ACTIVITY HAS BEEN REVISED IN THE FOLLOWING WAYS:

TITLE: Creating an Enabling Environment for Behavioral and Structural Interventions to Reduce HIV Risk

among IDUs and Overlapping Populations in the United Republic of Tanzania

NEED and COMPARATIVE ADVANTAGE: Before 2003, initiatives to reduce the spread of HIV/AIDS

among drug users were almost non-existent. In the last 5 years, however, a government and non-

government response has been established. At the government-level, the Drug Control Commission's

overall objective is to enhance the capacity of other government institutions and NGOs for HIV/AIDS

prevention, care, treatment and support among drug users and specifically to: (1) establish the nature and

magnitude of drug use and HIV/AIDS and identify best practices in Tanzania.; (2) ensure the provision of

education and information services to drug users and to the general population; (3) ensure availability of

voluntary or provider-initiated HIV counseling and testing (VCT/PICT) services to drug users and addicts,

increase access to drug treatment and increase access to antiretroviral therapy (ART) by establishing one

treatment and rehabilitation centre; and (4) enable seven regional hospitals to provide drug addiction

treatment services as well as establishing outreach and drop-in services in all major cities and towns in

Tanzania mainland. The Drug Control Commission provides technical assistance to achieve similar goals in

Zanzibar.

Current policy initiatives supported by the Drug Control Commission include the expansion of the scope of

strategies addressing HIV/AIDS among drug-using population in the National Multi-Sectoral Strategic

Framework for HIV (2007-2012); drafting a specific program plan for the prevention, care and support of

HIV among drug-using populations; and drafting of national standards for drug treatment, including using

the 1995 Drugs and Prevention of Illicit Traffic in Drugs to facilitate treatment of drug offenders. There is

limited access to direct drug treatment and rehabilitation services in Tanzania. When available, treatment

and rehabilitation services are provided by existing mental institutions and in select hospitals (Mirembe and

Lutindi). Tanzania does not currently have medication maintenance therapy available as an option for drug

treatment. This is a critical void and one that the Drug Control Commission is committed to addressing.

Beyond treatment services, there are additional gaps in the response to HIV/AIDS in drug-using

populations. Unfavorable legislation continues to prohibit the implementation of harm reduction

approaches, for example. Further, efforts to educate community, politicians, religious leaders and other

decision-makers about the urgent need to respond to HIV/AIDS with specific interventions for drug users

are as yet inadequate and need to be strengthened. With regards to measuring the problem of HIV among

drug users, there still is not a systematic mechanism for the collection and dissemination of research

findings. Moreover, efforts to describe injection drug use are mainly concentrated in Dar es Salaam and

Zanzibar, ignoring other parts of the country. Lastly, there is no sentinel surveillance system to monitor risk

behaviours and the prevalence and incidence of HIV among drug users. Prevention research is also

limited, as there is little emphasis on intervention evaluation.

ACCOMPLISHMENTS: Since receiving PEPFAR funds in March 2008, the Drug Control Commission has

begun to lay a foundation to strengthen its national coordination efforts and capacity to address gaps

identified above including medication maintenance therapy. Most notably, the commission participated in

the planning committee for the stakeholders' workshop on HIV prevention among IDU in Tanzania.

Connections made as a result of the workshop have facilitated the commission's work and generated

tremendous increase in the awareness of the link between drug use and HIV among key decision makers

as well as among the general population. For example, the National Multi-Sectoral Strategic Framework for

HIV (2007-2012) has expanded to include more on addressing the issue of HIV among drug users.

ACTIVITIES: Responding to the intertwined issues of HIV and injection drug use requires leadership and

coordination at a national level. The Drug Control Commission is the national agency responsible for

substance abuse prevention and the goals of PEPFAR funding are to strengthen the Commission's role as

a coordinating body, to foster innovative approaches to drug treatment, provide a forum in which funded

partners and local stakeholders can obtain tools, materials, standards, and guidelines relevant to

implementing and monitoring interventions for drug users. To achieve these goals, the Drug Control

Commission has identified seven core activities that will be completed over the course of this cooperative

agreement. The seven activities include: 1) sensitizing decision-makers at the Government level about

interventions addressing the co-infection of HIV and substance abuse; 2) developing a strategic framework

for HIV prevention services for IDUs and other at risk sub-populations; 3) establishing a drug information

system in Dar es Salaam; 4) establishing a drug information system in Zanzibar; 5) developing an outreach

workers field guide; 6) developing and adopting drop-in services standards; and 7) developing and adopting

service placement criteria.

The Drug Control Commission has prioritized the first two activities and has begun working on them with the

current funding. Continuing tasks for FY 2009 include the following:

Sensitizing Decision-Makers

?To conduct two-day stakeholders meetings to approve/review recommended action plan for project

implementation and selection of members of project steering committee.

?To design, produce and disseminate advocacy materials.

?To conduct a sensitization meeting with decision makers at the Government level.

Developing Strategic Framework for HIV Prevention for IDUs

?To conduct a 6-day expert workshop to develop a draft version.

?To conduct a stakeholders meeting involving 50 participants.

?To conduct a 3-days workshop to incorporate recommendations.

?To facilitate endorsement by the cabinet.

?To produce final copy for dissemination.

?To conduct dissemination workshop.

Activity Narrative: A core aspect of both activities will be addressing drug treatment, including medication maintenance

therapy, in FY 2009. Using advocacy, policy development and standardized service delivery components,

the Drug Control Commission hopes to cultivate an environment that is more conducive for HIV prevention

services among this population and makes the availability of treatment options more viable. The Drug

Control Commission will receive technical assistance and organizational capacity building assistance from

Pangea. Pangea is globally recognized as a leader in this field and members of the Pangea team have

worked with GOT previously on advocacy and training issues.

LINKAGES: Programmatic linkages will be established and maintained with mobile VCT providers, condom

distributors, and treatment partners supported by USG. Collaboration with substance abuse treatment

centers in Dar es Salaam and Zanzibar will be a priority.

SUSTAINABILITY: As a governmental agency, PEPFAR funds invested in the Drug Control Commission

builds organizational capacity. Technical assistance provided by Pangea will enhance the knowledge and

expertise of staff, which will support long-term growth of the agency.

*END ACTIVITY REVISIONS*

TITLE: Behavioral and Structural Interventions to Reduce HIV Risk Among IDUs, CSWs, and MSM

NEED and COMPARATIVE ADVANTAGE: In Tanzania, as in other sub-Saharan African countries, injecting

is a relatively new means of transmitting HIV. Current data indicates that injection drug use, specifically

heroin, is rapidly increasing in urban Tanzania and on the island of Zanzibar. Furthermore, injection

practices and unsafe sexual behaviors associated with selling sex to buy drugs, are contributing to HIV

transmission. Recent study data collected by university researchers in Dar es Salaam found the common

practice of unsafe behaviors such as needle sharing and a high prevalence of HIV. Risk for female IDUs is

heightened in many instances by a reliance on commercial sex, both formal and informal, to acquire the

financial resources to purchase drugs. However, commercial sex work in Tanzania extends beyond the link

with injection drug use and is related to the growing lack of employment opportunities and impoverishment.

This has resulted in an environment where urban residents of Tanzania are increasingly trading sex for

money. Another emerging risk population in Tanzania are men who have sex with men (MSM). Although

MSM tend to be a hidden population in Tanzania, a study conducted in Zanzibar identified a sizeable

population. Many of the Zanzibari MSM also injected drugs and/or traded sex for money, demonstrating the

overlapping nature of some most at risk populations (MARPS).

ACCOMPLISHMENTS: A funding announcement for FY 2007 funds was recently published and the

cooperative agreement will be awarded before the start of the new fiscal year.

