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, Australia2Médecins du Monde - France, Paris, France3Médecins du Monde, Dar es Salaam, United Republic of Tanzania

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

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), 832Nieburg P, Carty L. HIV Prevention among Injection Drug Users in Kenya and Tanzania. Centre forStrategic and International Studies; 2011

• There are currently an estimated 50,000 people who inject drugs (PWID) in Tanzania2

• Mainland Tanzania characterised by a generalised HIV epidemic

• Few studies of PWID substantially higher HIV prevalence

• No hepatitis C (HCV) prevalence estimates among PWID

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), 474-483

Background – HIV & HCV in Tanzania

Little progress toward NSP and opioid substitution therapy scale-up• Pilot OST at Muhimbili University Hospital

Background – IDU and Harm Reduction

• 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

RAR ObjectivesAmong PWID & other drug users in Temeke District:

1. Determine HIV and hepatitis C prevalence;

2. Assess knowledge of HIV status and access to HIV care; and

3. Describe risk behaviours.

… to inform an adapted operational response through the MdM F harm reduction program and inform policy ‐in Tanzania

RAR MethodsRAR was structured in 3 phases:

1. Brief qualitative assessment • key informant/drug user interviews, observations, local and national

stakeholder meetings

2. Quantitative survey accompanied with HIV and HCV testing

3. Preliminary response phase I – each participant receiving• information and prevention materials• HIV and HCV test results and referral if required

RAR was structured in three consecutive phases:

1. Brief qualitative assessment • key informants and drug user interviews, ethnographic observations, local

and national stakeholder meetings

2. Quantitative survey accompanied with HIV and HCV testing

3. Preliminary response phase I – each participant receiving• information and prevention materials• HIV and HCV test results and referral if required

RAR 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

Survey Methods

Survey MethodsSurvey data collection:

• 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)

Results – Sample Characteristics267 PWID recruited:• Demographics:

– 231 males (87%); 37 females– Median age 30 years (IQR 26-34 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

Results – HIV Prevalence

HIV positive Total n % (95% CI) Total 93 34.8 (29.1-40.9) 267Male 69 29.9 (24.0-36.2) 231Female 24 66.7 (49.0-81.4) 36

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

Results – Undiagnosed HIV Prevalence1

Among all PWID• 8 (1.9%) reported a HCV testing history• 2 self-reported positive

Results – HCV Antibody Prevalence

Anti-HCV positive Total n % (95% CI) Total 74 27.7 (22.4-33.5) 267Male 64 27.7 (22.0-34.0) 231Female 10 27.8 (14.2-45.2) 36

1 not accounting for HCV viral clearance

• Awareness of HIV was high – 97%• Awareness of HCV considerably lower – 35%

Results – HIV/HCV Co-Infection1 Prevalence

HIV/anti-HCV positive Total n % (95% CI) Total 45 16.9 (12.6-21.9) 267Male 35 15.2 (10.8-20.4) 231Female 10 27.8 (14.2-45.2) 36

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%)

Results – Drug Use Patterns & Risk Behaviours

At last injection … Total HIV PositiveWhere inject …

In camp/maskani 89 (33%) 32 (34%)Who injects with …

With a group in the camp 87 (33%) 34 (37%)

Results – Drug Use Patterns & Risk Behaviours

Results – Drug Use Patterns & Risk Behaviours

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

– Risks in refuelling general HIV epidemic• 54% of undiagnosed HIV+ participants reported

recent unprotected sex– Future HCV burden, especially with co-

infection

RAR Findings & Implications

Advocacy & policy responses:• Needs of PWID and benefits of IDU

harm reduction

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

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