Skip to main content
SpringerLink
Log in

Addressing the Micro- and Macro-Environmental Vulnerabilities to HIV of People Who Inject Drugs in Tanzania: A Case Study of the Muhimbili Medication-Assisted Treatment Clinic

  • Chapter
  • First Online:
Structural Dynamics of HIV

Part of the book series: Social Aspects of HIV ((SHIV,volume 4))

  • 681 Accesses

Abstract

It is estimated that there are 30,000 people who inject drugs in mainland Tanzania, with an approximate HIV prevalence of 35% in this key population. Drug use is criminalized in Tanzania and treatment options are limited. However, in February 2011, a cutting-edge medication-assisted treatment (MAT) clinic for opioid addiction offering methadone maintenance treatment was established at Muhimbili National Hospital in Dar es Salaam. The clinic, which began offering drug treatment and harm reduction services, now offers a multi-faceted array of health and social services to address the myriad of psychosocial and structural factors impacting the well-being of people who use drugs in that setting. These services include HIV counseling and testing and linkages to on-site HIV care and treatment services, screening and treatment for tuberculosis and other medical and mental disorders, and access to on-site social workers and affiliated occupational therapists. Social workers at the Muhimbili MAT clinic link MAT clients to community-based organizations that provide individual counseling, 12-step programs, family group therapy, and income-generating skills training, among other services for people who use drugs. This chapter uses a risk environment framework to describe the micro- and macro-environmental factors that place people who inject drugs at increased risk of HIV and documents innovative initiatives and partnerships that have been formed to address these factors through an in-depth case study of the Muhimbili National Hospital MAT clinic.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 84.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 109.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 109.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

Notes

  1. 1.

    In response to a very low number of female clients enrolling into methadone treatment, another MAT clinic at Mwananyamala Regional Hospital, established in September 2012, piloted an approach, beginning in February 2013, allowing women dependent on heroin to enroll directly at the clinic rather than having to first attend the series of sessions at the CBOs. In addition, existing female clients were encouraged to recruit their peers and one day of the week was set aside for enrolling female clients only. This approach improved women’s enrollment into the methadone clinic at Mwananyamala, thereby increasing the proportion of female MAT clients.

  2. 2.

    The first-line tuberculosis treatment regimen in Tanzania includes Isoniazid, Rifampicin, Pyrazinamide, Ethambutol, and Streptomycin formulated in fixed drug combinations (United Republic of Tanzania 2013). The recommended standardized multi-drug resistant tuberculosis treatment regimen includes Amikacin, Ofloxacin/Levofloxacin, Pyrazinamide, Ethionamide, Cycloserine, and Ethambutol (if no resistance to Ethambutol is documented) (United Republic of Tanzania 2012).

References

  • Anderson, J. F., & Warren, L. D. (2004). Client retention in the British Columbia Methadone Program, 1996–1999. Canadian Journal of Public Health, 95(2), 104–109.

    PubMed  Google Scholar 

  • Beckerleg, S., Telfer, M., & Hundt, G. L. (2005). The rise of injecting drug use in East Africa: A case study from Kenya. Harm Reduction Journal, 2, 12. doi:10.1186/1477-7517-2-12.

    Article  PubMed  PubMed Central  Google Scholar 

  • Blankenship, K. M., Bray, S. J., Merson, M. H., Reinhard, E., Sherman, S. G., & El-Bassel, N. (2000). Structural interventions in public health. AIDS, 14(Suppl 1), S11–S21. doi:10.1097/00002030-200006001-00003.

    Article  PubMed  Google Scholar 

  • Blankenship, K. M., Reinhard, E., Sherman, S. G., & El-Bassel, N. (2015). Structural interventions for HIV prevention among women who use drugs: A global perspective. JAIDS Journal of Acquired Immune Deficiency Syndromes, 69(Suppl 2), S140–S145. doi:10.1097/qai.0000000000000638.

    Article  PubMed  Google Scholar 

  • Booth, R. E., Corsi, K. F., & Mikulich-Gilbertson, S. K. (2004). Factors associated with methadone maintenance treatment retention among street-recruited injection drug users. Drug & Alcohol Dependence, 74(2), 177–185. doi:10.1016/j.drugalcdep.2003.12.009.

    Article  Google Scholar 

  • Bruce, R. D. (2010). Methadone as HIV prevention: High volume methadone sites to decrease HIV incidence rates in resource limited settings. International Journal of Drug Policy, 21(2), 122–124. doi:10.1016/j.drugpo.2009.10.004.

