The Street of Blood and Smoke

On a narrow, dusty street in Tanzania, two women are fighting the global battle against tuberculosis and HIV. One is a nurse, the other is a drug dealer.               

In a busy coastal city, in a poor part of town, two women work side by side toward opposite goals—one selling heroin and cocaine to her neighbors, the other trying to save them from addiction.

From a distance, the drug dealer and the nurse appear to counterbalance each other. Their workplaces sit like weights on opposite ends of a dusty block in the slum.

Get a little closer and it becomes clear that they are, in a way, partners. Fatuma Chande sells drugs to local addicts. Rehema Mpili hands out the clean needles. Together, they make it cheap and easy to do drugs in this corner of the world.

Both admit that harm is being done, but they also take pride in the fact that the arrangement is helping make their neighborhood healthier by reducing the rates of HIV, tuberculosis and even drug addiction itself.

It's a highly controversial idea. Most public health officials say that delivering so-called "harm reduction" services directly to the populations that need them most will be key to controlling some of the world's deadliest diseases in the long-run. Opponents, including former President George W. Bush, say it encourages drug use in society while fueling the cycle of addiction for current users.

But the stakes are clear: About 16 million injecting drug users now live throughout the world, some 3 million with HIV. The World Health Organization reports that one out of 10 new HIV infections worldwide can be attributed to IV drug use.

In the part of the world where the drug dealer and nurse spend their days, the HIV rate among those who inject drugs is closer to 40 percent, and the tuberculosis count is much higher.

This story could easily take place in eastern Europe, central Asia or even parts of the United States. But the setting is the east African nation of Tanzania, in a city called Dar es Salaam and a neighborhood known as Keko Mwanga.

Specifically targeting drug users with this kind of information is a growing priority for the global health community. Along with sex workers, prisoners and men who have sex with men, drug users, especially those who inject drugs, represent a disproportionate share of the population living with HIV and a “high risk” group for contracting tuberculosis.

Outside of sub-Saharan Africa, 30 percent of HIV infections—that translates to about 3 million people—are attributed to injecting drug use, according to UNAIDS. In Eastern Europe and central Asia, it’s as high as 80 percent. And in several countries in sub-Saharan Africa, “a new wave of infections due to drug injecting has emerged in recent years,” the agency reports.

In reference to a 2011 speech by former Secretary of State Hillary Clinton calling for an “AIDS-free Generation,” a group of World Bank researchers bluntly wrote in a recent report that “an AIDS-free generation will not be possible unless HIV prevention, treatment, and care are taken to scale for people who inject drugs.”

Tanzania has seen a dramatic rise in drug use in the last 10 years as its major cities—especially Dar es Salaam—have become entrenched more deeply in international drug trafficking routes. Even as the HIV prevalence rate dropped to 5.1 percent for adults in the general population, studies show that the rate among people who inject drugs remains somewhere between 35 and 42 percent. Among female drug users, it’s as high as 67 percent.

The majority of these addicts say they shoot up three times per day, with 41 percent of them sharing needles in the past 30 days, according to a 2013 report published in the journal Advances in Preventive Medicine. And those taking part in one kind of risky behavior are quite likely to be dabbling in others: When asked, only 42 percent reported using condoms during sex in the last 30 days.

After an “urgent request for help” from the French aid organization Doctors of the World, Dr. Mark Stoove of Melbourne’s Burnet Institute conducted a study of Tanzania’s injecting drug addicts. His conclusion: the HIV problem among them had become so severe it threatened to spill heavily into the general population.

"All of that work going into prevention in heterosexual populations through antiretroviral therapies can potentially be watered down by the lack of attention to particularly high-risk populations like drug users," Stoove told the press in 2012.

That’s why “harm reduction” advocates like Mpili and her colleagues at Mukikute say their work is so critically important. They believe it’s unrealistic to think that all drug users will quit cold turkey and even more so that jailing them will push down illegal drug use or prevent the transmission of HIV.

Recent analysis from the Global Commission on Drug Policy found that the same countries employing the most aggressive drug war strategies—including arresting and incarcerating drug users for drug or needle possession—saw increases of more than 25 percent in new HIV infections. Why the upswing? Health experts say such practices drive drug users so far underground that they’re almost guaranteed to share and reuse dirty needles.

Meanwhile, HIV rates among New York City’s injecting drug users dropped from 54 percent to 13 percent in the 10 years after its needle exchange programs went into effect. And harm reduction strategies in Amsterdam—one of the injecting drug capitals of the world—recently achieved a reality that many believed to be impossible. "We conclude that drug users no longer play a role in the HIV epidemic in Amsterdam," researcher Bart Francis Xavier Grady announced at the International AIDS Conference in 2012.

With all the used syringes and razor blades laying around, the drug dealer is apprehensive to hazard a guess about how many people have contracted HIV in this space.