title: Identifying programmatic gaps: inequities in harm reduction service utilization among male and female drug users in Dar es Salaam, Tanzania.
abstract: BACKGROUND
  Current estimates suggest an HIV prevalence of 42% among people who inject drugs (PWIDs) in Dar es Salaam, while HIV prevalence is estimated to be 8.8% among the general population in the city. To address the HIV epidemic in this population, the government of Tanzania began establishing HIV prevention, treatment and care services including outreach and medication assisted treatment (MAT) for PWIDs in 2010. We assessed gender inequities in utilization of outreach and MAT services and evaluated differences in HIV risk behaviors between female and male PWIDs.
  
  
  METHODS
  Routine outreach data between December 2010 to mid-August 2012 and baseline data on clients enrolling in methadone from February 2011 to August 2012 were utilized. Binomial regression was used to estimate adjusted relative risk estimates comparing females to males.
  
  
  RESULTS
  From December 2010 to August 2012, 8,578 contacts were made to drug users; among them 1,898 were injectors. A total of 453 injectors were eligible and referred to MAT, of which, 443 enrolled in treatment. However, regarding total outreach contacts, outreach to PWID, referral to MAT and enrollment in MAT, 8% or less of drug users accessing services were women. In contrast, weighted estimations from surveys suggest that 34% of PWIDs are female, and this approximation is similar to recent population size estimations. Overall, 43% of traditional outreach workers conducting outreach with drug users were female. Though reporting higher levels of condom usage, female PWID were more likely to report multiple sex partners, anal sex, commercial sex work and struggle under a higher burden of addiction, mental disorders and abuse.
  
  
  CONCLUSIONS
  Services have not been mobilized adequately to address the clear needs of females who inject drugs. A clear and urgent need exists for women-centered strategies that effectively engage female PWID into HIV prevention services.
authors.affiliation: Pangaea Global AIDS Foundation, Oakland, California, United States of America. blambdin@pgaf.org
authors.forename: Barrot H
authors.initials: BH
authors.lastname: Lambdin
authors.forename: R Douglas
authors.initials: RD
authors.lastname: Bruce
authors.forename: Olivia
authors.initials: O
authors.lastname: Chang
authors.forename: Cassian
authors.initials: C
authors.lastname: Nyandindi
authors.forename: Norman
authors.initials: N
authors.lastname: Sabuni
authors.forename: Sophia
authors.initials: S
authors.lastname: Zamudio-Haas
authors.forename: Sheryl
authors.initials: S
authors.lastname: McCurdy
authors.forename: Frank
authors.initials: F
authors.lastname: Masao
authors.forename: Yovin
authors.initials: Y
authors.lastname: Ivo
authors.forename: Amani
authors.initials: A
authors.lastname: Msami
authors.forename: Omar
authors.initials: O
authors.lastname: Ubuguy
authors.forename: Jessie
authors.initials: J
authors.lastname: Mbwambo
mesh_terms: D000328:Adult; D003159:Community-Institutional Relations; D055030:Drug Users / Q000706:statistics & numerical data*; D005260:Female; D015658:HIV Infections / Q000150:complications / Q000453:epidemiology; D040261:Harm Reduction; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D012309:Risk-Taking; D012737:Sex Factors; D012959:Socioeconomic Factors; D019966:Substance-Related Disorders / Q000150:complications / Q000188:drug therapy; D013636:Tanzania / Q000453:epidemiology