    Article  PubMed  PubMed Central  Google Scholar 

  • Burke, S. E., Calabrese, S. K., Dovidio, J. F., Levina, O. S., Uuskula, A., Niccolai, L. M., Abel-Ollo, K., & Heimer, R. (2015). A tale of two cities: Stigma and health outcomes among people with HIV who inject drugs in St. Petersburg, Russia and Kohtla-Jarve, Estonia. Social Science & Medicine, 130, 154–161. doi:10.1016/j.socscimed.2015.02.018.

    Article  Google Scholar 

  • Calabrese, S. K., Burke, S. E., Dovidio, J. F., Levina, O. S., Uuskula, A., Niccolai, L. M., & Heimer, R. (2016). Internalized HIV and drug stigmas: Interacting forces threatening health status and health service utilization among people with HIV who inject drugs in St. Petersburg, Russia. AIDS and Behavior, 20(1), 85–97. doi:10.1007/s10461-015-1100-4.

    Article  PubMed  PubMed Central  Google Scholar 

  • Ciccarone, D. (2009). Heroin in brown, black and white: Structural factors and medical consequences in the US heroin market. International Journal of Drug Policy, 20(3), 277–282. doi:10.1016/j.drugpo.2008.08.003.

    Article  PubMed  Google Scholar 

  • Connock, M., Juarez-Garcia, A., Jowett, S., Frew, E., Liu, Z., Taylor, R. J., Fry-Smith, A., Day, E., Lintzeris, N., Roberts, T., & Burls, A. (2007). Methadone and buprenorphine for the management of opioid dependence: A systematic review and economic evaluation. Health Technology Assessment, 11(9), 1–171, iii–iv. doi:10.3310/hta11090.

    Article  CAS  PubMed  Google Scholar 

  • Des Jarlais, D. C. (2000). Structural interventions to reduce HIV transmission among injecting drug users. AIDS, 14(Suppl 1), S41–S46. doi:10.1097/00002030-200006001-00006.

    Article  PubMed  Google Scholar 

  • Fullerton, C. A., Kim, M., Thomas, C. P., Lyman, D. R., Montejano, L. B., Dougherty, R. H., Daniels, A. S., Ghose, S. S., & Delphin-Rittmon, M. E. (2014). Medication-assisted treatment with methadone: Assessing the evidence. Psychiatric Services, 65(2), 146–157. doi:10.1176/appi.ps.201300235.

    Article  PubMed  Google Scholar 

  • Gossop, M., Marsden, J., Stewart, D., & Treacy, S. (2001). Outcomes after methadone maintenance and methadone reduction treatments: Two-year follow-up results from the National Treatment Outcome Research Study. Drug and Alcohol Dependence, 62(3), 255–264. doi:10.1016/s0376-8716(00)00211-8.

    Article  CAS  PubMed  Google Scholar 

  • Gupta, A., Mbwambo, J., Mteza, I., Shenoi, S., Lambdin, B., Nyandindi, C., Doula, B. I., Mfaume, S., & Bruce, R. D. (2014). Active case finding for tuberculosis among people who inject drugs on methadone treatment in Dar es Salaam, Tanzania. International Journal of Tuberculosis and Lung Disease, 18(7), 793–798. doi:10.5588/ijtld.13.0208.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  • Lambdin, B. H., Bruce, R. D., Chang, O., Nyandindi, C., Sabuni, N., Zamudio-Haas, S., McCurdy, S., Masao, F., Ivo, Y., Msami, A., & Ubuguy, O. (2013). Identifying programmatic gaps: Inequities in harm reduction service utilization among male and female drug users in Dar es Salaam, Tanzania. PloS One, 8(6), e67062. doi:10.1371/journal.pone.0067062.

    Article  PubMed  PubMed Central  Google Scholar 

  • Lambdin, B. H., Masao, F., Chang, O., Kaduri, P., Mbwambo, J., Magimba, A., Sabuni, N., & Bruce, R. D. (2014). Methadone treatment for HIV prevention-feasibility, retention, and predictors of attrition in Dar es Salaam, Tanzania: A retrospective cohort study. Clinical Infectious Diseases, 59(5), 735–742. doi:10.1093/cid/ciu382.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  • Lambdin, B. H., Mbwambo, J. K., Josiah, R. M., & Bruce, R. D. (2015). Service integration: Opportunities to expand access to antiretroviral therapy for people who inject drugs in Tanzania. Journal of the International AIDS Society, 18(1), 19936. doi:10.7448/ias.18.1.19936.

    Article  PubMed  PubMed Central  Google Scholar 

  • Liu, E., Liang, T., Shen, L., Zhong, H., Wang, B., Wu, Z., & Detels, R. (2009). Correlates of methadone client retention: A prospective cohort study in Guizhou province, China. International Journal of Drug Policy, 20(4), 304–308. doi:10.1016/j.drugpo.2008.09.004.

