Search

BackgroundAt increased risk for poor health outcomes, physical and/or sexual violence, and onward transmission of HIV, women who use drugs and are living with HIV (WWUDHIV) are vulnerable and in need of services. Understanding the role of trauma across their life history may offer insights into HIV and drug use prevention and opportunities for intervention. We explored trauma and drug use among WWUDHIV in Dar es Salaam, Tanzania.MethodsWe conducted in-depth interviews with 30 WWUDHIV from January-March 2019. Interviewers used semi-structured interview guides and asked questions about the life history as related to drug use. Interviews were audio recorded, transcribed, translated, coded, and life histories charted. We utilized content analysis.ResultsParticipants described death of family members as traumatic catalysts for drug use. Sexual partners early in their life history were often the point of introduction to drugs and source of HIV acquisition. Death of partners was present across many life histories and was a traumatic event negatively influencing life trajectories, including start of sex work for survival or to support drug use. Sex work in-turn often led to traumatic events including sexual and/or physical violence. HIV diagnosis for many participants followed the start of drug use, frequently occurred during pregnancy or severe illness and was described by most participants as a trauma. Despite this, particularly during pregnancy, HIV diagnosis was a turning point for some participant's desire to engage in drug use treatment. Traumatic events were often cumulative and regularly described as catalysts for poor mental health that could lead to new or increased drug use for coping.ConclusionsThese findings suggest trauma is common in the life history of WWUDHIV and has negative impacts on drug use and HIV vulnerability. Our life history charting highlights the cumulative and cyclical nature of trauma and drug use in this population. This study allows for better understanding of trauma, drug use, and HIV prevention, which offers opportunities for intervention among a group with limited access to services: during adolescence for orphaned youth, following the death of a child or partner, and when vulnerable women engage with the health system (HIV diagnosis, pregnancy, illness).

BackgroundStrong evidence supports the effectiveness of methadone-assisted therapy (MAT) to treat opioid dependence, reduce the risk of HIV transmission, and improve HIV related health outcomes among people who inject drugs (PWID). HIV prevalence reaches 71% in women who inject drugs (WWID) in Dar es Salaam, Tanzania; creating an urgent need for access to MAT. Despite the availability and potential benefits of treatment, few women have enrolled in services. This formative research sought to identify programmatic strategies to increase women's participation in outreach and their subsequent enrollment in MAT.MethodsWe conducted twenty-five, in-depth interviews with patients and their providers at a MAT clinic. Open-ended interviews explored enrollment experiences, with a focus on contextual barriers and facilitators unique to women. Ethnographic observations of harm reduction education at outreach sites and the MAT clinic enriched interview data. Trust/mistrust emerged as an overarching theme cross cutting patient and provider accounts of the connective process to enroll PWID in the methadone program. We explore trust and mistrust in relationship to the interrelated themes of family loss, social isolation, vehement discrimination and motivation for treatment.ResultsNarratives delineated both the generation of mistrust against PWID and the generation of mistrust in PWID against outsiders and medical institutions. In order to enroll PWID in treatment, community base organizations engaged outreach strategies to overcome mistrust and connect eligible patients to care, which varied in their success at recruiting women and men. Greater discrimination against WWID pushed them into hiding, away from outreach teams that focus on outdoor areas where men who inject drugs congregate. Building trust through multiple encounters and making a personal connection facilitated entry into care for women. Only PWID were eligible for MAT, due to resource constraints and the higher risk associated with injection drug use. Many women smoke heroin, yet still face high risk of HIV, resulting from low condom use during sex work to fund drug use.ConclusionExpanding outreach times and locations, by women peers, could increase women's enrollment in treatment. Allowing women who smoke heroin to enter the program could prevent onward transmission via sex work and reduce the chance of progressing from the lower risk smoking or sniffing to injection drug use.

This study explores how living with HIV affects fertility desires and reproductive identities in a context where HIV is highly stigmatised and parenthood is highly valued. We conducted interviews with 30 women and 30 men living with HIV, and 30 health care providers in Iringa, Tanzania. Using the conceptual framework of biographical disruption, we analysed interviews to characterise strategies participants living with HIV employed to regain a sense of normalcy. We found that living with HIV had consequences that disrupted notions of reproductive identity and that these disruptions influenced fertility desires and safer conception planning of both women and men living with HIV. Some participants relinquished the desire for children altogether, while others maintained the role of procreator as a strategy to conceal their HIV status and maintain their value in society. Perceptions of normalcy and notions of reproductive identity following an HIV diagnosis shape how people living with HIV navigate fertility decision-making in the face of biographical disruption. Findings can inform HIV programming to help those living with HIV regain a sense of normalcy by fostering solidarity, reducing community-based stigma and promoting safer conception for those who desire children and effective contraception for those who do not. [ABSTRACT FROM AUTHOR]

As safer conception services are expanded and integrated into HIV care systems, these services will need to address cultural, social, economic and medical concerns of women and men living with HIV. We conducted interviews with 30 HIV-positive women, 30 HIV-positive men, and 30 healthcare providers that examined factors specific to the experience of living with HIV that influence fertility desires in Iringa, Tanzania. HIV-related factors fell under five themes: knowing one could prevent mother-to-child transmission; reaching an ideal family size in the context of HIV-related infant mortality; concealing one's HIV status; being able to provide for children; and managing HIV disease progression. Integration of safer conception counseling that includes locally-tailored messaging around desired family size, health risks, stigma and financial considerations into safer conception services will help people living with HIV reach their reproductive goals, while reducing the risks of HIV transmission. [ABSTRACT FROM AUTHOR]

Background: Despite dramatic improvement in antiretroviral therapy (ART) access globally, people living with HIV who inject drugs continue to face barriers that limit their access to treatment. This paper explores barriers and facilitators to ART initiation among clients attending a methadone clinic in Dar es Salaam, Tanzania.Methods: We interviewed 12 providers and 20 clients living with HIV at the Muhimbili National Hospital methadone clinic between January and February 2015. We purposively sampled clients based on sex and ART status and providers based on job function. To analyze interview transcripts, we adopted a content analysis approach.Results: Participants identified several factors that hindered timely ART initiation for clients at the methadone clinic. These included delays in CD4 testing and receiving CD4 test results; off-site HIV clinics; stigma operating at the individual, social and institutional levels; insufficient knowledge of the benefits of early ART initiation among clients; treatment breakdown at the clinic level possibly due to limited staff; and initiating ART only once one feels physically ill. Participants perceived social support as a buffer against stigma and facilitator of HIV treatment. Some clients also reported that persistent monitoring and follow-up on their HIV care and treatment by methadone clinic providers led them to initiate ART.Conclusion: Health system factors, stigma and limited social support pose challenges for methadone clients living with HIV to initiate ART. Our findings suggest that on-site point-of-care CD4 testing, a peer support system, and trained HIV treatment specialists who are able to counsel HIV-positive clients and initiate them on ART at the methadone clinic could help reduce barriers to timely ART initiation for methadone clients. [ABSTRACT FROM AUTHOR]

Safer conception interventions can significantly reduce the risk of horizontal HIV transmission between HIV-serodiscordant partners. However, prior to implementing safer conception interventions, it is essential to understand potential barriers to their adoption so that strategies can be developed to overcome these barriers. This paper examines potential barriers to the adoption of safer conception strategies by HIV-affected couples in Iringa, Tanzania using an ecological framework. We interviewed 30 HIV-positive women, 30 HIV-positive men and 30 health providers engaged in delivering HIV-related services. We also conducted direct observations at five health facilities. Findings suggest that there are multiple barriers to safer conception that operate at the individual, relational, environmental, structural, and super-structural levels. The barriers to safer conception identified are complex and interact across these levels. Barriers at the individual level included antiretroviral adherence, knowledge of HIV status, knowledge and acceptability of safer conception strategies, and poor nutrition. At the relational level, unplanned pregnancies, non-disclosure of status, gendered power dynamics within relationships, and patient–provider interactions posed a threat to safer conception. HIV stigma and distance to health facilities were environmental barriers to safer conception. At the structural level there were multiple barriers to safer conception, including limited safer conception policy guidelines for people living with HIV (PLHIV), lack of health provider training in safer conception strategies and preconception counseling for PLHIV, limited resources, and lack of integration of HIV and sexual and reproductive health services. Poverty and gender norms were super-structural factors that influenced and reinforced barriers to safer conception, which influenced and operated across different levels of the framework. Multi-level interventions are needed to ensure adoption of safer conception strategies and reduce the risk of HIV transmission between partners within HIV-serodiscordant couples. [ABSTRACT FROM PUBLISHER]

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. [ABSTRACT FROM AUTHOR]

Timely initiation and sustained adherence to antiretroviral therapy (ART) are essential to improving the health outcomes of people living with HIV and preventing onward HIV transmission. However, women who use heroin often face challenges to initiating and adhering to ART. In this paper we identify spatial, temporal, and social factors that affect HIV treatment engagement among women who use heroin, drawing from a time geography framework. We conducted in-depth interviews with 30 heroin-using women living with HIV in Dar es Salaam, Tanzania between January and March 2019. We found that unstable housing, high mobility, HIV-related stigma, and unpredictable daily paths due to heroin use and involvement in sex work spatially and temporally constrained women who use heroin from incorporating HIV treatment behaviors into daily routines. Some women, however, were able to overcome these time-space constraints to HIV treatment engagement through social support and social role performance. Time geography, including concepts of time-space constraints and daily paths, is a useful framework for identifying barriers to ART engagement. Structural, relational, and individual interventions aimed at eliminating time-space constraints hold the potential to improve HIV treatment engagement among particularly vulnerable and mobile populations. • Time geography can identify barriers to antiretroviral therapy (ART) engagement. • Multiple time-space constraints hinder ART initiation, adherence, and sustainment. • Heroin-using women in Dar es Salaam have flexible and unpredictable daily paths. • Housing instability, high mobility and stigma constrain HIV treatment adherence. • Support systems and mother role performance may help women overcome barriers. [ABSTRACT FROM AUTHOR]