and HCV test results and referral if required
The focus of todays presentation is on the findings from the quantitative phase.

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 consent and consent to undergo HIV and HCV testing
Participants were recruited through convenience, snowball and targeted sampling, with an inclusion criteria of
Having injected any drugs in past month
Living in Temeke District
Able to speak and understand Swahili and provide signed informed consent, including consent for HIV and hepatitis C testing
As incentive for participation, reimbursement was provided to all participants in the form of a transport allowance of 1000 shillings, a nutritional pack (including rice, red beans, sugar and a drink), and a safe injecting kit. In addition, all female participants also received a mobile phone voucher of 2000 shillings.

9. Survey Methods Survey data collection: HIV & HCV rapid testing:
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)
Data collection was conducted face-to-face by trained field researchers.
With questions covering:
patterns of drug use
injecting & sexual risk behaviours
prevention & treatment service access; and
HIV and hepatitis C knowledge.
The survey was accompanied by rapid HIV antibody/antigen and rapid hepatitis C antibody testing.

10. Results – Sample Characteristics
267 PWID recruited:
Demographics:
231 males (87%); 37 females
Median age 30 years (IQR 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
267 people were recruited who reported injecting drug use. Participants were predominantly male with a median age of 30 years.
[click] In relation to injecting drug histories and patterns of drug use:
The mean age of 1st injection was 24 years and the median duration of injecting among participants was 5 years.
Daily injecting of heroin in the past month was almost universal.
More than 80% of participants reported first smoking heroin, with the median time of transitioning to injecting of 5 years.
However, there was a trend towards more rapid transitioning among younger and more recent initiates.
Those aged 25 years or under reported a median transition time between smoking and injecting of only 2 years, a result that I think underscores the growing urgancy for local harm reduction and prevention programs.
Also report past month cannabis (53%), alcohol (27%), Valium (7%) and crack/cocaine (n=3) use
Younger may be initiating injecting more rapidly - aged over 25 years = 5 years; aged 25 years and under = 2 years (p<.01)

11. Results – HIV Prevalence
HIV positive
Total n %
(95% CI) 93
34.8
( )
267
Male 69
29.9
( )
231
Female 24
66.7
( ) 36
HIV prevalence was largely consistent with the limited number of previous estimates.
Overall prevalence was 34.8%, about 30% for males but substantially higher at 66.7% for females.
Recent prevalence estimate among FSW in Dar es Salaam was 31.4%.

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
Of particular concern was the high rate of undiagnosed HIV in this group. Over 70% of both males and females were previously undiagnosed prior to study participation.
[click] This is perhaps unsurprising given that more than half of all participants reported no HIV testing history; more than ¾ had not tested in the past two years and about one-third reported not knowing where to access HIV testing.
68/93 (73%) Total
51/69 (74%) Males
17/24 (71%) Females

13. Results – HCV Antibody Prevalence
Among all PWID
8 (1.9%) reported a HCV testing history
2 self-reported positive
Anti-HCV positive
Total n %
(95% CI) 74
27.7
( )
267
Male 64
( )
231
Female 10
27.8
( ) 36
Hepatitis C antibody prevalence was 27.7% and consistent across gender.
[click] Almost all participants reported no hepatitis C testing history; of the 8 who had been tested, 2 self-reported a previous positive result.

14. HIV/anti-HCV positive
Results – HIV/HCV Co-Infection1 Prevalence
1 not accounting for HCV viral clearance
Awareness of HIV was high – 97%
Awareness of HCV considerably lower – 35%
HIV/anti-HCV positive
Total n %
(95% CI) 45
16.9
( )
267
Male 35
15.2
( )
231
Female 10
27.8
( ) 36
HIV and hepatitis C antibody co-prevalence was 16.9%.
While actual co-infection prevalence will be somewhat lower when accounting for hepatitis C viral clearance; likely increases in co-infection in this population will have substantial implications for co-morbidity and liver-related burden of disease in coming years.
[click] While knowledge of HIV was very high in the group, only about one-third had ever heard of hepatitis C.

15. Results – Drug Use Patterns & Risk Behaviours
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%)
In relation to injecting risk practices, the sharing of needle and syringes with others was not commonly reported.
The tendency instead was to report the personal resuse of needles and syringes, often after cleaning with water. With the proportion reporting reuse of needles and syringes similar regardless of HIV status.
[click] Where differences did emerge by HIV status, was in the sharing of other injecting equipment, including a significantly higher proportion of HIV positive participants reporting taking a drug solution from a shared mixing container at last injection.

16. Results – Drug Use Patterns & Risk Behaviours
 At last injection …
Total
HIV Positive
Where inject …
In camp/maskani
89 (33%)
32 (34%)
Who injects with …
With a group in the camp
87 (33%)
34 (37%)
The practice of communal sharing of a drug solution is facilitated by the locations where people inject and the social groups they inject with.
In this study, about one-third of both HIV positive and negative participants reported their last injection was with a group in a camp or maskani – a local term used to describe public spaces where people inject.
Previous studies of drug use in Tanzania have also identified drug-taking as common in such spaces, and qualitative observations in this RAR noted that nearly all drug users utilised communal public spaces to inject.

17. Results – Drug Use Patterns & Risk Behaviours
Of concern is the significant association we found between communal injecting and other injecting risk practices, including the sharing injecting equipment and drug solutions.
While these practices clearly enhance the risk of blood borne virus transmission through injecting peer networks, these communal and social spaces also provide fertile ground for adapted harm reduction approaches.

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
Which brings us to some of the key findings of the RA and their implications.
First, it was clear that, in the context of high frequency injecting and the common reuse of needle and syringes, that local NSP coverage is inadequate and requires scale-up. In addition, in light of the previous finding, such scale-up needs to include adapted distribution strategies beyond fixed-sites, and include outreach and peer distribution, alongside peer education.
[click] Second, high rates of undiagnosed HIV among participants means that harm reduction programs must also include VCT services, including appropriate treatment and referral for HIV. While the provision of hepatitis C treatment is currently beyond local capacity and resources, hepatitis C education for injectors should also be a key part of harm reduction programs.
[click] Third, extremely high HIV prevalence among female injectors supports a focus on services for women, including specific programs for women who engage in transactional sex work.

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
Finally, this study provides an important advocacy tool for policy responses in Tanzania and the region, primarily in relation to highlighting the needs of people who inject drugs and the benefits of injecting drug harm reduction, both for drug users and the general community.
In this study we found that more than half of those with undiagnosed HIV reported unprotected sex in the past month, emphasising the potential for onward HIV transmission to non-drug using populations.
The potential future burden of liver disease in co-infected drug users also needs to be highlighted in harm reduction advocacy.

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
I would like to finish by briefly detailing some of the recent reports of response outcomes from the Temeke Harm Reduction Program.
Field observations of PWID have indicated:
Improved knowledge of blood borne viruses and risk reduction …
… and improved hygiene and use of sterile syringes whenever possible
However, there remains acknowledgement that NSP coverage still needs to be improved
Recently 7 peer educators graduated through an MdM training program, with one now working in a paid part-time position with MdM
And importantly the concept of Harm Reduction has been planted in almost ‘virgin’ territory. The model has been well accepted by local district authorities and the ‘Temeke Harm Reduction Model’ is now being promoted to other parts of Dar es Salaam and nationally.

21. 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
I feel extrorindaily privileged to have been able to work on this project and present today, but I should really only be seen as the messenger.
The real acknowledgement needs to go the Temeke Harm Reduction Program Team, the Research Team at MdM, the participants in the study, and the local Tanzanian partners who have supported the Program.

22. And I’lI leave you with this image:
Not only because it is a beautiful photo
But because it represents some of the great work being conducted on the ground in Temeke District
Thanks you!