    Article  PubMed  Google Scholar 

  • Magimba, A. (2015). National scale up lan for medically assisted treatment using methadone for people who use drugs in Tanzania. Dar es Salaam: Ministry of Health and Social Welfare.

    Google Scholar 

  • Magura, S., Casriel, C., Goldsmith, D. S., Strug, D. L., & Lipton, D. S. (1988). Contingency contracting with polydrug-abusing methadone patients. Addictive Behaviors, 13(1), 113–118. doi:10.1016/0306-4603(88)90035-4.

    Article  CAS  PubMed  Google Scholar 

  • McCurdy, S., & Kaduri, P. (2016). The political economy of heroin and crack in Tanzania. Review of African Political Economy, 43(148), 312–319. doi:10.1080/03056244.2016.1170678.

    Article  Google Scholar 

  • McCurdy, S., & Maruyama, H. (2013). Heroin use, trafficking, and intervention approache in Sub-saharan Africa: Local and global contexts. In T. Giles-Vernick & J. L. A. Webb Jr. (Eds.), Global health in Africa: Historical perspectives on disease control (pp. 211–232). Athens: Ohio University Press.

    Google Scholar 

  • McCurdy, S. A., Williams, M. L., Kilonzo, G. P., Ross, M. W., & Leshabari, M. T. (2005a). Heroin and HIV risk in Dar es Salaam, Tanzania: Youth hangouts, mageto and injecting practices. AIDS Care, 17(Suppl 1), S65–S76. doi:10.1080/09540120500120930.

    Article  PubMed  Google Scholar 

  • McCurdy, S. A., Williams, M. L., Ross, M. W., Kilonzo, G. P., & Leshabari, M. T. (2005b). A theme issue by, for, and about Africa: New injecting practice increases HIV risk among drug users in Tanzania. BMJ, 331(7519), 778. doi:10.1136/bmj.331.7519.778-a.

    Article  PubMed  PubMed Central  Google Scholar 

  • McCurdy, S. A., Ross, M. W., Kilonzo, G. P., Leshabari, M. T., & Williams, M. L. (2006). HIV/AIDS and injection drug use in the neighborhoods of Dar es Salaam, Tanzania. Drug and Alcohol Dependence, 82(Suppl 1), S23–S27. doi:10.1016/s0376-8716(06)80004-9.

    Article  PubMed  Google Scholar 

  • McCurdy, S., Kilonzo, G. P., Williams, M., & Kaaya, S. (2007). Harm reduction in Tanzania: An urgent need for multisectoral intervention. International Journal of Drug Policy, 18(3), 155–159. doi:10.1016/j.drugpo.2007.05.001.

    Article  PubMed  Google Scholar 

  • McCurdy, S. A., Ross, M. W., Williams, M. L., Kilonzo, G. P., & Leshabari, M. T. (2010). Flashblood: Blood sharing among female injecting drug users in Tanzania. Addiction, 105(6), 1062–1070. doi:10.1111/j.1360-0443.2010.02908.x.

    Article  PubMed  PubMed Central  Google Scholar 

  • McNeil, D Jr. (2010). Desperate addicts inject others’ blood. New York Times. New York City.

    Google Scholar 

  • Metzger, D. S., Woody, G. E., McLellan, A. T., O’Brien, C. P., Druley, P., Navaline, H., DePhilippis, D., Stolley, P., & Abrutyn, E. (1993). Human immunodeficiency virus seroconversion among intravenous drug users in- and out-of-treatment: An 18-month prospective follow-up. Journal of Acquired Immune Deficiency Syndromes, 6(9), 1049–1056.

    CAS  PubMed  Google Scholar 

  • Mlunde, L. B., Sunguya, B. F., Mbwambo, J. K., Ubuguyu, O. S., Shibanuma, A., Yasuoka, J., & Jimba, M. (2016). A mismatch between high-risk behaviors and screening of infectious diseases among people who inject drugs in Dar es Salaam, Tanzania. PloS One, 11(2), e0148598. doi:10.1371/journal.pone.0148598.

    Article  PubMed  PubMed Central  Google Scholar 

  • MoHSW & DCC. (2014). Guideline for medically-assisted treatment of opioid dependence in Tanzania. Unpublished Draft.

    Google Scholar 

  • MoHSW & DCC (2015). Guideline for medically assisted treatment of opioid dependence in Tanzania (2nd ed.). Dar es Salaam.

    Google Scholar 

  • NACP (2014). Consensus estimates on key population size and HIV prevalence in Tanzania. Dar es Salaam: National AIDS Control Program.

    Google Scholar 

  • Njenga, F., Kiima, D., Siminyu, M., Munyi, E., Abdool, R., Muthui, M., Lambdin, B., Mbwambo, J., Mwamburi, E., McCurdy, S., Pick, B., Anderson, G., Mital, S., & Needle, R. (2012). Heroin scarcity in coastal Kenya: Consequence for persons who inject drugs (PWID) and national and provincial response to the crisis. XIX International AIDS Conference. Washington, DC.

    Google Scholar 

  • Nyandindi, C., Mbwambo, J., McCurdy, S., Lambdin, B., Copenhaver, M., & Bruce, R. (2014). Prevalence of HIV, hepatitis C and depression among people who inject drugs in the Kinondoni Municipality in Dar Es Salaam, Tanzania. Drug & Alcohol Dependence, 140, e164. doi:10.1016/j.drugalcdep.2014.02.461.

    Article  Google Scholar 

  • Office of National Drug Control Policy. (n.d.). The international heroin market. https://www.whitehouse.gov/ondcp/global-heroin-market. Accessed 14 Oct 2016.

  • Ratliff, E. A., Kaduri, P., Masao, F., Mbwambo, J. K., & McCurdy, S. A. (2016). Harm reduction as a complex adaptive system: A dynamic framework for analyzing Tanzanian policies concerning heroin use. International Journal of Drug Policy, 30, 7–16. doi:10.1016/j.drugpo.2015.12.008.

    Article  PubMed  Google Scholar 

  • Rhodes, T. (2009). Risk environments and drug harms: A social science for harm reduction approach. International Journal of Drug Policy, 20(3), 193–201. doi:10.1016/j.drugpo.2008.10.003.

    Article  PubMed  Google Scholar 

  • Rhodes, T., Singer, M., Bourgois, P., Friedman, S. R., & Strathdee, S. A. (2005). The social structural production of HIV risk among injecting drug users. Social Science & Medicine, 61, 1026–1044. doi:10.1016/j.socscimed.2004.12.024.

    Article  Google Scholar 

  • Saleem, H. T., Mushi, D., Hassan, S., Douglas Bruce, R., Cooke, A., Mbwambo, J., & Lambdin, B. H. (2016). ‘Can’t you initiate me here?’: Challenges to timely initiation on antiretroviral therapy among methadone clients in Dar es Salaam, Tanzania. International Journal of Drug Policy, 30, 59–65. doi:10.1016/j.drugpo.2015.12.009.

    Article  PubMed  Google Scholar 

  • Sarasvita, R., Tonkin, A., Utomo, B., & Ali, R. (2012). Predictive factors for treatment retention in methadone programs in Indonesia. Journal of Substance Abuse Treatment, 42(3), 239–246. doi:10.1016/j.jsat.2011.07.009.

    Article  PubMed  Google Scholar 

  • Soyka, M., Zingg, C., Koller, G., & Kuefner, H. (2008). Retention rate and substance use in methadone and buprenorphine maintenance therapy and predictors of outcome: Results from a randomized study. International Journal of Neuropsychopharmacology, 11(5), 641–653. doi:10.1017/s146114570700836x.

    Article  CAS  PubMed  Google Scholar 

  • The Economist. (2015). The smack track: Drug smuggling in Africa. 17 January 2015. http://www.economist.com/news/middle-east-and-africa/21639560-east-african-states-are-being-undermined-heroin-smuggling-smack-track. Accessed 29 Apr 2017.

  • Tran, O. C., Bruce, R. D., Masao, F., Ubuguyu, O., Sabuni, N., Mbwambo, J., & Lambdin, B. H. (2015). Implementation and operational research: Linkage to care among methadone clients living with HIV in Dar es Salaam, Tanzania. Journal of Acquired Immune Deficiency Syndromes, 69(2), e43–e48. doi:10.1097/qai.0000000000000582.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  • Ubuguyu, O., Tran, O. C., Bruce, R. D., Masao, F., Nyandindi, C., Sabuni, N., McCurdy, S., Mbwambo, J., & Lambdin, B. H. (2016). Improvements in health-related quality of life among methadone maintenance clients in Dar es Salaam, Tanzania. International Journal of Drug Policy, 30, 74–81. doi:10.1016/j.drugpo.2016.03.005.

    Article  PubMed  PubMed Central  Google Scholar 

  • United Republic of Tanzania. (1995). The Drugs and Prevention of Illicit Traffic in Drugs Act, Act No. 9 of 1995. United Republic of Tanzania. https://www.fiu.go.tz/PreventionOfIllicitTrafficInDrugsAct.pdf. Accessed 29 Apr 2017.

