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Published in final edited form as: Soc Sci Med. 2020 Sep 20;268:113379. doi: 10.1016/j.socscimed.2020.113379

Time-Space Constraints to HIV Treatment Engagement among Women who Use Heroin in Dar es Salaam, Tanzania: A Time Geography Perspective

Haneefa T Saleem 1, Samuel Likindikoki 2, Claire Silberg 3, Jessie Mbwambo 4, Carl Latkin 5
PMCID: PMC7755686  NIHMSID: NIHMS1633710  PMID: 32979773

Abstract

Timely initiation and sustained adherence to antiretroviral therapy (ART) are essential to improving the health outcomes of people living with HIV and preventing onward HIV transmission. However, women who use heroin often face challenges to initiating and adhering to ART. In this paper we identify spatial, temporal, and social factors that affect HIV treatment engagement among women who use heroin, drawing from a time geography framework. We conducted in-depth interviews with 30 heroin-using women living with HIV in Dar es Salaam, Tanzania between January and March 2019. We found that unstable housing, high mobility, HIV-related stigma, and unpredictable daily paths due to heroin use and involvement in sex work spatially and temporally constrained women who use heroin from incorporating HIV treatment behaviors into daily routines. Some women, however, were able to overcome these time-space constraints to HIV treatment engagement through social support and social role performance. Time geography, including concepts of time-space constraints and daily paths, is a useful framework for identifying barriers to ART engagement. Structural, relational, and individual interventions aimed at eliminating time-space constraints hold the potential to improve HIV treatment engagement among particularly vulnerable and mobile populations.

Keywords: Tanzania, HIV, adherence, people who use drugs, women, gender, heroin, time geography

INTRODUCTION

Women who use drugs, specifically heroin, are disproportionately burdened by the HIV epidemic in Tanzania, with HIV prevalence over 60% among women who inject drugs by some estimates (Bowring et al., 2013) compared to 5% in the general population (“Global AIDS Response Country Progress Report,” 2014). Timely initiation and sustained adherence to ART are essential to improving health outcomes of people living with HIV and preventing onward HIV transmission. Yet women who use drugs, and people who use drugs in general, often fail to initiate antiretroviral therapy (ART) or face challenges with adherence once initiated (Wolfe et al., 2010).

People who use drugs have suboptimal engagement in HIV treatment due to a combination of individual, social, and structural factors (Feelemyer et al., 2015; Hanna et al., 2013; Heimer et al., 2017; Karch et al., 2016; T. K. Kiriazova et al., 2013; Wolfe et al., 2010). Inadequate information on ART enrollment, misperceptions about ART, side effects, and current drug use are just some individual factors that have been found to affect ART uptake and adherence among people who use drugs (Davis et al., 2018; Go et al., 2019). Lack of social support, which is common among people who use drugs due to strained relationships with family and friends and the stigma associated with drug use, is a known obstacle to HIV treatment (Chu et al., 2015; Davis et al., 2018; T. Kiriazova et al., 2017), including within the Tanzanian context (Saleem et al., 2016). At the structural level, the criminalization of drug use, siloed health care systems, poverty, and discrimination against people who use drugs contribute to poor HIV treatment engagement (Davis et al., 2018; Joseph et al., 2015; T. Kiriazova et al., 2017). And though medication-assisted treatment (MAT) and its integration with HIV care services improves HIV outcomes among people who use drugs (Low et al., 2016; Mlunde et al., 2016), MAT coverage remains low globally, including in Tanzania (Larney et al., 2017).

In Tanzania, women who use drugs may engage in sex work and other forms of transactional sex as their primary source of income. Female sex workers in sub-Saharan Africa have been found to have sub-optimal HIV engagement, influenced by stigma, discrimination, poor nutrition, food insecurity, and substance use (Lancaster et al., 2016). The syndemic of drug use, sex work, and HIV experienced by vulnerable women in Tanzania may result in unique constraints on their ability to engage in HIV treatment behaviors.

