Improvements in Health-Related Quality of Life among Methadone Maintenance Clients in Dar Es Salaam, Tanzania

BACKGROUND:

Injection of heroin has become widespread in Dar es Salaam, Tanzania and is spreading throughout the country. To prevent potential bridging of HIV epidemics, the Tanzanian government established a methadone maintenance treatment (MMT) clinic in February 2011. We assess the effect of MMT on health-related quality of life (HRQOL) and examine factors, particularly HIV infection and methadone dose, associated with changes in HRQOL.

METHODS:

This study utilized routine data on clients enrolling in methadone from February 2011 to April 2012 at Muhimbili National Hospital. Change in physical (PCS) and mental health (MCS) composite scores, as measured by the SF-12 tool, were the primary outcomes. Backward stepwise linear regression, with a criterion of p<0.2 was used to identify baseline exposure variables for inclusion in multivariable models, while adjusting for baseline scores.

RESULTS:

A total of 288 MMT clients received baseline and follow-up assessments. Mean methadone dose administered was 45mg (SD±25) and 76 (27%) were confirmed HIV-positive. Significant improvements were observed in PCS and MCS, with mean increases of 15.7 and 3.3, respectively. In multivariable models, clients who had previous poly-substance use with cocaine [p=0.040] had a significantly higher mean change in PCS. Clients who were living with HIV [p=0.002]; satisfied with current marital situation [p=0.045]; had a history of suicidal thoughts [p=0.021]; and previously experienced cognitive difficulties [p=0.012] had significantly lower mean change in PCS. Clients with shorter history of heroin use [p=0.012] and who received higher methadone doses [p=0.028] had significantly higher mean change in MCS, compared to their counterparts.

CONCLUSION:

Aspects of mental and physical health, risk behaviors and quality of life among drug users are intertwined and complex. Our research revealed positive short-term effects of MMT on HRQOL and highlights the importance of sustained retention for optimal benefits. Comprehensive supportive services in addition to provision of methadone are needed to address the complex health needs of people who inject drugs.

Purchase full article at:   http://goo.gl/8Tsmh0

By:  Ubuguyu O1, Tran OC2, Bruce RD3, Masao F1, Nyandindi C1, Sabuni N4, McCurdy S5, Mbwambo J1, Lambdin BH6.

• 1Muhimbili University of Health and Allied Sciences, PO Box 65001, Dar es Salaam, Tanzania.
• 2Pangaea Global AIDS, 436 14th St, Suite 920, Oakland, CA 94612, USA.
• 3Yale University, New Haven, CT 06520, USA.
• 4Tanzania Ministry of Health and Social Welfare, 6 Samora Machel Ave, Dar es Salaam, Tanzania.
• 5University of Texas School of Public Health, 7000 Fannin St, Houston, TX, USA.
• 6RTI-International, 351 California St, Suite 500, San Francisco, CA 94104, USA; Department of Global Health, University of Washington, Seattle, WA, USA; Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA. Electronic address: blambdin@rti.org. 
• Int J Drug Policy. 2016 Mar 11. pii: S0955-3959(16)30065-2. doi: 10.1016/j.drugpo.2016.03.005

More at:  https://twitter.com/hiv insight

And: http://twitter.com/Prison Health

Generating Trust: Programmatic Strategies to Reach Women Who Inject Drugs with Harm Reduction Services in Dar Es Salaam, Tanzania

BACKGROUND:

Strong 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.

METHODS:

We 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.

RESULTS:

Narratives 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.

CONCLUSION:

Expanding 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.

Purchase full article at:   http://goo.gl/ZEjW8A

By:  Zamudio-Haas S1, Mahenge B2, Saleem H3, Mbwambo J4, Lambdin BH5.

