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A theme issue “by, for, and about” Africa

BMJ 2005; 330 doi: http://dx.doi.org/10.1136/bmj.330.7493.684 (Published 24 March 2005) Cite this as: BMJ 2005;330:684

‘Flashblood’ and HIV risk among IDUs in Dar es Salaam, Tanzania

During 2005, female sex workers who are heroin injectors in Dar es
Salaam, Tanzania created a new needle sharing practice they call
'flashblood'. Flashblood is the English term Swahili speakers use to
describe drawing blood back in a syringe until the barrel is full, and
then passing the syringe to a female companion who injects the blood. By
injecting the syringe, about 4 cc’s of blood, women believe that they can
avert symptoms associated with heroin withdrawal because the first
injector’s blood is thought to have ‘some heroin in it.’ Female sex
workers began the flashblood practice amongst themselves in the last
couple of months in an altruistic attempt to help their impoverished and
more desperate associates. Male injectors interviewed are still unaware
of this practice. These data are based on ongoing in-depth interviews
with 63 heroin injectors.

The rationale for flashblood may be the price and quality of heroin
in Dar es Salaam. During 2003, one kete of high quality, mostly pure
white heroin cost US$0.50. One kete was all many injectors needed to get
high. Now the price of heroin has increased to US$1 per kete, and the
heroin is reportedly adulterated. By the summer of 2005, most injectors
claimed they need two kete to get high.

Most female heroin users in Dar es Salaam trade sex for money to
support their habits. Women most affected by the increase in cost and
decline in quality of heroin are those who are in poor health as the
result of chronic heroin abuse. Because of their appearance and obvious
poor health, these women are unable to attract enough clients to support
their habits. Other female injectors still able to attract customers for
sex have begun accommodating women in more desperate circumstances by
providing them with flashblood.

Female sex workers in Dar es Salaam prefer to use condoms with their
clients, but when desperate for money or drugs will agree to forgo the
condom at the clients’ request. Many Tanzanian men prefer not to use
condoms and routinely ask female sex workers not to use them. Female
heroin injectors who are desperate, like the women who accept
‘flashblood’, are the most likely to agree to forgo condoms. In their
sexual relationships with intimate partners most women and men do not use
condoms.

Research on the relationship between drug injection and HIV
transmission has long focused on the serial use of syringes/needles,
practices such as "backloading”, and reuse of paraphernalia used to
prepared drugs prior to injecting (Johnson and Williams 1992, Needle et
al., 1999; Zhou et al., 1994). The practice of flashblood is a new
phenomenon that is, in a sense, a dangerous exaggeration of the practice
of needle sharing which magnifies HIV transmission risk beyond
backloading. Rather than injecting a very small quantity of blood
residue, women who practice flashblood inject several cc’s of blood. If
the first injector is HIV or HCV infected, the amount of virus directly
transmitted into the bloodstream by the second injector could be quite
large.

The only apparent reason for the emergence of flashblood in Dar es
Salaam is the idea that blood drawn immediately back into the syringe
after injecting contains enough heroin to help a second injector escape
the pains of withdrawal. To our knowledge this is a myth, as there is not
enough heroin in a syringe of flashblood to do anything other than provide
a placebo effect. Myths and rumours, however, are powerful motivators and
explanatory devices. During the 1920s in East, Central, and Southern
Africa, mumiani rumours circulated about European vampires who used human
blood for medical purposes. Tranfusion technology and the concept of
blood donation emerged in Africa at the same time that an intensification
of colonial efforts at domination were exerted post World War I. At that
time, some Africans believed that Europeans drained the blood of Africans to
provide it to anaemic Europeans (White, 2000). Some older East Africans
still believe that British colonial use of mumiani explains why there was
enough blood in blood banks prior to independence, but a lack of supply
now (White 2000, McCurdy field notes, 1993). Perhaps traces of these
rumours are the source of flashblood.

Injection drug use has now reached almost all developing nations in
the world (Aceijas et al., 2004; McCoy and Rodriquez, 2005). The practice
has emerged in East Africa in the last 5 to 6 years, and it is spreading
rapidly throughout the region (Beckerleg, 2004, Beckerleg and Hundt 2004,
McCurdy et al. 2005). If the practice of ‘flashblood’ spreads from Dar es
Salaam to other cities in East Africa, its impact on the rate of HIV and
HCV transmission could be substantial. The emergence of the practice of
flashblood promises only to intensify the AIDS epidemic. Injection drug
use in developing countries, and local cultural variations that may
exacerbate HIV transmission risk, must be recognised by national
governments and international organisations. Further research is
desperately needed to develop culturally appropriate HIV/HCV risk
reduction interventions and drug treatments programmes.

REFERENCES

Aceijas C, Stimson GV, Hickman M, Rhodes T. (2004). United Nations
Reference Group of HIV/AIDS Prevention and Care among IDU in Developing
and Transitional Countries. Global view of injecting drug use and HIV
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Beckerleg, S. (2004). How 'Cool' is heroin injection at the Kenya
coast. Drugs: Education, Prevention & Policy (11)1, 67-78.

Beckerleg, S., Hundt, G. L. (2004). The characteristics and recent
growth of heroin injecting in a Kenyan coastal town. Addiction Research
& Theory (12)1, 41-54.

Johnson J, Williams, M. (1992). Nuance of needle sharing among
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McCoy, C.B., Rodriguez, F. (2005). Global overview of injecting drug
use and HIV infection. www.thelancet.com 365, 1008-1009.

McCurdy, S.A., Williams, M.L., Kilonzo, G.P., Ross, M.W., Leshabari,
M.T. (2005). The emerging heroin epidemic in Dar es Salaam, Tanzania:
Youth hangouts, maghetto and injecting practices. AIDS Care 17 (Supplement
1): S65-76.

Needle, R.H., Coyle, S., Cesari, H.., Trotter, R., Clatts, M.,
Koester, S., Price, L., McLellan, E., Finlinson, A, Bluthenthal, R.N.,
Pierce, T., Johnson, J., Jones, T.S., Williams, M. (1998). HIV risk
behaviors associated with the injection process: multiperson use of drug
injection equipment and paraphernalia in injection drug user networks.
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White, Luise. (2000). Speaking with vampires: Rumor and history in
colonial Africa. Berkeley: University of California Press.

Zhuo Z, Williams, M., Bell, D. (1994). An evaluation of drug
injection behaviors and HIV infection. National AIDS Research Consortium.
International Journal of Addiction 29(12), 1499-518.

Competing interests:
None declared

Competing interests: No competing interests
25 August 2005
Sheryl A. McCurdy
Assistant Professor
Mark. L. Williams, Michael W. Ross, Gad P. Kilonzo, and M.T. Leshabari
University of Texas Houston Health Science Center, SPH, 7000 Fannin, #2520, Houston, TX 77030
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