The majority of KII and FGD participants were male (51 male and 9 women) and represented different socioeconomic and educational levels. Those who participated in FGD or KII came from a variety of backgrounds including current and former PWID, health and social services, and peer educators/community health workers. KII participants were representative of several organizations such as drug abuse prevention services, faith-based organizations, social reintegration services, psychological and psychotherapeutic assistance, treatment organizations, and government institutions.
Sociodemographic characteristics of PWID
Participants reported that PWID were a diverse group between the ages of 15 and 60 years, the large majority of whom were male, from all income levels, and spoke various national, regional and global languages. A participant described the diversity of socioeconomic status among PWID, as follows:
I can see people who consume [drugs] that have limited financial resources, so poor. Sometimes I do not know how they can afford the drugs they consume. And also, there are people of high social level who are consuming cocaine, even injecting heroin [...]
Participants reported that although some PWID have regular jobs and can in some way afford drugs, others often have unstable economic conditions and are eventually involved in unlawful activities to support their drug use:
There are those who live from garbage bins, there are those who are street vendors, there are those who sell second hand clothes, there are street burglars, there are others who use knives to steal money, there are others who steal clothes in buildings, there are others who steal bottles, there are others who have money because of work, there are scammers, there are taxi drivers, there are the children whose papa and mama give them money [...]
Sexual Risk behaviors
There was a high level of sexual risk behaviors reported by participants, particularly low condom use among PWID often due to a preference for “carne com carne” (flesh on flesh,a term commonly used to describe sex without a condom). It was reported that drug use impaired condom use: “You need to remember that after consuming drugs, you see Jesus, so just imagine, after seeing Jesus, you don’t have time to use a condom.”
Participants also mentioned sex work as a common practice among PWID. Women who inject drugs were reported to trade sex for drugs or for money to buy drugs. As one participant mentioned, "girls end up in prostitution to support their habit because they have no easy access to money." However, sex work was not perceived to be exclusively associated with women who inject drugs.
Often, gays in their fancy cars go to the places frequented by the PWID and call one and ask if they want cigarettes. They then invite them to stroll and go to a discrete location. Here, they propose to trade sex for money. When the act takes place, these men do not pay little, they pay well [...]
Access to injection materials
Participants mentioned that although PWID had knowledge of where to access clean needles, needles were often bought through illicit means because of stigma and fear of criminalization:
And even dealers themselves purchase a certain amount of syringes and you purchase the syringe there, done. This [buying syringes from dealers] is more for people who do not want anyone to find out that, ‘wow… he’s doing these things’ (i.e.: injecting drugs).
[...] The syringes are rented for about 50 meticais (<$2 USD) in crack houses (houses where people sell or do drugs), because it is safer, instead of buying the [syringe for] 10 meticais (<$0.40 USD) in pharmacies and then hanging around and risk of police finding and arresting the person on charges of being under the influence of drugs.
In both study sites, it was also reported that health professionals often trade new and/or used syringes from health facilities: “There are syringes sold by employees of health facilities. Some employees collect used syringes that should be disposed off in the trash, and sell them.”
Needle sharing and exchange was also commonly reported:
In the crack houses, [renting of syringes] happens "without a lease," meaning that no one questions whether the syringe and needle is sterile or not.
“One thing I can be sure of, when there are no syringes, a single syringe serves for many users, they do not take care of themselves very well, so the risk is still there."
Despite knowledge of where to obtain clean needles, sharing was reported to be motivated by the immediacy of drug need, compounded by structural barriers such as transportation and pharmacy operating hours, as one participant explained:
[If] I'm in need at this time…I'm having withdrawal symptoms and I have to run up there to the pharmacy, take public transport, go to the pharmacy [that’s] closed from 12pm to 2pm, to be able to get another syringe and then go to inject myself… it's easier to take another [needle, that someone else has used] and use it, because it has an immediate effect [of getting me high].
Barriers to Access and Use of Health and Social Services
The need for health and social services for PWID was mentioned during both KII and FGD especially given that this population often suffers from problems resulting not only from drug use but also from associated risk behaviors and poor living conditions. As mentioned in a FGD: "Many of us, who are drug users, right, we have health problems, yeah, and HIV, TB…"
Participants also perceived there to be a shortage of PWID-targeted programs. Respondents often indicated that the lack of treatment options forced them to end their drug addiction abruptly (“cold turkey”,) without opioid replacement therapy to reduce withdrawal symptoms.
Some respondents felt that HIV counseling and testing services have to be more accessible in terms of location and working hours. For PWID who were aware of health services, the poor quality of these services was a barrier to health-seeking behavior:
[T]here are centers that do not treat us well. For example, there is bad food and when one goes to be hospitalized, but then sees the conditions, they can’t endure the time required to get better.
The distance between where PWID live and socialize and health care and social services was another barrier to the access and use of services. One respondent noted, "The problem is the characteristic of this group. People are closed off (isolated in certain areas) so it automatically gets complicated for them to go to an institution [providing services]."
Participants also mentioned other structural barriers, some of which were specific to the Mozambican context, where services cannot be given anonymously and an identity document must be presented to receive services: “For example, I don’t go to the hospital because I have no (identity) document.”
This structural barrier was linked to the fear of potential criminalization:
The first thought is that there is lack of trust for these people [health workers]….they want to collect information about us that can be referred to the police about where we are to later cause problems..
Finally, the participants mentioned that state-sponsored treatment services located at psychiatric hospitals was a barrier to use of such services because of the stigma associated with mental illnesses:
I said yes, I am a drug user…[and] they sent me to the psychiatric hospital and I thought, ‘the mental hospital is a hospital for crazy people and I'm not crazy.’
[T]he only hospital that provides such services is the psychiatric hospital. The psychiatric hospital deters young PWID because they have the fear of being labeled as mentally ill, crazy and somehow end up crazy.
PWID also mentioned their experience with stigma from healthcare providers or centers as a barrier to care:
So, these are the conditions we need in a health center. We got there, we are well received as anyone else, but because there are those who go there and ... you know, “this is a junkie or because he is poorly dressed” or because he appears to be half dizzy and treatment is done... but not equally [to other patients]. So these are things [equal treatment] we also need as drug addicts.
Finally, the lack of one-stop services was mentioned as a barrier where PWID had to ask “several times for support” at a centralized location. One key informant described the long referral process and the resulting gap in linkage to services:
Facilitators of Access and Use of Health and Social Services
Despite most participants being dissatisfied with the quality of services received, some described a positive experience with the health system. One of them reported, “in my case for example, I had treatment for about six months or something when I contracted tuberculosis, years ago, and we were well attended”.
One participant noted that a staff member from a treatment organization explained the purpose of treatment in order to address the stigma associated with the use of psychiatric services:
[I]t required a deep conversation for him (the staff member from a treatment organization) to explain that no, the hospital is not for crazy people but that (drug use) is a type of mental illness. So eventually, I accepted and went there.
Participants mentioned the existence of different institutions and organizations where they could obtain physical and mental health support, which included disease and drug abuse prevention, peer educators, counseling and public informational meetings; voluntary HIV counseling and testing at health facilities; psychosocial support including psychological and psychotherapeutic assistance for detox; social reintegration through the development of professional skills and competencies, and social re-integration programs (Table 2).
A key informant, who worked as a service provider, described a comprehensive list of services offered by a local institution:
This institution [is a] rehab center based on a spiritual care program, and also some other extra activities such as occupational therapy and vocational training which are included in various activities such as car repair/mechanic activities, [for] example. You know, therapy for a process of transformation and also capacity building so people can be self-sustainable.