ACTIVITY HAS BEEN REVISED IN THE FOLLOWING WAYS:

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

Zanzibar

NEED and COMPARATIVE ADVANTAGE: In the United Republic of Tanzania, as in other sub-Saharan

African countries, injecting drugs 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 in Unguja Island of Zanzibar found the

prevalence among a recent cohort of approximately 500 IDU in Zanzibar is 15% and unsafe behaviors such

as needle sharing are common. 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 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). 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 (MARP). In Zanzibar, an

estimated 46% of HIV/AIDS patients are drug users. ICAP is the regional partner assigned to Zanzibar for

clinical services and the organization successfully competed and won the funding to conduct this activity.

Given the epidemiology of HIV and the nature of injection drug use, ICAP is in a comparative advantage to

deliver services to IDU and overlapping populations. ICAP's United for Risk Reduction and HIV/AIDS

Prevention (URRAP) project will build upon data collected during a recent study to develop comprehensive

programming for IDU and other MARP.

ACCOMPLISHMENTS: On June 19, the URRAP project was launched in Zanzibar; the First Lady has been

consulted along with the Principal Secretary, MOHSW,and the program is now moving forward. ICAP works

with the Department of Substance Abuse Prevention/ZACP and three NGOs (Zayedesa, Zanzibar Youth

and Zaiada) along with the Care and Treatment and VCT clinics to support addressing HIV prevention

among most at risk persons (MARPS). A key target population is injecting drug users.

As a start up of URRAP in Zanzibar, the team has carried out community mapping and sensitization

meetings with stakeholders (e.g., community leaders). A jointly conducted collaborative needs assessments

with CBO partners was also done. The four primary stakeholders presented information on the services

currently offered, their strengths, the gaps in services, and each organizations' need to effectively

participate in the URRAP project. Through these presentations, the following strengths were identified: peer

education programs, community-based outreach and the network of social services currently available to

substance users. The following gaps were also identified: relevant policies and guidelines for medical

interventions; the sustainability of current programs; and integrated HIV and substance use services. Based

on these gaps, participants agreed that the following needs should be addressed through the URRAP

project:

• Monitoring and evaluation training for staff at each partner organization.

• Capacity building at each partner organization, including training on HIV, substance use and STIs.

• Financial management training at each partner organization for the execution of URRAP activities.

ICAP-TZ worked with each of the key strategic partners to identify their primary roles in URRAP. This

included examining how the services at each organization fit into the goals and objectives of the URRAP

proposal, as well as designing specific activities to achieve these goals and objectives. This information will

allow ICAP-TZ to assist each key strategic partner to develop and write their proposals, work plans and

budgets.

Prior to the launch of URRAP, ICAP conducted a two and a half day training on injection drug use and

addiction for staff from facilities providing HIV care on Zanzibar and to partners in the CDC grant providing

counseling and testing to IDUs. In consultation with the Zanzibar Department of Substance Abuse and

Prevention (ZDSAP), it was agreed that a primary focus of the training would be on treatment (including

medically assisted treatment such as methadone) and harm reduction strategies. The training also

addressed 12 step philosophies in an effort to further inform a plan to adapt a program based on Islam.

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 2009 funds for URRAP will be used to expand the comprehensive, multi-component initiated in FY 2008.

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

Activity Narrative: treatment for those found to be HIV-positive.

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, challenges and strategies for HIV

prevention efforts with IDU populations. To this end, ICAP will facilitate educational forums and liaise with

appropriate governmental bodies in Zanzibar to increase collaboration.

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

distributors, and governmental partners.

M&E: ICAP 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 in consultation

with the Ministry of Health. 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.

*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

Activity Narrative: 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.

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.

Geographic Coverage Areas: (Regions)

Please indicate if there are any changes from COP 08

Zanzibar

New/Continuing Activity: New Activity

Continuing Activity:

Table 3.3.06: