# Presentation: 404444

## Injection Drug Use in Dar es Salaam: Results and Public Health Implications

- Mark Williams, Ph.D.
- Gad Kilonzo, M.D.
- Sheryl McCurdy, 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 2x 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*

## Slide 4

## 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 15th International Conference on the Reduction of Drug Related Harm (15th 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		    27%		  -
- 	Female		    64%		4.71   	(3.25, 6.81)
- Age
- 	< 25		    44%		2.09	(1.15, 3.81)
- 	25 to 29	    46%		2.24	(1.24, 4.05)
- 	30 to 24	    44%		2.04 	(1.09, 3.82)
- 	_>_ 35		    27%		  -

## Characteristic          		 % HIV+           OR    	 (95% CI)

- Source of Income
- 	Family/Friends	    18%		  -
- 	Job			    28%		1.78	         ns
- 	Trading/illegal 	    53% 	5.16	(1.09, 24.33)
- 	Spouse 		    74%		12.75  	(2.12, 76.57)
- Income
- 	< 150,000		    49%		 1.70 	(1.12, 2.58)
- 	150,000-199,000	    46%		 1.46 	         ns
- 	 _>_ 200,000		    36% 	   -
-  Considers self homeless
- 	no			    38%		   -
- 	yes			    54%		 1.90	(1.27, 2.82)

## Characteristic          		 % HIV+         OR     (95% CI)

- Living arrangements
- 	Own house		     18%	  -
- 	Parent’s house		     28%	1.58	     ns
- 	Someone else’s house      53% 	3.21	(1.80, 5.73)
- 	Rented room 		     74%	3.93	(2.03, 7.61)		Streets/empty building     55%	2.36	(0.99, 5.63)
- Time living in Dar es Salaam
- 	< 13 years		     57%	2.50	(1.53, 4.11)
- 	13 to 24 years		     35%	  -
- 	25 to 29  years		     41%	 1.33 	      ns
- 	 _>_ 30 years		     37%	 1.13	      ns

## Characteristic          		 % HIV+         OR       (95% CI)

- Years injected drugs
- 	1 - 2 years		     43%	1.49	     ns
- 	3  years		     54%	2.24	(1.33, 3.79)
- 	4 - 5   years		     34%	  -
- 	 _>_ 6  years		     41%	1.35	     ns
- Number of recent sex partners
- 	one			     32%	  -
- 	2 - 49      		     38% 	1.29	     ns
- 	_>_ 50			     67%	4.24	(2.71, 6.63)

## Characteristic          		 % HIV+         OR     (95% CI)

- Number of sex partners while
- recently binging drugs
- 	none			     34% 	  -
- 	one			     41%	1.36	      ns
- 	_>_ 2       		     66% 	3.78	(1.80, 5.87)
- Recently traded sex for money
- 	no			     31%	  -
- 	yes			     63%	3.92 	(2.70, 5.70)
- Recently traded money for sex
- 	no			     20%  	  -
- 	yes			     46%	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: 

- 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

- HIV and drug use in Dar es Salaam:
- Public health implications

## 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.

- 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.