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

25 August 2005

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 infection among injecting drug users. AIDS 18: 2295–303.

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 intravenous drug users in Houston. Southern Medical Journal 85(7), pp. 784 -5.

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. Substance Use and Misuse 33(12), 2403-23.

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: None declared

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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