ACTIVITIES: As indicated by current epidemiologic and behavioral data and anecdotal information, IDU,

commercial sex workers (CSW) and MSM are MARPS with often intertwined risks. The increase in injection

drug use, coupled with unsafe sexual behaviors associated with females and males selling sex to buy

drugs, has resulted in increased HIV transmission. The changing epidemiology of HIV/AIDS risks

associated with these MARP in Tanzania requires innovative HIV prevention approaches that are able to

address multiple and changing levels of risks and contexts (e.g., social network, dyadic, family, community

and structural).

FY 2008 funds are requested to expand the comprehensive, multi-component interventions planned for FY

2007. Planned scale-up includes enhanced efforts to develop appropriate services for men who have sex

with men and commercial sex workers, risk groups that often overlap with injection drug users in Tanzania.

Each MARP (IDUs, CSWs, and MSM) will have a separate and specialized NGO working with them. The

focus of project activities will remain on community-based outreach that engages these most at risk

populations (i.e., IDU, MSM and CSW) in risk reduction and refers them to a range of services, including

VCT and HIV care and treatment.

Specific activities will respond to the evolving epidemiology and assist most at risk populations reducing

their risk for HIV/AIDS, other sexually transmitted infections (STDs), and hepatitis B and C by: 1) conducting

community-based outreach and engaging the target populations in HIV prevention, including condom

distribution;

2) communicating appropriate prevention and risk reduction messages which will help address their HIV risk

behaviors (e.g., for IDUs this would be to reduce drug use, increase safer injection practices, and increase

utilization of evidence-based, integrated care for injection drug abuse when available);

3) providing outreach through mobile vans with HIV counseling and testing and STI services; and

4) linking members of most at-risk groups with follow-up care at STD clinics and facilities providing HIV care

and treatment for those found to be HIV-positive. In Zanzibar, additional activities tailored for MSM and

CSW (including activities targeting migratory CSWs) will be developed following the completion of ongoing

targeted evaluations conducted by the Zanzibar AIDS Control Program (ZACP) and Tulane University with

funding from USG.

An additional intent of this activity is to foster greater understanding and awareness of injection drug use in

Tanzania and provide forums for discussing opportunities, gaps, challenge,s and strategies for HIV

prevention efforts with IDU populations. To this end, the TBD partner will facilitate educational forums and

liaise with appropriate governmental bodies to increase collaboration.

LINKAGES: Programmatic linkages will be established and maintained with mobile VCT providers, condom

distributors, and treatment partners supported by USG. Collaboration with substance abuse treatment

centers in Dar es Salaam and Zanzibar will be a priority.

Activity Narrative: CHECK BOXES: Human capacity development: in-service training

Local organization capacity building

Wrap around programs: family planning

Most at risk populations (injecting drug users, men who have sex with men, non-injecting drug users,

persons in prostitution, persons who exchange sex for money and/or other goods, and street youth)

M&E: The TBD partner will develop an M&E system to track client encounters, services delivered, and

referrals (e.g., to counseling and testing, and care and treatment centers). Other variables will be explored

depending on the exact activities. Whenever possible, national tools will be used and the existing system

will be supported.

SUSTAINABILITY: Local organizations are being sought for this activity and they will receive capacity

building which will enable them to maintain activities and, should the need arise, seek additional funding

sources. Furthermore, appropriate bodies within the Government of Tanzania will be involved in forums to

promote the integration of this issue into their plans.

Targets:

Geographic Coverage Areas: (Regions)

Please indicate if there are any changes from COP 08

Dar es Salaam, Tanga, Arusha, Zanzibar

New/Continuing Activity: New Activity

Continuing Activity:

Program Budget Code: 07 - CIRC Biomedical Prevention: Male Circumcision

Total Planned Funding for Program Budget Code: $1,890,078

Total Planned Funding for Program Budget Code: $0

Table 3.3.07: