Generating trust: Programmatic strategies to reach women who inject drugs with harm reduction services in Dar es Salaam, Tanzania

Adapting a health facility HIV stigma-reduction participatory training intervention to address drug use stigma in HIV care and treatment clinics in Dar es Salaam, Tanzania

BACKGROUND

HIV prevalence among people who use drugs (PWUD) in Tanzania is 4-7 times higher than in the general population, underscoring an urgent need to increase HIV testing and treatment among PWUD. Drug use stigma within HIV clinics is a barrier to HIV treatment for PWUD, yet few interventions to address HIV-clinic drug use stigma exist. Guided by the ADAPT-ITT model, we adapted the participatory training curriculum of the evidence-based Health Policy Plus Total Facility Approach to HIV stigma reduction, to address drug use stigma in HIV care and treatment clinics (CTCs).

METHODS

The first step in the training curriculum adaptation process was formative research. We conducted 32 in-depth interviews in Dar es Salaam, Tanzania: 18 (11 men and 7 women) with PWUD living with HIV, and 14 with a mix of clinical [7] and non-clinical [7] CTC staff (5 men and 9 women). Data were analyzed through rapid qualitative analysis to inform initial curriculum adaptation. This initial draft curriculum was then further adapted and refined through multiple iterative steps of review, feedback and revision including a 2-day stakeholder workshop and external expert review.

RESULTS

Four CTC drug use stigma drivers emerged as key to address in the curriculum adaptation: (1) Lack of awareness of the manifestations and consequences of drug use stigma in CTCs (e.g., name calling, ignoring PWUD and denial of care); (2) Negative stereotypes (e.g., all PWUD are thieves, dangerous); (3) Fear of providing services to PWUD, and; (4) Lack of knowledge about drug use as a medical condition and absence of skills to care for PWUD. Five, 2.5-hour participatory training sessions were developed with topics focused on creating awareness of stigma and its consequences, understanding and addressing stereotypes and fears of interacting with PWUD; understanding drug use, addiction, and co-occurring conditions; deepening understanding of drug use stigma and creating empathy, including a panel session with people who had used drugs; and working to create actionable change.

CONCLUSION

Understanding context specific drivers and manifestations of drug use stigma from the perspective of PWUD and health workers allowed for ready adaptation of an existing evidence-based HIV-stigma reduction intervention to address drug use stigma in HIV care and treatment clinics. Future steps include a pilot test of the adapted intervention.

Patient and Provider Perspectives on Processes of Engagement in Outpatient Treatment for Opioid Use Disorder: A Scoping Review

Effective treatment for opioid use disorder (OUD) is available, but patient engagement is central to achieving care outcomes. We conducted a scoping review to describe patient and provider-reported strategies that may contribute to patient engagement in outpatient OUD care delivery. We searched PubMed and Scopus for articles reporting patient and/or provider experiences with outpatient OUD care delivery. Analysis included: (1) describing specific engagement strategies, (2) mapping strategies to patient-centered care domains, and (3) identifying themes that characterize the relationship between engagement and patient-centered care. Of 3,222 articles screened, 30 articles met inclusion criteria. Analysis identified 14 actionable strategies that facilitate patient engagement and map to all patient-centered care domains. Seven themes emerged that characterize interpersonal approaches to OUD care engagement. Interpersonal interactions between patients and providers play a pivotal role in encouraging engagement throughout OUD treatment. Future research is needed to further evaluate promising engagement strategies.

People Who Inject Drugs in Mozambique: We need to normalize HIV treatment and care services in specialized community centers for people who inject drugs!

Globally, People Who Inject Drugs (PWID) have limited healthcare, treatment, and prevention services, and they frequently experience stigma and negative attitudes toward healthcare providers when accessing services. Mozambique, with a general population HIV prevalence of 12.5%, has one of the highest rates in the world, and the PWID population has the highest HIV prevalence among key populations, estimated at nearly 50%. Less than half of HIV positives who inject drugs are linked to HIV treatment and are retained in care. One of the main reasons is that HIV treatment is mainly provided in a public health facility and PWID delayed accessing healthcare since they anticipated mistreatment from multiple levels of healthcare providers. To improve the health outcomes in this group, we need to treat them where they feel comfortable and respected. In this commentary, we outline the importance of innovative approaches to enhance the management of HIV-positive PWID. As a country gets close to controlling the HIV epidemic, refocusing and targeting responses to the highest-risk groups becomes even more essential for shaping more effective HIV interventions and achieving epidemic control.

Translation and cultural adaptation of drug use stigma and HIV stigma measures among people who use drugs in Tanzania

INTRODUCTION

People who use drugs (PWUD) experience stigma from multiple sources due to their drug use. HIV seroprevalence for PWUD in Tanzania is estimated to range from 18 to 25%. So, many PWUD will also experience HIV stigma. Both HIV and drug use stigma have negative health and social outcomes, it is therefore important to measure their magnitude and impact. However, no contextually and linguistically adapted measures are available to assess either HIV or drug use stigma among PWUD in Tanzania. In response, we translated and culturally adapted HIV and drug use stigma measures among Tanzanian PWUD and described that process in this study.

METHODS

This was a cross-sectional study. We translated and adapted existing validated stigma measures by following a modified version of Wild's ten steps for translation and adaptation. We also added new items on stigmatizing actions that were not included in the original measures. Following translation and back translation, we conducted 40 cognitive debriefs among 19 PWUD living with and 21 PWUD not living with HIV in Dar es Salaam to assess comprehension of the original and new items. For challenging items, we made adaptations and repeated cognitive debriefs among ten new PWUD participants where half of them were living with HIV.