  • United Republic of Tanzania. (2012). Operational guidelines for the management of drug resistant TB in Tanzania (1st ed.). Dar es Salaam: National TB and Leprosy Programme, Ministry of Health and Social Welfare. https://drive.google.com/file/d/0By0MeTLkdAyFbmhORUtqa09hWUE/view. Accessed 29 Apr 2017.

    Google Scholar 

  • United Republic of Tanzania. (2013). Manual for the management of tuberculosis and leprosy (6th ed.). Dar es Salaam: National TB and Leprosy Programme Ministry of Health and Social Welfare.

    Google Scholar 

  • United Republic of Tanzania. (2014). Global AIDS response country progress report. Dar es Salaam: Ministry of Health and Social Welfare. http://www.unaids.org/sites/default/files/country/documents/TZA_narrative_report_2014.pdf. Accessed 29 Apr 2017.

    Google Scholar 

  • United Republic of Tanzania. (2015). The Drug Control and Enforcement Act, Act No. 5 of 2015. United Republic of Tanzania. http://www.parliament.go.tz/uploads/documents/1476204842-GN%20173-DRUGS%20CONTROL%20AND%20ENFORCEMENT%20(GENERAL)%20REGULATIONS,%202016.pdf. Accessed 29 Apr 2017.

  • WHO. (2012). Global tuberculosis report 2012. Geneva: WHO.

    Google Scholar 

  • WHO. (2013). Systematic screening for active tuberculosis: Principles and recommendations. Geneva: WHO.

    Google Scholar 

  • WHO, UNODC, & UNAIDS. (2012). WHO, UNODC, UNAIDS technical guide for countries to set targets for universal acces to HIV prevention, treatment and care for injecting drug users – 2012 revision. Geneva: WHO.

    Google Scholar 

  • Wolfe, D., Carrieri, M. P., & Shepard, D. (2010). Treatment and care for injecting drug users with HIV infection: A review of barriers and ways forward. Lancet, 376(9738), 355–366. doi:10.1016/s0140-6736(10)60832-x.

    Article  PubMed  Google Scholar 

  • Zamudio-Haas, S. (2013). Providing medication assisted treatment (MAT) as an HIV prevention intervention: Programmatic strategies to maximize service utilization in Dar es Salaam, Tanzania. Doctoral dissertation, University of California-Berkeley.

    Google Scholar 

  • Zamudio-Haas, S., Mahenge, B., Saleem, H., Mbwambo, J., & Lambdin, B. H. (2016). Generating trust: Programmatic strategies to reach women who inject drugs with harm reduction services in Dar es Salaam, Tanzania. International Journal of Drug Policy, 30, 43–51. doi:10.1016/j.drugpo.2016.01.012.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Psychiatry and Mental Health, Muhimbili National Hospital, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania

    Jessie Mbwambo & Pamela Kaduri

  2. Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA

    Haneefa T. Saleem

  3. Behavioral Health and Criminal Justice Research Division, RTI International, San Francisco, CA, USA

    Barrot H. Lambdin

  4. Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA

    Barrot H. Lambdin

  5. Department of Global Health, University of Washington, Seattle, WA, USA

    Barrot H. Lambdin

  6. School of Public Health, University of Texas Health Science Center at Houston, Houston, TX, USA

    Sheryl A. McCurdy

Authors
  1. Jessie Mbwambo
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Haneefa T. Saleem
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Pamela Kaduri
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Barrot H. Lambdin
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Sheryl A. McCurdy
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Jessie Mbwambo .

Editor information

Editors and Affiliations

  1. Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA

    Deanna Kerrigan

  2. University of North Carolina (UNC) Gillings School of Global Public Health, Chapel Hill, North Carolina, USA

    Clare Barrington

Rights and permissions

Reprints and permissions

Copyright information

© 2018 Springer International Publishing AG

About this chapter

Cite this chapter

Mbwambo, J., Saleem, H.T., Kaduri, P., Lambdin, B.H., McCurdy, S.A. (2018). Addressing the Micro- and Macro-Environmental Vulnerabilities to HIV of People Who Inject Drugs in Tanzania: A Case Study of the Muhimbili Medication-Assisted Treatment Clinic. In: Kerrigan, D., Barrington, C. (eds) Structural Dynamics of HIV. Social Aspects of HIV, vol 4. Springer, Cham. https://doi.org/10.1007/978-3-319-63522-4_3

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-63522-4_3

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-63521-7

  • Online ISBN: 978-3-319-63522-4

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation