In the United Republic of Tanzania, as in other sub-Saharan African countries, HIV transmission through injection drug use is acknowledged to contributing to the spread of the epidemic. Current data indicate that injection drug use is rapidly increasing in urban Tanzania and on the island of Zanzibar. Recent study data collected in Unguja Island of Zanzibar found 16.1% of injecting drug users (IDUs) are infected with HIV and unsafe behaviors, such as needle sharing, are common. Risk is heightened by unsafe sexual practices, in many instances associated with reliance on commercial sex to fund purchase of drugs. Formal and informal commercial sex work 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 Zanzibar are increasingly trading sex for money. Another emerging risk population are men who have sex with men (MSM). A study conducted in Zanzibar identified a sizeable population of MSM and many were found to also inject drugs and/or trade sex for money, demonstrating the overlapping nature of some most at risk populations (MARPs). ICAP is the regional partner assigned to Zanzibar for clinical services, having the comparative advantage to deliver services to IDU and overlapping populations. ICAP's United for Risk Reduction and HIV/AIDS Prevention (URRAP) project builds upon data collected during a recent study to develop comprehensive programming for IDU and other MARPs. Interventions focus on risk reduction and referral to a range of services, including VCT and HIV care and treatment. URRAP brings together three local CBOs and in 2010 a fourth CBO, based on Pemba Island, for a collaborative intervention throughout Zanzibar. Additionally, ICAP works with the Ministry of Health and Social Welfare (MOHSW) on Zanzibar for introducing overdose prevention tools and Naloxone overdose treatment. Finally, as Medically Assisted Therapy (MAT) is approved and actualized on Zanzibar, ICAP will work with ZACP to support linking clients into MAT, provide technical assistance to initiate and manage MAT, and support quality improvement of MAT.

ICAP contributes to Health Systems Strengthening through training at different levels, including pre-service training for 90 MARPs outreach workers; in-service training for 99 health care workers and 24 pharmacists on harm reduction, management of PMTCT, HIV care and ART in MARPS, and STI screening and treatment; and in-service training for health care providers on MAT.

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).

Coordination of services and strengthened capacity among implementers renders cost efficiency over time. As an example, in 2010, activities are expanding to Pemba Island without budgetary increase in this IM. ICAP facilitates educational fora to foster greater understanding and awareness of injection drug use and liaison with appropriate governmental bodies in Zanzibar to increase collaboration. ICAP, through URRAP, works with many other partners in carrying out the program, including UNAIDS and UNODC (the latter based in Nairobi). MARPS are also in need of income generation, general health and education services, and ICAP through URRAP will seek opportunities for active linkages.

Direct program implementation is on the two Islands of Unguja and Pemba in Zanzibar, where the major target populations are IDUs, MSM and CSW, as well as health care workers. Furthermore, ICAP provides support to the Department of Substance Abuse Prevention and Rehabilitation (DSAPR) on Zanzibar in overall program strengthening. On mainland, ICAP supports the Drug Control Commission (DCC) in developing national IDU / MARPs M&E tools.

This mechanism links to the PF goals on prevention, leadership and strategic decision making by improving and scaling up strategies to avert new infections among an extremely high risk group. Working with policy-making entities and building capacity of local CBOs creates an enabling environment and contributes to improved leadership, management, accountability and governance. ICAP provides technical support in developing national M&E for MARPs, facilitating access to reliable information to guide strategies and decisions.

URRAP is taking the lead among USG partners to support development of national M&E tools for MARPS and IDUs, supporting the DCC on mainland Tanzania and the DSAPR in Zanzibar. It is envisioned that one set of tools will be adopted by all partners for use in government and NGO run programs. ICAP will support DSAPR to manage and use the national M&E system to improve services and program outcomes.

Support for MARPs/IDU peer education and outreach services, Voluntary HIV Counseling and Testing, screening for STIs and hepatitis, on Unguja and Pemba, incl. sub-grants to 3 local NGOs/CBOs for MARPs/DU outreach on Znz; support for referral of HIV-infected MARPs/IDU into HIV/AIDS services; training of health care workers to improve service provision for MARPs/IDU; TA for MARPs/DU M&E National working group developing National MARPS/IDU M&E tools and database. Support to ZACP for the establishment of first for MAT service site on Zanzibar, including support for training of providers on MAT; TA and support for National MARPS DU/IDU working group fro development of tools for MAT M&E