RESULTS

Most of the original items (42/54, 78%), response options and all items with new 12 stigmatizing actions were understood by participants. Challenges included response options for a few items; translation to Swahili; and differences in participants' interpretation of Swahili words. We made changes to these items and the final versions were understood by PWUD participants.

CONCLUSION

Drug use and HIV stigma measures can successfully be translated and culturally adapted among Tanzanian PWUD living with and without HIV. We are currently conducting research to determine the stigma measures' psychometric properties and we will report the results separately.

Prevalence and predictors of depressive and anxiety symptoms in a sample of women who use drugs in Tanzania: the key role of drug use stigma

BACKGROUND

Globally, women who use drugs face multiple health vulnerabilities, including poor mental health. Little is known about the mental health burden among women who use drugs in sub-Saharan Africa. This cross-sectional study examined the prevalence and predictors of depressive and anxiety symptoms among a sample of women who use drugs in Dar es Salaam, Tanzania.

METHODS

We administered a cross-sectional survey to a non-random sample of 200 women who use drugs in Dar es Salaam between November 2018 and March 2019. We used descriptive statistics to characterize the study sample and fitted separate logistic regression models to assess depressive and anxiety symptoms and their predictors.

RESULTS

The percentages of women reporting depressive and anxiety symptoms were 67.5% and 43.7%, respectively. Internalized drug use stigma (AOR = 1.34, 95% CI: 1.03-1.75) and prior attempts to stop heroin use (AOR = 2.99, 95% CI: 1.28-7.00) were associated with depressive symptoms. Enacted drug use stigma from health workers (AOR = 2.02, 95% CI: 1.34-3.04) and anticipated drug use stigma from family (AOR = 1.49, 95% CI: 1.02-2.16) were associated with anxiety symptoms.

CONCLUSIONS

Depressive and anxiety symptoms were high among our study sample, with higher reports of symptoms of depression than anxiety. Drug use stigma was a key factor that contributed to elevated symptoms of depression and anxiety.

Barriers to accessing internationally controlled essential medicines in sub-saharan Africa: A scoping review

BACKGROUND

Access to internationally controlled essential medicines (ICEMs), medicines that are listed on both the World Health Organization's Essential Medicines List and one of three international drug control conventions, remains problematic in Sub-Saharan Africa (SSA). Previous reviews have focused only on specific ICEMs or ICEM-related healthcare fields, but none have focused on all ICEMs as a distinct class. This scoping review therefore aims to identify the barriers to accessing ICEMs across all relevant healthcare fields in SSA.

METHODS

A scoping review was conducted across indexing platforms Embase, PubMed, Scopus and Web of Science of studies published between January 1 2012 and February 1 2022. Articles were eligible if they mentioned barriers to accessing ICEMs and/or ICEM-related healthcare fields, if studies were conducted in SSA, or included data on an SSA country within a multi-country study. The review was guided by the Access to Medicines from a Health System Perspective framework.

RESULTS

The search identified 5519 articles, of which 97 met the inclusion criteria. Many barriers to access were reported and were common across the ICEMs drug class. Main barriers were: at the individual level, the lack of knowledge about ICEMs; at the health service delivery level, low availability, stockouts, affordability, long distances to health facilities, insufficient infrastructure to store and distribute ICEMs, and lack of ICEM knowledge and training among healthcare workers; at the health sector level, lack of prioritisation of ICEM-related healthcare fields by governments and subsequent insufficient budget allocation. Cross-cutting, governance-related barriers pertained to lack of proper quantification systems, cumbersome procurement processes, and strict national laws controlling ICEMs, leading to overly restrictive prescription practices.

CONCLUSION

This review showed that there are a multitude of barriers to accessing ICEMs in SSA across all health system levels. Many of the barriers identified are applicable to all ICEMs, highlighting the importance of tackling barriers for this entire class of drugs together.

Housing instability and violence among women who use drugs in Dar es Salaam, Tanzania

BACKGROUND

Women who use heroin and other drugs (WWUD) are a key population with elevated risk of physical and sexual violence perpetrated by intimate partners and non-partners. While housing instability has been shown to be associated with violence in high-income settings, this is an underexplored topic in sub-Saharan Africa. In this research, we aimed to assess the relationship between housing instability and various forms of violence within a sample of WWUD in Dar es Salaam.

METHODS

This analysis uses data from a parent study from 2018. A total of 200 WWUD were recruited through respondent-driven sampling methods and administered a survey. Two multivariable logistic regression models were built to assess the relationship between housing instability and physical violence (Model 1) and housing instability and sexual violence (Model 2) while controlling for a number of sociodemographic characteristics.

RESULTS

Approximately 35% of participants were classified as housing unstable. More than half of participants (62%) reported experiencing physical violence in the past 12 months, and more than a third (36%) reported sexual violence in the same time period. Housing instability was found to be independently associated with both physical and sexual violence victimization in the past year when adjusting for covariates (Model 1 adjusted odds ratio [AOR]: 2.40, 95% CI 1.22-4.46; Model 2 AOR: 1.93. 95% CI 1.02-3.67).

CONCLUSION

To our knowledge, this is the first study to document a significant association between housing instability and violence among WWUD communities in sub-Saharan Africa. This analysis adds to the growing body of literature on the relationship between stable housing and livelihood and health outcomes across differing populations. The cyclical nature of housing instability and violence may be disrupted through housing programming that provides safety, security, and stability for WWUD.

