Injection Drug Use in Dar es Salaam Results

Injection Drug Use in Dar es Salaam: Results and Public Health Implications Mark Williams, Ph. D. Gad Kilonzo, M. D. Sheryl Mc. Curdy, Ph. D. M. T. Leshabari, Ph. D.

Qualitative Research 2003 - 2006 122 in-depth interviews conducted over 3, 6, and 9 month periods 90 heroin injectors 52 men 38 women 32 other heroin users and drug users • alcohol • mirungi/khat • marijuana

Changes in Heroin related practices between 2003 -2006 • Heroin tripled in price • Heroin is now adulterated (reportedly need 2 x as much for • • same high) Very little brown heroin in circulation Progression steps skipping snorting and chasing Introduction of Flashblood and Vipoint Gender based violence increasing: Men stealing blood, syringes and money from women in geto

Blood Sharing: Flashblood & Vipoint • Flashblood (giving a syringe of blood) emerged spring/summer 2005 • Vipoint (injecting only a measured cc amount and passing back the syringe) is also a common practice among those who share needles* *A similar practice emerged in Pakistan at same time and may be related to connections between the two countries Kuo I, ul-Hasan S, Galai N, Zafar T, Strathdee SA. Correlates of hepatitis C virus infection among injection drug users in Pakistan. Poster presentation at the 15 th International Conference on the Reduction of Drug Related Harm (15 th ICRDRH), April 20 -24, 2004, Melbourne, Australia.

Syringe use and disposal Leave syringe and needle unit bought at pharmacy for 100 shillings at the maskani and mageto to use again later • • • Leave with “doctor” or owner of geto Hide at maskani There is no way of knowing if others used it Disposal of syringe and needle • Throw ‘overboard’ anywhere • Drop it down a latrine

2003 -2004 Survey Were drug users in Dar es Salaam injecting, and if they were, were they engaging in needle use and sexual behaviors that could transmit HIV, other blood borne pathogens, and STIs? Eligibility • Aged 18 • Injected heroin at least once in the last 7 days • Informed consent • A least 1/3 of the sample to be women

2003 -2004 Survey Results 328 men and women participated in the study Significant differences in findings by gender • Men were older • Men were earned less money and were living with others • Women earned more money and lived on their own • Men and women preferred different forms of heroin • Men were more likely to share needles • Men were less likely to be having sex • Women were more likely to be sexually active, to have had greater numbers of sex partners, and to be engaged in sex worker

2003 -2004 Survey Conclusions • Drug users are injecting in Dar es Salaam • Injectors do engage in behaviors that could have public health consequences • Gender and economic situations are related to needle risk of HIV transmission • Gender and economic situations are related to sex risk of HIV transmission • Needle use and sexual risk of HIV transmission are independent

Survey of syringes in Dar es Salaam If drug users were injecting and engaging in risk behaviors that could transmit HIV, was HIV in needles that had been used by drug injectors? • Syringes were collected from injectors who volunteered to provide them • Syringes were tracked by neighborhood • In the seven neighborhoods from which syringes were collected, HIV in syringes ranged from 90% in one neighborhood to zero percent in three neighborhoods

Tanzania AIDS Prevention Project What is the HIV prevalence among drug injectors in Dar es Salaam? To what conditions and behaviors are higher prevalence rates related? • • • Eligibility 18 years and older Injection drug use at least once in the 7 days before being interviewed Vaginal sex at least once in the 7 days before being interviewed Consent to voluntary HIV testing and counseling, including collection of biological specimen and participation in safer needle cleaning and condom use demonstrations Balanced sample between men and women

Interviewers, start of day at Dar es Salaam TAPP study office site

Tanzania AIDS Prevention Project: HIV test results 537 participants 318 men, 219 women HIV-positive 227/537 (42%)

Tanzania AIDS Prevention Project: Analysis of factors related to increased risk of HIV infection Characteristic % HIV+ OR (95% CI) Gender Male Female Age < 25 25 to 29 30 to 24 > 35 27% 64% 4. 71 (3. 25, 6. 81) 44% 46% 44% 27% 2. 09 (1. 15, 3. 81) 2. 24 (1. 24, 4. 05) 2. 04 (1. 09, 3. 82) -

Characteristic Source of Income Family/Friends Job Trading/illegal Spouse Income < 150, 000 -199, 000 > 200, 000 Considers self homeless no yes % HIV+ OR (95% CI) 18% 28% 53% 74% 1. 78 ns 5. 16 (1. 09, 24. 33) 12. 75 (2. 12, 76. 57) 49% 46% 36% 1. 70 1. 46 - 38% 54% 1. 90 (1. 27, 2. 82) (1. 12, 2. 58) ns

Characteristic % HIV+ OR (95% CI) Living arrangements Own house 18% Parent’s house 28% Someone else’s house 53% Rented room 74% Streets/empty building 55% Time living in Dar es Salaam < 13 years 57% 13 to 24 years 35% 25 to 29 years 41% > 30 years 37% 1. 58 3. 21 3. 93 2. 36 2. 50 1. 33 1. 13 ns (1. 80, 5. 73) (2. 03, 7. 61) (0. 99, 5. 63) (1. 53, 4. 11) ns

Characteristic % HIV+ OR (95% CI) Years injected drugs 1 - 2 years 43% 3 years 54% 4 - 5 years 34% > 6 years 41% Number of recent sex partners one 32% 2 - 49 38% > 50 67% 1. 49 ns 2. 24 (1. 33, 3. 79) - 1. 35 ns 1. 29 4. 24 ns (2. 71, 6. 63)

Characteristic % HIV+ OR (95% CI) Number of sex partners while recently binging drugs none 34% one 41% > 2 66% Recently traded sex for money no 31% yes 63% Recently traded money for sex no 20% yes 46% 1. 36 3. 78 ns (1. 80, 5. 87) 3. 92 (2. 70, 5. 70) 3. 39 (1. 87, 6. 15)

HIV and drug use in Dar es Salaam: Implications • Drug practices changing rapidly in Dar es Salaam • HIV prevalence high in sub-cultural setting • Danger of injecting risk practices, however: • Injectors willing to participate in VCT • Injectors are aware of bleach • Bridges between sexual risk and injecting risk populations

HIV and drug use in Dar es Salaam: Public health implications • Injection and related practices may create an • • • epidemiological core group for HIV infection Need for research that examined the intersection of needle use and sexual risk behaviors and populations Need for research on context specific interventions to reduce incidence of HIV infections and increase the likelihood of maintaining low STD incidence Need for low cost or free drug treatment services

• We are grateful to the U. S. National Institute on Drug Abuse for its financial support of our research. • We are also indebted to our colleagues Stella Mujaya, Samueli Kiore, Mary Anderson Mbwambo, Brown Emmanuel, Doris Msuali, Charles Msumari, Dr. Sandra Timpson, and Dr. John Atkinson for their assistance in data collection, management, and analysis.