Fighting Twin Epidemics in Tanzania: Heroin and HIV

Sub-Saharan Africa is struggling with twin epidemics — HIV and heroin addiction — and Tanzania, in eastern Africa, is one of the hardest-hit regions.

But now, with funding from the U.S. government and organizational expertise from Yale, an effort is underway there to get heroin addiction and the viruses spawned by the sharing of contaminated needles — HIV, Hepatitis B and C — under control.

Dr. R. Douglas Bruce, assistant professor of internal medicine (AIDS) at Yale School of Medicine, recently helped open the first public, nationally available methadone maintenance program in Sub-Saharan Africa to treat heroin addiction. The program is funded by the U.S. President’s Emergency Plan For AIDS Relief and has been embraced by the Tanzanian government.

Thanks to this program Tanzania is the first and, so far only, country in Sub-Saharan Africa to offer treatment to all heroin injectors, regardless of their ability to pay. Other countries, such as South Africa and Kenya, have made methadone available only to those who could afford the high prices of private clinics.

“If you are just an average injector who’s at high risk for HIV, there are no services available,” says Bruce.

In Tanzania, however, “people involved in the government had experience with drug addiction, having seen it affect friends and family, so there was a consensus that they had to do something about it,” Bruce explains.

There was another reason: A few years ago, epidemiological reports began to surface in Tanzania’s largest city, Dar es Salaam, of a new phenomenon known as “flashblood,” where female sex workers who are also heroin addicts would draw up a vial of their own blood and give it to another woman to inject. “The idea,” Bruce says, “is that if I have heroin in my body, I can inject someone else and stave off their withdrawal. It’s scary.”

Today, Tanzania has between 25,000 and 40,000 drug injectors. Drug-addicted female sex workers have a concurrent HIV infection rate of between 50% and 65%, which says a lot about the primary infection route today for HIV in Tanzania, notes Bruce. Among male injectors the HIV infection rate is 25%.

Although the Tanzanian government was willing and the money was there, Bruce and his team had many hurdles to overcome before the first patients could be treated. “It was a long process with many unsung heroes,” he says. “We had the privilege of working with the government to develop the minimum standards of clinical care for methadone maintenance in the country and the rules and regulations of treatment for injection drug users.”

Then, the team had to start training people, which is where Bruce’s expertise came into play. “It was a pleasure to work with the physicians and nurses on the team, who have a passion to help the men and women affected by heroin addiction and HIV,” he says. “I worked as the technical adviser to teach them about how to implement methadone maintenance. This entailed working with them on documents, walking them through the protocols, and providing assistance when we started treatment. I will go back in a couple of months to monitor how the first cohort is doing.”

Muhambili Hospital in Dar es Salaam was chosen to be the first site for the methadone maintenance program because it has the most resources. “The facility had to be renovated for the clinic, including creating a pharmacy that was secure so the methadone would not be stolen,” notes Bruce.

That took six months. Then, Bruce and his team had to find a distributor for the methadone. They chose the Montreal-based Pharmascience because it offered the best price, but it took another two months to get the Canadian government’s permission to ship the drug. The methadone arrived in December 2010; the maintenance program in Dar es Salaam was launched in February of this year.

The first patients were chosen by non-governmental organizations (NGOs) that work with injectors in the community. The first wave consisted of three people a day for four days. There was no cost to the patients for the methadone — but, Bruce notes, with drug users, even free treatment and a regular schedule do not guarantee results.

“When you’re dealing with drug users who don’t feel well, you have to be ready to provide a service,” he explains. “On the first day, one patient who was coming to the clinic to start methadone was reported to have run off from the NGO workers. Either he was afraid of the methadone or afraid the methadone would not make him feel better.”

The team treated 11 people in the first go-round, and then in the second week added 16 more. They hope to have 200 people by the end of the year. Treatment will last around two years; Bruce says that’s how long it takes for the brain to re-wire itself and forget the heroin high. “Methadone isn’t the thing that fixes you,” he says. “It just makes you feel better while you go through drug treatment.”

Strictly speaking, methadone is a “replacement drug” for heroin. It’s a synthetic opioid that is chemically different from morphine or heroin and makes patients feel better without making them “high.” It works on the same brain receptors. Unlike heroin, methadone is given orally. As with all opioids, methadone creates physical dependence, but it is widely recognized as one of the best medications to treat heroin addiction.

Adherence to treatment is always complex, as heroin addicts have novel ways of getting high and avoiding detection, Bruce says. “We need to ask, for example, are they smoking heroin to supplement their methadone? We need to keep close watch on them — we don’t want this program to be a treatment failure.”

Sub-Saharan Africa became the epicenter for this heroin crisis, Bruce says, because that’s where the drug is coming in. “It is grown in places like Afghanistan, then transported through the Middle East through Iran (which, as a result, has its own heroin crisis), down the Persian Gulf and Arabian Sea, straight into Eastern Africa. From there it goes through North Africa and up into the high-dollar markets of Western Europe.”

Until recently, the standard drug route took heroin from Afghanistan through Iran, Iraq, Turkey and across the Black Sea to the Ukraine and other Eastern European countries before reaching Western Europe. But that old route is heavily policed now, so the drug makers and couriers have moved south — utilizing ancient slave trade routes that go back a millennium in some cases. When they arrive in Western Europe, Bruce says, they often escape detection.

“If you’re flying from Dar es Salaam into London,” he notes, “customs people are worried that you’re bringing illegal fruits into the country and checking that your papers are in order. The big things in the press aren’t the Tanzanian heroin trade, so they’re not looking for that.”

“Slaves used to be traded from Tanzania to the island of Zanzibar, and from Zanzibar to the Middle East,” he continues, “so for a thousand years they’ve been shipping back and forth between the Middle East and Eastern Africa. It wasn’t a big stretch to turn around and start shipping heroin that way.” To add to the problem, drug couriers are often paid with heroin.

It makes for a nightmarish stew, says Bruce — easily available heroin, well-worn transport routes, women getting paid for sex, the sharing of contaminated needles and blood, the men who frequent sex workers then go home and infect their wives. It all starts with the heroin, Bruce says. “Needle exchanges are not yet available, so they’re all getting viruses from each other.”

Changing the culture that supports the HIV-heroin epidemics will be a long, uphill road, says Bruce “The government is doing nothing to stop the sex trade in Tanzania. In South Africa, people are using heroin and have even branched out to smoking HIV therapy to get high. Anti-retrovirals are getting stolen and being abused.”

But the new methadone program in Dar es Salaam gives him hope, he says. “There are no questions about methadone’s effectiveness.” Tanzania’s decision to make it available to the tens of thousands of its citizens caught in heroin’s deadly grip is, he says, an important first step.

“The U.S. is funding the effort. There is the political will, the financing, and now the organizational skill. So all the pieces are there,” he says.

This report is written by: Helen Dodson.

*Source: Yale University.

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