Structural, everyday, and symbolic violence and the heightened vulnerability to HIV of women who use drugs in Tanzania

Women who use drugs shoulder a disproportionate burden of the HIV epidemic in Tanzania. The mechanisms through which violence contributes to their excessively high rates of HIV have not been explored. In this paper, we use concepts of everyday, symbolic, and structural violence to critically examine the relationship between violence and heightened HIV vulnerability of women who use drugs in Dar es Salaam, Tanzania. We conducted cross-sectional surveys with 200 women who use drugs and follow-up, in-depth interviews with 30 survey participants who identified as living with HIV between November 2018 and March 2019. We drew from grounded theory methods to analyze qualitative data and complemented qualitative findings with survey results. Structural violence perpetuated constraints on women's economic opportunities and reduced their agency in sexual encounters manifesting in their disproportionately high rates of HIV. Nearly all women in our study engaged in sex work to meet basic needs and to support their drug use. Their involvement in overlapping drug use and sex work scenes exposed them to physical and sexual violence. Despite the pervasiveness of structural and everyday violence, some women reenacted agency by adopting strategies to maintain control and safety, and to exercise harm reduction. A multi-pronged, structural harm reduction strategy is critical to reducing violence experienced by women who use drugs and their ability to protect themselves from HIV.

High occurrence of witnessing an opioid overdose in a sample of women who use heroin in Tanzania: Implications for overdose prevention

BACKGROUND

Opioid overdose is preventable and reversible. To target overdose prevention training and naloxone distribution, it is important to understand characteristics of those people who use drugs most likely to witness an overdose. In this paper we report the proportion and characteristics of women who use heroin that have witnessed an opioid overdose in Dar es Salaam, Tanzania.

METHODS

We conducted a cross-sectional survey with 200 women who use heroin. We fitted unadjusted and adjusted logistic regression models with witnessing an opioid overdose as the dependent variable and sociodemographic and drug use-related variables as independent variables.

RESULTS

The majority of participants (85%) reported having ever witnessed an opioid overdose. Age (adjusted Odds Ratio [aOR] = 1.09; 95% CI: 1.02-1.12), having ever attempted to stop heroin use (aOR = 11.27; 95% CI: 2.25-56.46), history of arrest (aOR = 3.75; 95% CI: 1.32-10.63), and spending time daily in places where people use drugs (aOR = 3.72; 95% CI: 1.43-9.64) were found to be independently associated with ever witnessing an overdose.

CONCLUSIONS

Findings suggest the need for expanded access to naloxone to lay people and community and peer-based overdose prevention training in Tanzania, including the distribution of naloxone in settings with high drug use.

"He's under oath": Privacy and Confidentiality Views Among People Who Inject Drugs Enrolled in a Study of Social Networks and Human Immunodeficiency Virus/Hepatitis C Virus Risk

Despite the promise of social network research, this method raises important ethical questions regarding privacy and confidentiality. Although researchers and bioethicists have considered research obligations in relation to marginal or vulnerable populations, the views of people who inject drugs (PWIDs) have not been sufficiently considered. To elicit participants' views of research obligations, we conducted in-depth interviews with a subset (n = 40) of active PWIDs enrolled in a large social network study. Findings suggest participants have an expectation of confidentiality but believe this obligation need not be absolute and can be waived if a participant violates community norms or place others at risk. Ethics boards should recognize that marginalized populations are able to articulate complex moral views about privacy and confidentiality. Engaging participants in dialogue about the responsible conduct of research presents an opportunity to correct under- or overestimations of research vulnerabilities when such decisions are restricted to the perspectives of investigators or Institutional Review Board members.

Barriers and Facilitators to Substance Use Disorder Treatment in Low-and Middle-Income Countries: A Qualitative Review Synthesis

BACKGROUND AND AIMS

One of the ways to address the treatment gap for substance use disorders is to understand the barriers and facilitators to treatment. This study aimed to synthesize the literature on barriers and facilitators of treatment in Low- and Middle-Income Countries (LMICs).

METHODS

We search Medline electronic database to identify English language peer reviewed empirical studies, both qualitative and quantitative which reported barriers and/or facilitators of treatment of substance use disorders.

RESULTS

Of 1389 titles, we selected 28 studies (14 were qualitative and 14 quantitative studies). The sample sizes of the qualitative studies ranged from 11 to 235. The majority of studies were from community or clinic settings. A wide range of barriers and facilitators were identified from the qualitative studies and were synthesized according to perceived susceptibility/seriousness, self-efficacy, perceived costs, perceived benefits, and cues to action. Most of the quantitative studies were community-based cross sectional-observational by design. Commonly identified barriers in these quantitative studies were perceived lack of problem or lack of need for treatment and low motivation whereas factors such as good family support and availability of effective treatment was found to facilitate substance use disorder treatment.

CONCLUSION

There are a wide range of barriers that hinder the substance use disorder treatment as well as certain factors that facilitate the treatment. Addressing them can help to minimize the treatment gap, which in turn can help in reducing the familial and social burden due to substance use disorders.

Women and barriers to harm reduction services: a literature review and initial findings from a qualitative study in Barcelona, Spain

Background

There are an estimated 3.2 million women who inject drugs worldwide, constituting 20% of all people who inject drugs. The limited data that are available suggest that women who inject drugs are at greater risk of HIV and viral hepatitis acquisition than men who inject drugs. This increased vulnerability is a product of a range of environmental, social and individual factors affecting women, which also affect their ability to engage in health promoting services such as harm reduction.

Methods

The researchers undertook a narrative literature review examining access to harm reduction services for women who use drugs in Europe and conducted semi-structured focus groups with women who use drugs and harm reduction and prison health workers in Barcelona, Spain.

Results

Women who use drugs face multiple barriers to accessing harm reduction services. These include stigma, both in society in general and from health and harm reduction workers in prisons and in the community; gender-based violence and a lack of services that are equipped to address the interaction between drug use and experiences of violence; criminalisation in the form of legal barriers to access, arrest and harassment from law enforcement, and incarceration; and a lack of services focused on the specific needs of women, notably sexual and reproductive health services and childcare. In Barcelona, participants reported experiencing all these barriers, and that their engagement with the Metzineres harm reduction centre had to some extent mitigated them. However, women continued to experience structural barriers to harm reduction service access.

Conclusions

Women and gender non-conforming people who use drugs face unique barriers to accessing harm reduction services. While services such as Metzineres can be life changing and life affirming for its members, it is incumbent on states to act to address the structural barriers to health faced by women who use drugs.

Hepatitis B, hepatitis C and HIV prevalence and related sexual and substance use risk practices among key populations who access HIV prevention, treatment and related services in South Africa: findings from a seven-city cross-sectional survey (2017)

Background

People who use drugs including people who inject drugs (PWUD/ID), sex workers (SWs) and men who have sex with men (MSM) are at increased risk of HIV and viral hepatitis infection. Limited epidemiological data on the infections exists in key populations (KPs) in South Africa. We investigated the prevalence of hepatitis B (HBV), hepatitis C (HCV) and HIV and selected risk factors among these KPs to inform effective responses.

Methods

We used convenience sampling to recruit a targeted 3500 KPs accessing HIV-related health services across Cape Town (SWs, MSM, PWUD/ID), Durban (SWs, PWUD/ID), Pietermaritzburg (SWs), Mthatha (SWs), Port Elizabeth (SWs), Johannesburg (MSM) and Pretoria (MSM and PWUD/ID) into a cross-sectional survey. An interviewer questionnaire to assess socio-demographic characteristics, drug use and sexual risk practices, was administered. HBV surface antigen (HBsAg); HCV antibody, viral load and genotype, and HIV antibody, was tested.

Results

Among the 3439 people included in the study (1528 SWs, 746 MSM, 1165 PWUD/ID) the median age was 29 years, most participants were black African (60%), and 24% reported homelessness. 82% reported substance use in the last month, including alcohol (46%) and heroin (33%). 75% were sexually active in the previous month, with condom use at last sex at 74%. HIV prevalence was 37% (highest among SWs at 47%), HBsAg prevalence 4% (similar across KPs) and HCV prevalence was 16% (highest among PWUD/ID at 46%).

Conclusions

HBV, HCV and HIV pose a health burden for KPs in South Africa. While HIV is key for all included KPs, HCV is of particular importance to PWUD/ID. For KPs, HBV vaccination and behavioural change interventions that support consistent condom and lubricant access and use are needed. Coverage of opioid substitution therapy and needle and syringe services, and access to HCV treatment for PWUD/ID need to be expanded.

HIV-Related Implementation Research for Key Populations: Designing for Individuals, Evaluating Across Populations, and Integrating Context

INTRODUCTION

Key populations, including men who have sex with men, transgender people, sex workers, people who inject drugs, and incarcerated populations, experience high burdens of HIV and urgently need effective interventions. Yet the evidence base for implementation research (IR) with key populations remains weak and poses specific challenges to epidemiologic inference. We apply the Consolidated Framework for IR to consider specific challenges and recommendations for IR with key populations.

DISCUSSION

Individuals within key populations exist within inner and outer settings-including organizational structures, legal (eg, criminalization), and funding environments-which influence the design, adoption and fidelity of interventions, and the potential sustainability of intervention scale-up. Underlying vulnerabilities and external stressors experienced at the individual level (eg, homelessness, violence) further impact participation and retention in IR. Thus, researchers should account for representation in the research process, beginning with community engagement in IR design and consideration of enumeration/sampling methods for key populations who lack probabilistic sampling frames. Interventions for key populations require substantial adaptation and complexity (eg, individually tailored, multicomponent) to ensure appropriateness; however, there is tension between the need for complexity and challenges to internal validity (fidelity) and external validity (generalizable scale-up). Finally, integrating contextual, sampling, and implementation elements into analytic approaches is critical for effectiveness evaluation.

CONCLUSIONS

Translation of efficacious findings at the individual level to effectiveness at the population level requires recognition of risk heterogeneity. Recognizing the nuances of working with key populations is essential to ensure that individuals are represented by design and therefore gains in population health can be achieved.

Prevalence and risk factors associated with HIV-1 infection among people who inject drugs in Dar es Salaam, Tanzania: a sign of successful intervention?

Background

Prevalence of HIV infection among people who inject drugs (PWID) has been reported to be higher than that of the general population. The present study aimed to estimate the prevalence of HIV infection and associated risk factors among PWID in Dar es Salaam, Tanzania, following the introduction of a comprehensive HIV intervention package (CHIP) for PWID in the country in 2014.

Methods

We conducted an integrated bio-behavioral survey (IBBS) among PWID using respondent-driven sampling (RDS) in Dar es Salaam, Tanzania, between October and December 2017. Data on socio-demographic characteristics and risky behaviors were collected through face-to-face interviews. Blood samples were collected and tested for HIV infection. We accounted for weighting in the analyses, and logistic regression was performed to assess risk factors for HIV infection.

