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

Presentation Outline

Background Methods Key findings Discussion Conclusion

HIV in Dar es Salaam, Tanzania

Estimated HIV Prevalence

Population

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.

MAT Continuum of Care

Street Based Outreach

Street Based Outreach

Storefront CBO

Storefront CBO

Storefront

CBO

MAT ClinicMuhimbili 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

Gender Differences in HIV Risk, Mental Health and History of Abuse

   aRR (95% CI)p-

valueMultiple Sex Partners (last 6 months) 2.42 (1.46, 3.98)

<0.001

High Substance Dependence 1.18 (1.05, 1.34) 0.007

Depression in Last 30 Days 1.85 (1.09, 3.14) 0.024

Anxiety in Last 30 Days 1.87 (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

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.

Study Participant Overview

No. MATParticipa

nts

Married or Cohabitin

g

Parent to ≥1 child

HIV Status Violence Survivor

+ - ? Sexual

Physical

Men 6 3 4 0 6 0 0 3

Women 13 8 9 6 3 4 5 5

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

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

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

New Outreach Strategies

Nighttime

Women’s Hang-

outsPeer

CSW/PWI

Outreach

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

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

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

Enrollment Strategies: Low Threshold

Evidence of Injection

CBO Sessions

CBO Referral

No evidence of injection

No CBO Requirement

Self or Peer Referral

Enrollment Strategies: Low Threshold

Retention Strategies

Female-specific clinic hours Dedicated dosing window

Retention Strategies

Take Away Dose

Reduce Transport

$

Reduce Time at Health Facility

Reduce Waiting Time

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

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

Sophia Zamudio-HaasCenter for AIDS Prevention Studies, UCSFSophia.Zamudio-Haas@ucsf.edu

Questions and Comments Welcome!

MAT as HIV Prevention

Eliminates craving

and withdrawa

l

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.

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