Drug Use Careers and Blood-borne Pathogen Risk Behavior in Male and Female Tanzanian Heroin Injectors Michael W. Ross,* Sheryl A. McCurdy, G. P. Kilonzo, Mark L. Williams, and M. T. Leshabari Center for Health Promotion and Prevention Research, School of Public Health, University of Texas, Houston Texas; Muhimbili Medical College, University of Dar es Salaam, Dar es Salaam, Tanzania Abstract. Injection drug use in sub-Saharan Africa is a relatively new phenomenon that expands the repertoire of human immunodeficiency virus (HIV)–associated risk behaviors in Africa. We carried out a study of 537 injection drug users (56% men and 44% women) in Dar es Salaam, Tanzania, to examine their HIV risk behaviors and their drug-using careers that had culminated in injecting heroin. Data were collected in 2005–2006 using the Swahili version of the Tanzanian AIDS Prevention Project questionnaire. Marijuana, alcohol, and heroin were the first drugs reported for both men and women. Most drug milestones appeared in a similar order for men and women. Mandrax, khat, and injecting appeared close to one another in chronological time for both men and women, suggesting they were introduced into the country and appeared on the drug scene at about the same (real) time. Drug careers for women were shorter than for men, and time from first use of heroin to first injection was shorter for women. Years of injecting suggested that injecting had increased in males approximately five years prior to data collection, with males injecting earlier, but females being increasingly introduced to injecting in the previous two years. Injecting appears at a mean of five years (men) and three years (women) into their heroin-using career. Heroin use appears to occur in binges, with women being more likely to have sex during a binge. In this sample, more than 90% of women but only 2% of men reported ever trading sex for money. More than 90% of men and women reported using new needles for injection. These data confirm that heroin injecting is well established in large cities in east Africa, and that HIV prevention in the region must now include drug injectors and other drug users. INTRODUCTION Drug use and associated risks infection with human immu- nodeficiency virus (HIV) in sub-Saharan Africa has received little attention but is a growing problem. Until recently, illicit drug use in sub-Saharan Africa was not seen as a major issue. Affinnih reported that up to 1980, marijuana use was the only drug issue in the region, but by the mid-1980s and early 1990s, sub-Saharan Africa had become a staging point for drugs in transit from Asia and the Middle East to the United States and Europe, and that some of these drugs found their way onto local markets through marijuana trade channels. 1 These drugs included heroin, Mandrax (methaqualone), Valium (di- azepam), and amphetamines. Air links between India and Pakistan were widely used by drug traffickers and Dar es Salaam, Tanzania, was a promi- nent entrance route for these staging operations to the United States and Europe. Local production of Mandrax in Zambia, khat (chewed leaves of Catha edulis, which contain the stimu- lant cathinone), and dagga (marijuana) in southern Africa also developed. 1 Drug use is now well-established and in- creasing in sub-Saharan Africa; however, little is known about the development of drug use temporally and in the drug-using careers of what is an early generation of drug users in Africa generally and east Africa specifically. Affinnih notes that by the mid-1990s, heroin and Mandrax began progressively penetrating Kenyan society. 1 Beckerleg and others conducted a rapid assessment of heroin use in Mombasa, Kenya, and reported that brown heroin had been a street drug for more than 25 years and was replaced by white injectible heroin from southeast Asia, which lead to a move toward injecting. 2 Most of the nearly 500 heroin users (95%) interviewed by Beckerleg and others were men. More than 15% of their respondents reported they had ever in- jected and 7% (which Beckerleg and others consider an un- derestimate) indicated they were current injectors. Kenya shares language, culture, and a long border with Tanzania. Drug use in urban centers paralleled the rapid population growth and spread of urbanization, and associated high unemployment. Much of this drug use occurred along the trafficking routes. Recently, Beckerleg 3 and Beckerleg and Hundt 4 have reported that injecting of drugs has emerged as a new phenomenon in coastal Kenya. McCurdy and others report that social workers in Dar es Salaam, Tanzania, estimate that there are approximately 200,000–250,000 illicit drug users in a city of approximately 3 million. 5,6 Traditionally, Kilonzo and Kaaaya 7 reported that cannabis has been used in Tanzania since the early 20th century, with mirungi (khat) being used by people who needed to stay awake, such as drivers and night watchmen. These investigators suggested that breakdown in traditional family structures was also associated with recent increases in drug use, and that these were highest among margin- alized people on the fringes of society. New trends in drug use (Mandrax, heroin, Valium) appear to target a different popu- lation. More recently, McCurdy and others carried out a qualita- tive study of 87 male and female injection heroin users in Dar es Salaam, and their data suggested that injecting was intro- duced in approximately 1998–1999 into the main market and red light district of Dar es Salaam. 5 For the two previous decades, heroin had been smoked, sniffed, or inhaled. 8 In 2000 when white (refined) heroin became more readily avail- able, its ease of use facilitated a change from smoking to injection (it is not necessary to cook white heroin before in- jecting). McCurdy and others suggested that heroin use fol- lows a regular progression pattern from smoking to sniffing or inhaling (chase) to injecting and to injecting with sedatives. 5,6 The inhaling period may last six months to two years, and * Address correspondence to Michael W. Ross, Center for Health Promotion and Prevention Research, School of Public Health, Uni- versity of Texas, PO Box 20036, Houston TX 77225. E-mail: Michael .W.Ross@uth.tmc.edu Am. J. Trop. Med. Hyg., 79(3), 2008, pp. 338–343 Copyright © 2008 by The American Society of Tropical Medicine and Hygiene 338