Transcript Powerpoint

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
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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
Storefront
CBO
Storefront
CBO
Street Based Outreach
Storefront
CBO
Storefront
CBO
MAT Clinic
Muhimbili National Hospital
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-value
Multiple 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
20.21 (3.40, 120.13)
0.001
Any History of Sexual Abuse
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
Methods: Adapted Grounded Theory
Process
Data collection/
Initial coding/
Memos
Draft writing and
Saturating
theoretical
categories
Developing
theoretical
concepts as
categories
Standard
Codebook
Development
Literature Review
Continued
analysis and
Theoretical
sampling
Initial analysis
and revisions to
Standard
Codebook
Charmaz. (2006) Constructing Grounded Theory: A practical Guide Through Qualitative Analysis. Thousand Oaks, CA: Sage.
Study Participant Overview
No. MAT
Married or Parent to
Participants Cohabiting ≥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
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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-outs
Peer
CSW/PWI
Outreach
Barriers to Women’s Enrollment
Retention in MAT: Common Themes
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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
CBO Referral
CBO Sessions
Evidence of
Injection
Enrollment Strategies: Low Threshold
Self or Peer
Referral
No CBO
Requirement
No evidence of
injection
Retention Strategies
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Female-specific clinic hours
Dedicated dosing window
Retention Strategies
Reduce
Transport $
Take
Away
Dose
Reduce
Waiting
Time
Reduce Time
at Health
Facility
Conclusion
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.
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
Questions and Comments Welcome!
Sophia Zamudio-Haas
Center for AIDS Prevention Studies, UCSF
[email protected]
MAT as HIV Prevention
Eliminates
craving and
withdrawal
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