Results

A total of 611 PWID (94.4% males and 5.6% females) with a median age of 34 years (IQR 29–38) were recruited. The overall prevalence of HIV infection was 8.7% (95% CI 6.5–10.9). The prevalence of HIV infections for males and females were 6.8% (95% CI 4.7–8.9%) and 41.2% (95% CI 23.7–58.6%) respectively. Adjusted weighted logistic regression analysis (WLRA) showed that being a female (aOR 19.1; 95% CI 5.9–61.8), injecting drugs for more than 10 years (aOR = 7.32; 95% CI 2.1–25.5) compared to 1 year or less and being 45 years or older (aOR = 34.22; 95% CI 2.4–489.5) compared to being 25 years or younger were associated with increased odds of HIV infection. Use of a sterile needle at last injection decreased odds of HIV infection (aOR = 0.3; 95% CI 0.1–0.8).

Conclusions

The present study observed a decline in prevalence of HIV infections among PWID in Dar es Salaam (8.7%) compared to a previous estimate of 15.5% from an IBBS conducted in 2013. Despite the decrease, HIV prevalence remains high among PWID compared to the general population, and women are disproportionally affected. The decline may be possibly attributed to the on-going implementation of CHIP for PWID, highlighting the need for strengthening the existing harm reduction interventions by incorporating access to sterile needle/syringe and addressing the layered risks for women.

A Global Meta-analysis of the Prevalence of HIV, Hepatitis C Virus, and Hepatitis B Virus Among People Who Inject Drugs-Do Gender-Based Differences Vary by Country-Level Indicators?

BACKGROUND

Women-specific factors exist that increases vulnerability to drug-related harms from injection drug use, including blood-borne viruses (BBVs), but gender-based differences in BBV prevalence have not been systematically examined.

METHODS

We conducted meta-analyses to estimate country, regional, and global prevalence of serologically confirmed human immunodeficiency virus (HIV), hepatitis C virus (HCV; based on detection of anti-HCV antibody), and hepatitis B virus (HBV; based on detection of HBV surface antigen) in people who inject drugs (PWID), by gender. Gender-based differences in the BBV prevalence (calculated as the risk among women relative to the risk among men) were regressed on country-level prevalence and inequality measures (Gender inequality index, Human development index, Gini coefficient, and high, low or middle income of the country).

RESULTS

Gender-based differences varied by countries and regions. HIV prevalence was higher among women than men in sub-Saharan Africa (relative risk [RR], 2.8; 95% confidence interval [CI], 1.8-4.4) and South Asia (RR, 1.7; 95% CI, 1.1-2.7); anti-HCV was lower among women in the Middle East and North Africa (RR, 0.6; 95% CI, .5-.7) and East and Southeast Asia (RR, 0.8; 95% CI, .7-.9). Gender-based differences varied with country-levels of the BBV prevalence in the general population, human development, and income distribution.

CONCLUSION

HIV was more prevalent in women who inject drugs as compared to their male counterparts in some countries, but there is variation between and within regions. In countries where women are at higher risks, there is a need to develop gender-sensitive harm-reduction services for the particularly marginalized population of women who inject drugs.

HIV/HCV co-infection and associated risk factors among injecting drug users in Dar es Salaam, Tanzania: potential for HCV elimination

Background

Chronic HCV infection causes substantial morbidity and mortality and, in co-infection with HIV, may result in immunological and virological failure following antiretroviral treatment. Estimates of HCV infection, co-infection with HIV and associated risk practices among PWID are scarce in Africa. This study therefore aimed at estimating the prevalence of HCV and associated risk factors among PWID in the largest metropolitan city in Tanzania to inform WHO elimination recommendations.

Methods

An integrated bio-behavioral survey using respondent-driven sampling was used to recruit PWID residing in Dar es Salaam, Tanzania. Following face-to-face interviews, blood samples were collected for HIV and HCV testing. Weighted modified Poisson regression modeling with robust standard errors was used in the analysis.

Results

A total of 611 PWID with a median age of 34 years (IQR, 29–38) were recruited through 4 to 8 waves. The majority of participants (94.3%) were males, and the median age at first injection was 24 years (IQR, 19–30). Only 6.55% (40/611) of participants reported to have been enrolled in opioid treatment programs. The weighted HCV antibody prevalence was 16.2% (95%CI, 13.0–20.1). The corresponding prevalence of HIV infection was 8.7% (95%CI, 6.4–11.8). Of the 51 PWID who were infected with HIV, 22 (43.1%) were HCV seropositive. Lack of access to clean needles (adjusted prevalence ratio (APR), 1.76; 95%CI, 1.44; 12.74), sharing a needle the past month (APR, 1.72; 95%CI, 1.02; 3.00), not cleaning the needle the last time shared (APR, 2.29; 95%CI, 1.00; 6.37), and having unprotected not using a transactional sex (APR, 1.87; 95%CI, 1.00; 3.61) were associated with increased risk of HCV infection. On the other hand, not being on opioid substitution therapy was associated with 60% lower likelihood of infection.

Conclusions

The HCV antibody prevalence among PWID is lower than global estimates indicating potential for elimination. Improving access to safe injecting paraphernalia, promoting safer injecting practices is the focus of prevention programing. Screening for HIV/HCV co-infection should be intensified in HIV care, opioid substitution programs, and other point of care for PWID. Use of direct-acting antiretroviral treatment would accelerate the achievement of hepatitis infection elimination goal by 2030.

Effectiveness of health care workers and peer engagement in promoting access to health services among population at higher risk for HIV in Tanzania (KPHEALTH): study protocol for a quasi experimental trial

Background

While there are indications of declining HIV infection rates in the general population globally, Tanzania included, men who have sex with men (MSM), female sex workers (FSW) and people who inject drugs (PWID), now called Key Populations (KP) for HIV epidemic have 2–20 times higher infections rates and contributes up to 30% of new HIV infection. Tanzania have developed a Comprehensive Guideline for HIV prevention among key population (CHIP) to address the epidemic among KPs. However, these populations are stigmatized and discriminated calling for innovative approaches to improve access to CHIP. This project seeks to test the effectiveness of healthcare workers and peer-to-peer engagement in promoting access to CHIP among HIV at risk populations in Tanzania.

Methods

A quasi-experimental design involving Dar es Salaam City as an intervention region and Tanga as a control region will be done. Using respondent driven sampling, 1800 at risk population (900 from Intervention site and 900 from control site) will be recruited at baseline to identify pull and push factors for health services access. Stakeholder’s consultation will be done to improve training contents for CHIP among health care workers and peers. Effectiveness of healthcare workers training and peer engagement will be tested using a quasi-experimental design.

Discussion

The results are expected to co-create service provision and improve access to services among KPs as a human right, reverse HIV infection rates among KPs and the general population, and improve social and economic wellbeing of Tanzanian.

Trial registration

Retrospectively registered on 28th August, 2019 with International Standard Randomized Clinical Trial Number (ISRCTN11126469).

Understanding hepatitis B, hepatitis C and HIV among people who inject drugs in South Africa: findings from a three-city cross-sectional survey

BACKGROUND

People who inject drugs (PWID) are at high risk for hepatitis C (HCV), hepatitis B (HBV) and HIV without accessible harm reduction programmes. Coverage of needle and syringe and opioid substitution therapy (OST) services in South Africa is below global recommendations and no hepatitis services exist for PWID. We assessed HCV, HBV and HIV prevalence and risk factors among PWID accessing harm reduction services in Cape Town, Durban and Pretoria to inform policy and programming.

METHODS

We conducted a cross-sectional survey among PWID in these cities between August 2016 and October 2017. Participants were opportunistically sampled while accessing services. Study team members administered a questionnaire that assessed sociodemographic characteristics, drug use and sexual risk practices. We tested for HCV (antibody, viral load and genotype), HBV surface antigen (HBsAg) and HIV. Bivariate and multivariate analyses assessed associations with HCV serostatus.

RESULTS

Nine hundred and forty-three PWID were included in the per protocol analysis. The majority (87%, 819/943) were male, the overall median age was 29 and most lived on the street (66%, 626/943). At last injection, 77% (722/943) reported using a new needle and syringe and 17% (163/943) shared equipment. HIV prevalence was 21% (196/926), HBsAg positivity 5% (47/936), HCV seroprevalence 55% (513/937), HCV viraemic prevalence (proportion tested with detectable HCV) 43% (404/937) and HCV viraemic rate (proportion HCV antibody positive with detectable HCV) 79% (404/513). HCV genotype 1a (73%, 270/368) was the most prevalent. In multivariate analysis, HCV infection was positively associated with residing in Pretoria (adjusted odds ratio (aOR) 1.27, 95% CI 1.21-1.34), living on the street (aOR 1.90, 95% CI 1.38-2.60), frequent injecting (aOR 1.58, 95% CI 1.15-2.16) and HIV infection (aOR 1.69, 95% CI 1.15-2.47), and negatively associated with black race (aOR 0.52, 95% CI 0.36-0.74) and sexual activity in the previous month (aOR 0.61, 95% CI 0.42-0.88).

CONCLUSIONS

HCV and HIV are major health threats affecting PWID in these cities. Access to OST and needle and syringe services needs to be increased and integrated with HCV services. Social and structural factors affecting PWID who live on the street need to be addressed.

HIV risk behaviours among women who inject drugs in coastal Kenya: findings from secondary analysis of qualitative data

Background

Injecting drug users are at high risk of HIV infection globally. Research related to female drug users is rare in Kenya, yet it is required to inform the development of gender-sensitive HIV prevention and harm reduction services in East Africa, where injecting drug use is on the rise.

Methods

This study aimed to document the nature of HIV risks encountered by women who inject drugs in the Mombasa and Kilifi, Kenya. Secondary data analysis was conducted on an existing dataset from a 2015 primary qualitative study involving 24 interviews and 3 focus group discussions with 45 women who inject drugs. These were complemented with five interviews with key stakeholders involved in the provision of services to women who inject drugs. Guided by the social ecology theory, a thematic analysis was conducted to identify the nature of HIV risks and their underlying determinants.

Results

HIV risk behaviours fell into two broad categories: unsafe injecting and unprotected sex. These risks occurred in the form of sharing of needles, unprotected oral, anal, and vaginal sex, sexual assaults, injecting drug use during sex, sex work, and other types of transactional sex. The primary determinants underlying these risks were a low-risk perception, inequitable gender power, economic pressures, and poor availability of needles and condoms. These social-ecological determinants did not exist in isolation, but intersected with each other to create powerful influences which exposed women to HIV. Social-ecological determinants exerted constant influence and created a persistent ‘HIV risk environment’ that was involuntarily experienced by women.

Conclusion

Individual, interpersonal, and societal-structural factors intersect to produce HIV risk behaviours. As a minimum, these risks will require a combination of multifaceted micro-level interventions including self-efficacy training, risk assessment skills, couple counselling, and universal access to the recommended harm reduction package. In addition, the current focus on micro-level interventions in Kenya needs to shift to incorporate macro-level interventions, including livelihood, employability, and gender norms-transforming interventions, to mitigate economic and gender-related drivers of HIV risks. In the Kenyan context, injecting drug use during sex work is emerging as an increasingly important HIV risk behaviour needing to be addressed.

You can't do this job when you are sober: Heroin use among female sex workers and the need for comprehensive drug treatment programming in Kenya

AIMS

Globally, women who use drugs often practice sex work and experience multiple health and social harms that complicate their drug treatment needs. In East Africa, understanding the emergence of heroin use among women is critical in efforts to build effective drug treatment programming, including the ongoing scale-up of medication-assisted treatment (MAT). We explored heroin use among women engaged in sex work in Kenya to inform services.

METHODS

In a qualitative study of 45 female sex workers reporting substance use in Kisumu, Kenya, 32 reported lifetime heroin use and comprise the focus of this analysis. Semi-structured interviews explored histories of substance use and sex work and health programming needs. Thematic analysis focused on the contexts and meanings of heroin use.

RESULTS

Among 32 women, median age was 28 (range: 18-37). Women commonly smoked cocktails containing heroin while using alcohol and other drugs prior to sex work. Most women perceived heroin to engender "morale" and "courage" to engage in sex work and "fight" potentially abusive clients. Sex work reinforced drug use in ways that both managed and created new risks.

CONCLUSIONS

Drawing on the concept of "paradoxical autonomy," we suggest that heroin use engenders new forms of autonomy allowing women to support themselves in conditions of uncertainty, yet does not enable them to entirely overcome their vulnerabilities. Drug treatment programs for sex workers should address the situated logics of substance use in contexts of sexual risk, including patterns of poly-substance use that may render MAT inappropriate for some women who use heroin.

Establishing trust in HIV/HCV research among people who inject drugs (PWID): Insights from empirical research

BACKGROUND

The establishment of trust between researchers and participants is critical to advance HIV and HCV prevention particularly among people who inject drugs (PWID) and other marginalized populations, yet empirical research on how to establish and maintain trust in the course of community health research is lacking. This paper documents ideas about trust between research participants and researchers amongst a sub-sample of PWID who were enrolled in a large, multi-year community health study of social networks and HIV/HCV risk that was recently conducted in rural Puerto Rico.

METHODS

Qualitative research was nested within a multi-year Social Network and HIV/HCV Risk study involving N = 360 PWID > 18 years of age living in four small, rural Puerto Rican communities. Semi-structured interviews were conducted between March 2017 and April 2017 with a subset of 40 active PWID who had been enrolled in the parent study. Interview questions invited participants to draw upon their recent experience as research participants to better understand how PWID perceive and understand participant-researcher trust within the context of HIV/HCV-related epidemiological research.

RESULTS

Fear of police, stigma and concerns regarding confidentiality and anonymity were identified as structural factors that could compromise participation in HIV/HCV-related research for PWID. While monetary compensation was an important motivation, participants also valued the opportunity to learn about their HIV/HCV status. During their participation in the study, gaining knowledge of safe injection practices was perceived as a valuable benefit. Participant narratives suggested that PWID may adopt an incremental and ongoing approach in their assessment of the trustworthiness of researchers, continuously assessing the extent to which they trust the research staff throughout the course of the research. Trust was initially generated through peer Respondent Driven Sampling recruitment. Research staff who maintained a presence in the community for the entire duration of the prospective study reinforced trust between participants and the research team.

CONCLUSION

Although PWID face numerous structural barriers to research-related trust in HIV/HCV research, we found that using a peer-based recruitment method like RDS, and employing a research staff who are knowledgeable about the targeted population, culturally sensitive to their needs, and who maintain a long-term presence in the community may help mitigate many of these barriers. The reputation of the research is built incrementally as participants join the study. This contributes to a "street reputation" that grows as current or former participants vouch for the study. Establishing trust was identified as only the first step towards building a collaborative relationship with participants, and our findings suggest that steps to address criminalization and stigmatization also are necessary to support research trust.

The Opioid Epidemic in Africa And Its Impact

Purpose of review

Opioid use disorder (OUD) is a global phenomenon and is on the rise in Africa, denoting a shift from historical patterns of drug transport to internal consumption. In contrast, opioids for clinical pain management in Africa remain among the least available globally. This region also has the highest HIV and HCV disease burden, and the greatest shortages of health workers and addiction treatment. We undertook a systematic review of the literature to describe opioid use in Africa and how it is being addressed.

Recent findings

A total of 84 articles from 2000 to 2018 were identified. Descriptions of country-specific populations and patterns of opioid misuse were common. A smaller number of articles described interventions to address OUD.

Summary

OUD occurs in sub-Saharan Africa, with attendant clinical and social costs. Evidence-based policies and health system resources are needed to promote OUD prevention and management, and infectious disease transmission reduction.

"Who has ever loved a drug addict? It's a lie. They think a 'teja' is as bad person": multiple stigmas faced by women who inject drugs in coastal Kenya

BACKGROUND

A tenth of all people who inject drugs in Kenya are women, yet their social contexts and experiences remain poorly understood. This paper reports how multiple forms of stigma are experienced by women who inject drugs in coastal Kenya and the impact that they have on their ability to access essential health services.

METHODS

In 2015, in-depth interviews and focus group discussions were held with 45 women who inject drugs in two coastal towns. These data were supplemented with in-depth interviews with five individual stakeholders involved in service provision to this population. Data were analyzed thematically using NVivo.

RESULTS

Women who inject drugs experience multiple stigmas, often simultaneously. These included the external stigma and self-stigma of injection drug use, external gender-related stigma of being a female injecting drug user, and the external stigma of being HIV positive (i.e., among those living with HIV). Stigma led to rejection, social exclusion, low self-esteem, and delay or denial of services at health facilities.

CONCLUSION

HIV and harm reduction programs should incorporate interventions that address different forms of stigma among women who inject drugs in coastal Kenya. Addressing stigma will require a combination of individual, social, and structural interventions, such as collective empowerment of injecting drug users, training of healthcare providers on issues and needs of women who inject drugs, peer accompaniment to health facilities, addressing wider social determinants of stigma and discrimination, and expansion of harm reduction interventions to change perceptions of communities towards women who inject drugs.

Barriers and facilitators of access to HIV, harm reduction and sexual and reproductive health services by women who inject drugs: role of community-based outreach and drop-in centers

There is limited data regarding women who inject drugs, and how harm-reduction services can be made more women-centered. This study explored experiences of Kenyan women who inject drugs, with regard to access to HIV, harm reduction and sexual and reproductive health (SRH) services. A total of 45 women who inject drugs and 5 key stakeholders participated in-depth interviews and focus group discussions. Thematic analysis of the data revealed that stigma, long distances, lack of confidentiality, user fees, multiple appointments, drug users' unfamiliarity with health facilities, disconnect in communication with healthcare providers, and healthcare providers' lack of understanding of women's needs were factors that impede women's access to health services. Community-based services, comprising of outreach and drop-in centers mitigate these barriers by building trust, educating women on their health and rights, linking women to health facilities, sensitizing health providers on the needs of women who inject drugs, and integrating women's SRH services into community-based harm-reduction outreach. Inclusion of SRH services into community-based harm-reduction activities increased women's interest and access to harm-reduction interventions. These findings underscore the need to strengthen community-based programming for women who inject drugs, and to integrate SRH services into needle and syringe exchange programs.

Convenience without disclosure: a formative research study of a proposed integrated methadone and antiretroviral therapy service delivery model in Dar es Salaam, Tanzania

Background

Though timely initiation of antiretroviral therapy (ART) is a vital component of effective HIV prevention, care and treatment, people who inject drugs are less likely to receive ART than their non-drug using counterparts. In an effort to increase access to ART for people who inject drugs, we examined perceived benefits, challenges, and recommendations for implementing an integrated methadone and ART service delivery model at an opioid treatment program (OTP) clinic in Dar es Salaam, Tanzania.

Methods

We conducted in-depth interviews with 12 providers and 20 HIV-positive patients at the Muhimbili National Hospital OTP clinic in early 2015. We used thematic content analysis to examine patient and provider perspectives of an integrated model.

Results

Respondents perceived that offering on-site CD4 testing and HIV clinical management at the OTP clinic would improve the timeliness and efficiency of the ART eligibility process, make HIV clinical care more convenient, mitigate stigma and discrimination in HIV care and treatment settings, and improve patient monitoring and ART adherence. However, perceived challenges included overburdened OTP clinic staff and limited space at the clinic to accommodate additional services. Limited privacy at the OTP clinic and its contribution to fear among HIV-positive patients of being stigmatized by their peers at the clinic was a common theme expressed particularly by patients, and often corroborated by providers. Co-dispensing ART and methadone at the clinic’s pharmacy window was viewed as a potential deterrent for patients. Providers felt that an electronic health information system would help them better monitor patients’ progress, but that this system would need to be integrated into existing health information systems. To address these potential barriers to implementing an integrated model, respondents recommended increasing OTP provider and clinic capacity, offering flexible ART dispensing options, ensuring privacy with ART dispensing, and harmonizing any new electronic health information systems with existing systems.

Conclusions

An integrated methadone and ART service delivery model at the MNH OTP clinic could improve access to HIV care and treatment for OTP patients. However, specific implementation strategies must ensure that OTP providers are not overburdened and confidentiality of patients is maintained.

Opioid users with comorbid hepatitis C spent more time in agonist therapy: A 6-year observational study in Taiwan

BACKGROUND

Hepatitis C virus (HCV) infection is highly prevalent among opioid agonist therapy (OAT) patients, but little is known about long-term OAT use among this population.

METHODS

Subjects diagnosed as opioid dependence were recruited from Mar. 2006 to Jul. 2008 in a psychiatry center in southern Taiwan with the OAT censored in 2012, and their socio-demographics, drug use characteristics, and markers of blood-borne infection were assessed at entry. Correlates with HCV infection and OAT retention were analyzed by multivariate logistic regression. Retention (OAT utilization) was defined as the in-treatment period of OAT during the 6-year observation period.

RESULTS

A total of 983 patients (88.3% men) were included. The prevalences of HCV and HIV infection were 91.4% and 17.9%, respectively. The mean duration of OAT during the study period was 2.3±0.8years. Significant correlates with HCV infection were retention of at least three years in OAT (AOR: 4.24, 95%CI: 1.49-12.03), ever sharing injection equipment (AOR: 227.04, 95%CI: 57.22-900.87), not living with family (AOR: 5.54, 95%CI: 1.45-21.16), lower educational attainment (AOR: 2.10, 95%CI: 1.15-3.82) and previous drug offense (AOR: 6.35, 95%CI: 1.69-23.83). Significant correlates with retention were HCV infection (AOR: 2.53, 95%CI: 1.30-4.93) and divorced or separation in marriage (AOR: 0.65, 95%CI: 0.44-0.96).

CONCLUSIONS

This six-year observational study revealed a better retention in OAT if opioid-dependent individuals had comorbid hepatitis C. This provided opportunities for OAT patients with HCV infection to obtain medical treatment while staying in an OAT program. Further research could explore the possibility of eradicating comorbid HCV infection among these long-term treatment cases.