• 1Department of Preventative Medicine, University of California, 550, 16th Street, San Francisco, CA 94143, United States. Electronic address: Sophia.Zamudio-Haas@ucsf.edu.
• 2Department of Psychology, University of Dodoma, P.O. Box 259, Dodoma, Tanzania.
• 3Pangaea Global AIDS, 436, 14th Street, Suite 920, Oakland, CA 94612, United States.
• 4Department of Psychiatry, Muhimbili University of Health and Allied Sciences, P.O. Box 65293, Dar es Salaam, Tanzania.
• 5Behavioral and Urban Health Program, RTI International, 351, California St, Suite 500, San Francisco, CA 94104, United States; Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, United States; Department of Global Health, University of Washington, Seattle, WA, United States. 
• Int J Drug Policy. 2016 Jan 23. pii: S0955-3959(16)00035-9. doi: 10.1016/j.drugpo.2016.01.012.

More at:  https://twitter.com/hiv insight

And: http://twitter.com/Prison Health

Prevalence & Risk Factors of Cervical Squamous Intraepithelial Lesions among HIV-Infected Women in Dar es Salaam, Tanzania

To determine the prevalence and predictors of cervical squamous intraepithelial lesions (SIL) among HIV-infected women in Tanzania, a cross-sectional study was conducted among HIV-infected women at HIV care and treatment clinics. 

A Papanicolaou (Pap) smear was used as a screening tool for detection of cervical SIL. From December 2006 to August 2009, 1365 HIV-infected women received cervical screening. The median age was 35 (interquartile range [IQR]: 30-42) years, and the median CD4 + cell count was 164 (IQR: 80-257) cells/mm(3). 

The prevalence of cervical SIL was 8.7% (119/1365). In multivariate analysis, older age (≥50 versus 30-<40 years: prevalence ratio [PR], 2.36; 95% confidence interval [CI], 1.45-3.84, p for trend = 0.001), lower CD4 + cell counts (<100 versus ≥200 cells/mm(3): PR, 1.55; 95% CI, 1.01-2.36, p for trend = 0.03) and cervical inflammation (PR, 1.73; 95% CI, 1.16-2.60, p = 0.008) were associated with an increased risk of cervical SIL. Women with advanced WHO HIV disease stage (IV versus I/II: PR, 3.45; 95% CI, 1.35-8.85, p for trend = 0.01) had an increased risk for high-grade SIL. 

In resource-limited settings where it is not feasible to provide cervical cancer prevention services to all HIV-infected women, greater efforts should focus on scaling-up services among those who are older than 50 years, with lower CD4 cell counts and advanced HIV disease stage.

Purchase full article at:   http://goo.gl/ZX3r69

By:  Liu E1, McCree R2, Mtisi E3, Fawzi WW4, Aris E5, Lema IA5, Hertzmark E6, Chalamilla G5, Li N1, Vermund SH7, Spiegelman D8.

• 1Department of Global Health and Population, Harvard School of Public Health, Boston, MA, USA.
• 2National Cancer Institute, Center for Global Health, Rockville, MD, USA.
• 3Africa Academy for Public Health, Dar es Salaam, Tanzania.
• 4Department of Global Health and Population, Harvard School of Public Health, Boston, MA, USA Department of Nutrition, Harvard School of Public Health, Boston, MA, USA Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA.
• 5Management and Development for Health, Dar es Salaam, Tanzania.
• 6Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA.
• 7Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, TN, USA.
• 8Department of Global Health and Population, Harvard School of Public Health, Boston, MA, USA Department of Nutrition, Harvard School of Public Health, Boston, MA, USA Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA Department of Biostatistics, Harvard School of Public Health, Boston, MA, USA stdls@hsph.harvard.edu. 
• Int J STD AIDS. 2016 Mar;27(3):219-25. doi: 10.1177/0956462415584466. Epub 2015 May 7.

More at:  https://twitter.com/hiv insight

And: http://twitter.com/Prison Health

Generating Trust: Programmatic Strategies to Reach Women Who Inject Drugs with Harm Reduction Services in Dar Es Salaam, Tanzania

Highlights

• We examine causes for disparity in outreach and enrollment among men and women IDU.
• We present interview data from patients and providers at the first methadone clinic in Tanzania.
• Current outreach strategies focus on public areas where men IDU congregate during the day.
• Changing outreach locations and times will increase access to women IDU.
• Including more women outreach workers will help connect women to treatment. 

Abstract

Background

Strong 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.

