1. STRATEGIES TO INCREASE WOMEN’S PARTICIPATION IN AVAILABLE HARM REDUCTION SERVICES IN DAR ES SALAAM, TANZANIA Sophia Zamudio-Haas, DrPH MSc Presented by Olivia Chang, MPH

2. Presentation Outline  Background  Methods  Key findings  Discussion  Conclusion

3. HIV in Dar es Salaam, Tanzania Estimated HIV PrevalencePopulation 6.9%General City Population 35-50%People Who Inject Drugs 24%Men Who Inject Drugs 64%Women Who Inject Drugs TACAIDS ZAC et al. (2013) Tanzania HIV/AIDS Indicator Survey. Available: http://www.measuredhs.com/pubs/pdf/AIS11/AIS11.pdf Williams et al. (2009) HIV Seroprevalence in a sample of Tanzanian Intravenous Drug Users. AIDS Edu Prev 21(5): 474-483.

4. MAT Continuum of Care Street Based Outreach Storefront CBO Storefront CBO Storefront CBO MAT Clinic Muhimbili National Hospital MAT Clinic Muhimbili National Hospital Storefront CBO Lambdin BH, Bruce RD, Chang O, et al. (2013) “Identifying Programmatic Gaps: Inequities in Harm Reduction Service Utilization among Male and Female Drug Users in Dar es Salaam, Tanzania” PLOSone available at: http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0067062

5. Gender Differences in HIV Risk, Mental Health and History of Abuse aRR (95% CI)p-value Multiple Sex Partners (last 6 months)2.42 (1.46, 3.98)<0.001 High Substance Dependence1.18 (1.05, 1.34)0.007 Depression in Last 30 Days1.85 (1.09, 3.14)0.024 Anxiety in Last 30 Days1.87 (1.10, 3.20)0.021 Any History of Sexual Abuse20.21 (3.40, 120.13)0.001 Lambdin BH, Bruce RD, Chang O, et al. (2013) “Identifying Programmatic Gaps: Inequities in Harm Reduction Service Utilization among Male and Female Drug Users in Dar es Salaam, Tanzania” PLOSone available at: http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0067062

6. Data collection/ Initial coding/ Memos Literature Review Developing theoretical concepts as categories Standard Codebook Development Initial analysis and revisions to Standard Codebook Continued analysis and Theoretical sampling Draft writing and Saturating theoretical categories Methods: Adapted Grounded Theory Process Charmaz. (2006) Constructing Grounded Theory: A practical Guide Through Qualitative Analysis. Thousand Oaks, CA: Sage.

7. Study Participant Overview No. MAT Participants Married or Cohabiting Parent to ≥1 child HIV StatusViolence Survivor +-?SexualPhysical Men63406003 Women138963455

8. Outreach Barriers: Common Themes  Women IDU: use heroin in different, more secluded spaces than men  Women IDU: sex workers who ‘go to the road’ at night and sleep all day  Outreach happens during the day, when women not available  Peer outreach workers: mainly male, picking spots for outreach frequented by men

9. Outreach Barriers: Different Hangouts, Different Times “You know women, to get them is difficult because most of them are prostitutes. You see they normally work at night, so they are available during the night and I do the services until 4pm. But these women work during the night and during the day they sleep. To get the women, we have to go to them where they are available so as to reach them. If we go to the places they are available, they do not deny our information. I think the best time is at night for this kind of work.” -Male Peer Outreach Worker

10. Outreach Barriers: Lack of Sex Workers for Peer Outreach “Drug use amongst young girls is very hidden in this community actually by culture and by the way they operate. But sex work is a bit more obvious, but also a lot of silence around it. Meeting with the girls can be difficult. In the afternoons, they need rest. In the evenings, they go out. So the best person to work with the girls is somebody from the same group who can be with the girls when the time is appropriate for the girls.” - Female Program Manager

11. New Outreach Strategies Nighttime Women’s Hang-outs Peer CSW/PWI Outreach

12. Barriers to Women’s Enrollment Retention in MAT: Common Themes  Double stigma: prevents women from receiving the support that they need to stay in treatment  Limited job opportunities for women in treatment  Lack of finances to get to and from clinic everyday  Discrimination and intimidation from male counterparts at the clinic  Perceived stigma on hospital grounds

13. Barrier to MAT: Double Stigma “In Dar, a woman who does drugs is more vehemently discriminated against than a man who does drugs because she is a woman. A man who does drugs is more tolerated. So a woman is discriminated against. There is a difference. A woman cannot get any support. She will not receive any support. So she is shut out, but a man can be given work to do, heavy lifting manual labor, stuff like that, but for a woman it is difficult.” – Female MAT Clients

14. Barrier to MAT: Transportation “Many of [the women MAT clients] do not have social support, they are chased from their homes and they are not acceptable in the community. The main challenge they face is transportation fee. They have to come here daily for medication and you cant take the medications without a meal. I think its really just about whether they can afford it financially. ” -Female MAT Client

15. Enrollment Strategies: Low Threshold Evidence of Injection CBO SessionsCBO Referral

16. No evidence of injection No CBO Requirement Self or Peer Referral Enrollment Strategies: Low Threshold

17. Retention Strategies  Female-specific clinic hours  Dedicated dosing window

18. Retention Strategies Take Away Dose Reduce Transport $ Reduce Time at Health Facility Reduce Waiting Time

19. The same gendered inequities that drive the greater need for HIV prevention and treatment among women who inject drugs reduce access to harm reduction services. Conclusion

20. Thank You and Acknowledgements Co-Authors:  Bathsheba Mahenge, Barrot Lambdin, Samuel Likindikoki, Megan Dunbar, Jessie Mbwambo Research funded in part by:  Pangaea Global AIDS, UC Berkeley Center for African Studies, UC Berkeley Center for Rights and Reproductive Justice

21. Sophia Zamudio-Haas Center for AIDS Prevention Studies, UCSF Sophia.Zamudio-Haas@ucsf.edu Questions and Comments Welcome!

23. MAT as HIV Prevention Eliminates craving and withdrawal Reduces HIV risk behavior Improves physical and mental health Metzger et al. (1999) Drug abuse treatment as AIDS prevention. Public Health; 113: 97-106. Roux et al. (2009) The impact of methadone or buprenorphine treatment and ongoing injection on highly active antiretroviral therapy (HAART) adherence: evidence form the MANIF2000 cohort study. Addiction; 103(11): 1828-36.

24. Outreach: Sex Worker Peers “We must work at night if we want to get the women IDU. My suggestion is that we should be close to the female clients who are already here, because they used to go the road with them so they know where they stay. We should use those who are here to bring in the others. ” –Male Outreach Supervisor