Methods

We 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 mistrustin relationship to the interrelated themes of family loss, social isolation, vehement discrimination and motivation for treatment.

Results

Narratives 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.

Conclusion

Expanding 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.

Purchase full article at:   http://goo.gl/otTNSc

By:  Sophia Zamudio-Haas, Bathsheba Mahenge, Haneefa Saleem, Jessie Mbwambo, Barrot H. Lambdin

Affiliations

Sophia Zamudio-Haas, Department of Preventative Medicine University of California, San Francisco 550 16^th Street San Francisco, California 94143

Department of Epidemiology and Biostatistics University of California San Francisco, CA

Department of Global Health University of Washington Seattle, WA

More at:  https://twitter.com/hiv insight

And: http://twitter.com/Prison Health

Correlates of Health Care Seeking Behavior among People Who Inject Drugs in Dar Es Salaam, Tanzania

Highlights

• We interviewed people who inject drugs in Dar es Salaam, Tanzania.
• Many people who inject drugs do not seek needed healthcare.
• Being employed improves healthcare-seeking behavior.
• Knowing where to seek affordable care improves healthcare-seeking behavior.
• Providing both health education and income-generating skills is crucial.

Background

People who inject drugs (PWID) suffer from a high burden of infectious disease. At the same time, they often have poor access to health care. As in other East African countries, the population of PWID is growing in Tanzania, but little is known about their contact with health care services. In this paper we examine patterns of health care use among PWID in Dar es Salaam and identify what factors are associated with regular contact with clinicians during illness.

Methods

We conducted a baseline cross-sectional study as part of a prospective cohort study involving PWID. We recruited 578 PWID, of whom 273 were newly enrolled on an integrated methadone-assisted treatment (MAT) program and 305 were community-recruited. At baseline, we interviewed the MAT program enrollees before they received services at the program clinics. We used bivariate and multiple logistic regression analyses to identify the factors associated with seeking medical care when ill.

Results

Only 25.4% of 578 participants reported seeing clinicians regularly when they needed medical care. Participants were more likely to see clinicians regularly if they were employed, (OR: 2.25, 95% CI: 1.28–3.98), had higher income levels (OR: 1.10, 95% CI: 1.00–1.22), were parents (OR: 1.71, 95% CI: 1.09–2.68), or knew where to seek affordable care (OR: 3.42, 95% CI: 2.12–5.52).

Conclusion

PWID in Dar es Salaam generally did not seek health care when needed. To improve their health care seeking behavior, it is important to advise PWID about where to seek affordable health care and to increase their income-generating skills.

Purchase full article at:   http://goo.gl/uris9a

By:   Linda Beatrice Mlunde, Bruno Fokas Sunguya, Jessie Kazeni Kilonzo Mbwambo, Omary Said Ubuguyu, Akira Shibanuma, Junko Yasuoka, Masamine Jimba

Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan

More at:  https://twitter.com/hiv insight

And: http://twitter.com/Prison Health

Utilization of cervical cancer screening services and its associated factors among primary school teachers in Ilala Municipality, Dar es Salaam, Tanzania

Background

Worldwide cervical cancer is one of the more common forms of carcinoma among women, causing high morbidity and high mortality. Despite being a major health problem in Tanzania, screening services for cervical cancer are very limited, and uptake of those services is low. We therefore conducted a study to investigate utilization of cancer screening services, and its associated factors among female primary school teachers in Ilala Municipality, Dar es Salaam.

Method

We conducted a cross-sectional study between May – August 2011 which involved 110 primary schools in Ilala Municipality in Dar es Salaam. Five hundred and twelve female primary school teachers were sampled using a two-stage cluster sampling procedure. Data on utilization of cervical cancer and risk factors were collected using a self-administered questionnaire. Proportional utilization of cervical cancer screening services was identified through a self report. Risk factors for services utilization were assessed using logistic regression analyses.

Results

Out of 512 female primary school teachers, only 108 (21 %) reported to ever been screened for cervical cancer.

Utilization of cervical cancer screening services was 28 % among those aged 20–29, 22 % among married and 24 % among those with higher level of education. Women were more likely to utilize the cancer-screening service if they were multiparous (age-adjusted OR = 3.05, 95 % CI 1.15–8.06, P value 0.025), or reported more than one lifetime sexual partner (age-adjusted OR 2.17, 95 % CI 1.04–4.54, P value 0.038), or did not involve their spouse in making health decisions (adjusted OR 3.56, 95 % CI 2.05–6.18, P value <0.001).

Conclusion

The study has demonstrated low level of utilization of cervical cancer screening service among female primary school teachers in Ilala munipality. Female primary school teachers with more than one previous pregnancy and those with more than one life-time sex partners were more likely to report utilization of the service. Spouse or partners support was an important factor in the utilization of cervical cancer screening service amongst the study population.

Below:  A map of Ilala District

Full article at:   http://goo.gl/9zW8IX

By:   Neema Minja Kileo¹, Denna Michael^2*, Nyasule Majura Neke² and Candida Moshiro³

¹World Health Organization, Tanzania Country Office, Dar es Salaam, P O Box 9292, Tanzania

²National Institute for Medical Research, Mwanza Medical Research Center, Mwanza, P O Box 1452, Tanzania

³Muhimbili University of Health and Allied Sciences (MUHAS), Dar Es Salaam, P O Box 67005, Tanzania

 

More at:  https://twitter.com/hiv_insight

And: http://twitter.com/Prison_Health

How Long-Distance Truck Drivers & Villagers in Rural Southeastern Tanzania Think About Heterosexual Anal Sex

Objective To explore ideas of truck drivers and villagers from rural Tanzania about heterosexual anal sex (HAS) and the associated health risks.

Methods Qualitative study using 8 in-depth interviews (IDIs) and 2 focus group discussions (FGDs) with truck drivers and 16 IDIs and 4 FGDs with villagers from the Morogoro region. Study participants included 24 women and 46 men. Data analysis was performed thematically employing standard qualitative techniques.

Results Reasons why men would practice HAS included sexual pleasure, the belief that anal sex is safer than vaginal sex, alternative sexual practice, exploration and proof of masculinity. Reasons why women would practice HAS included financial need, retaining a partner, alternative for sex during menses, pregnancy prevention and beauty enhancement because HAS is believed to ‘fatten the female buttocks’. Most participants believed that condoms are not needed during HAS. This was linked to the ideas that infections only ‘reside in wet places’ (vagina) and that the anus is not ‘conducive’ for condom use; condoms reduce ‘dryness’ and ‘friction’ (pleasure) and may ‘get stuck inside’.

Conclusions The study participants reported practices and ideas about HAS that put them at risk for HIV and sexually transmitted infections. Greater attention to education about HAS is urgently needed in Tanzania, where this sexual practice is still regarded as a taboo. This study offers useful information that could be included in sex education programmes.

Full article at:  http://goo.gl/rRKXi3

By:  S Mtenga¹, D Shamba¹, J Wamoyi², D Kakoko³, J Haafkens⁴, A Mongi⁵, S Kapiga⁵, E Geubbels¹

-Author Affiliations

¹Department of Impact Evaluation, Ifakara Health Institute (IHI), Dar es Salaam, Tanzania

²National Institute for Medical Research Institute (NIMR), Mwanza Center, Mwanza, Tanzania

³Department of Behavioural Sciences, Muhimbili University of Health and Allied Science (MUHAS), School of Public Health, Dar es Salaam, Tanzania

⁴Department of General Practice, Centre for Social Science and Global Health, University of Amsterdam and Academic Medical Centre, Amsterdam, The Netherlands

⁵Mwanza Intervention Trial Unit (MITU), Mwanza, Tanzania

 

More at:  https://twitter.com/hiv_insight

And: http://twitter.com/Prison_Health

Lubricant Use & Condom Use During Anal Sex in Men Who Have Sex with Men in Tanzania

The lack of data on condom and lubricant use among African men who have sex with men hinders prevention efforts. We describe use, knowledge, and access to lubricants in Dar es Salaam and Tanga, Tanzania. Data were collected in 2012 and 2013 from a cross-sectional survey of 200 men who have sex with men in Dar es Salaam and 100 men who have sex with men in Tanga, Tanzania. 

The most common reason for not using condoms was dislike of condoms. Two-thirds of the men reported always using a lubricant for anal sex. Fewer men who have sex with both men and women know about lubricants, more gay men look for, have difficulty finding, and find lubricants to be expensive; and men who have sex with men use lubricants to facilitate penetration. Men who have sex with both men and women commonly receive their lubricants from their sexual partner, while gay men got them from friends and pharmacies. HIV-negative men who have sex with men used lubricants to facilitate penetration and reduce pain. HIV-positive men who have sex with men are likely to get their lubricants from pharmacies or friends. Men who have sex with men and women use Vaseline® significantly more than gay men as a lubricant. 

Results suggest that HIV prevention knowledge among gay men is greater; HIV prevention efforts should emphasise carrying water-based lubricant among men who have sex with men and women. Consequently, there is an opportunity to co-market condoms and water-based lubricants.

Purchase full article at: http://goo.gl/jJ5tgb

By: Romijnders KA1, Nyoni JE2, Ross MW3, McCurdy SA4, Mbwambo J5, Kok G6, Crutzen R7.

• 1Faculty of Health, Medicine and Life Sciences, Maastricht University, the Netherlands k.romijnders@student.maastrichtuniversity.nl.
• 2Department of Sociology and Anthropology, University of Dar es Salaam, United Republic of Tanzania.
• 3Program in Human Sexuality, Department of Family Medicine, University of Minnesota, MN USA.
• 4Division of Health Promotion and Behavioral Sciences, School of Public Health, Center for Health Promotion and Prevention Research, The University of Texas Health Science Center at Houston, USA.
• 5Department of Psychiatry and Mental Health, Muhimbili University of Health and Allied Sciences, United Republic of Tanzania.
• 6School of Psychology and Neuroscience, Maastricht University, Maastricht, the Netherlands.
• 7CAPHRI School for Public Health and Primary Care, Maastricht University, the Netherlands.  

More at:  https://twitter.com/hiv_insight

Characteristics & Geographic Distribution of HIV-Positive Women Diagnosed with Cervical Cancer in Dar es Salaam, Tanzania

Cervical cancer is the leading incident cancer and the main cause of cancer-related mortality among women in sub-Saharan Africa. Furthermore, HIV-infected women are at a higher risk of developing cervical cancer than are HIV-negative women. The purpose of this study was to distinguish differences in characteristics of HIV-positive and HIV-negative patients with cervical cancer in Dar es Salaam, Tanzania.

The HIV status of cervical cancer patients diagnosed and/or treated at Ocean Road Cancer Institute in Dar es Salaam, Tanzania, during the period 2007-2011 was abstracted from the medical records. Additional abstracted information included patient's name, age, place of residence, occupation, education, marital status, age at marriage, gravidity, and screening clinic visit results. Ocean Road Cancer Institute patients came from two sources, the screening clinic followed by treatment clinic or the treatment clinic without prior screening. HIV-positive and HIV-negative patients were compared regarding the above-listed clinical and epidemiologic factors. Multivariable analysis was also performed to assess the risk factors associated with cervical cancer treatment without prior screening at Ocean Road Cancer Institute.

HIV-positive cervical cancer patients tended to be younger, with higher education, and lower parity. Patients screened for cervical cancer prior to treatment were more likely to be HIV-positive, less likely to have higher disease stages, and less likely to reside outside of Dar es Salaam.

Screening for cervical cancer at Ocean Road Cancer Institute is utilised by more HIV-positive patients from Dar es Salaam. Future studies should focus on identifying the reasons for lower utilisation of screening by HIV-negative patients and patients from other distant rural regions in Tanzania.

Full article at: http://goo.gl/NT30eY

By: Lovgren K1, Soliman AS2, Ngoma T3, Kahesa C3, Meza J4.

• 1Department of Epidemiology, College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA.
• 2Department of Epidemiology, College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA amr.soliman@unmc.edu.
• 3Ocean Road Cancer Institute (ORCI), Dar es Salaam, Tanzania.
• 4Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA.  

More at:  https://twitter.com/hiv_insight