Time Geography Framework

Time geography is a useful framework for examining HIV treatment engagement among women who use drugs (Hägerstrand, 1970; Pred, 1977). Time geography, as a theoretical framework, is derived from the underlying premise that people participate in activities distributed in space and time. Emphasis is placed not only on spatial and temporal contexts, but also on social interactions. Space refers not only to the geographic and physical features of that space, but also the human interactions, social norms, and meanings attached to space (Gesler, 1992). A fundamental concept of time geography is the daily path, or life path, which represents the sequence of activities and movements of people through space and time (Hägerstrand, 1970; Pred, 1977).

As people conduct these daily activities and interactions, they are faced with various spatial and time constraints that dictate their movements and ability to perform certain behaviors (Neutens et al., 2011). Activities can be categorized along a continuum from fixed to flexible. Fixed activities define “anchor points” in one’s daily path and often must be performed at specific locations during specific times, whereas flexible activities can be conducted anywhere at any point in time. In the context of HIV management, attending HIV care appointments might be viewed as a fixed activity both spatially and temporally, since it often happens at the HIV care and treatment clinic where one is registered during specific clinic hours. Taking ART medications, on the other hand, is spatially flexible as this task can be performed anywhere, but only when one has easy access to the medications. In their study examining how people living with HIV in the United States navigate the time-space context of accessing HIV care and social services, Takahashi et al. identified three types of structure in daily paths: rigid, flexible, and chaotic (Takahashi et al., 2001). A rigid daily path is relatively stable and includes activities planned in advance in similar and regularly visited places. A flexible daily path might be centered around what are described as “temporal and spatial anchors,” where similar activities are conducted in regularly visited places, with some allowance for unplanned changes in daily schedules. A chaotic daily path, on the other hand, is characterized as little temporal or spatial control over daily schedules and extreme flexibility. The level of order along daily paths of women and men living with HIV in their study was found to be central to their ability to access services (Takahashi et al., 2001). People living with HIV who use drugs might have particularly high levels of flexibility or chaos in their daily paths.

A time geography framework allows us to identify time-space constraints that prevent certain types of activities from being performed, which might elucidate specific barriers to target for intervention. For people who use heroin, daily paths might be constrained by the need to generate income to buy drugs and to find places of escape from persecution and discrimination, as well as places of acceptance. Movement between spaces can mean shifts in one’s exposure to certain risks, protections, or access to resources. The activities of obtaining and using drugs might be perceived by a person who uses drugs as fixed activities, with their timing determined by withdrawal symptoms.

HIV Treatment Engagement in the Context of Daily Paths

There are temporal, spatial, and social dimensions to HIV treatment engagement that people living with HIV encounter along their daily paths. The geography of HIV clinics, restrictions on HIV clinic operating hours, ART dosing time schedules, and the need to take ART medications with food all configure into the management of HIV. These and other time-space constraints on people living with HIV can create both obstacles to and opportunities for HIV treatment engagement. Takahashi et al. (2001) emphasized aspects of identity in their assertion that bracketing is imposed on people living with HIV through fixed drug regimens and the geography of HIV service provision. They used the concept of bracketing to describe the segmentation of daily paths of people living with HIV into activities focused on specific social identities. For example, performing one’s identity as a person living with HIV might involve going to the HIV clinic for a regularly scheduled medical appointment and taking ART medications at the appropriate time in the right place, i.e. where ART medications are accessible. The concepts of daily paths and bracketing can be particularly useful in understanding HIV treatment engagement from accessing HIV care services and adhering to daily ART regimens to sustaining treatment.

Beyond Takahashi et al., few researchers have examined daily paths and time-space constraints in the context of HIV treatment engagement. However, there are exceptions that have incorporated concepts of time geography, including daily paths, to various degrees (Bond et al., 2018; Robles & Canoy, 2019). For example, Robles and Canoy described how ART adherence unfolds at HIV clinics, home spaces, and workspaces for men who have sex with men in the Philippines, noting that HIV-related stigma contributed to time-space constraints and affected whether, when, and where men were able to take ART medications (Robles & Canoy, 2019). Borrowing from Takahashi et al.’s taxonomy of daily routine structures, Bond et al. found that more chaotic and varied daily paths among women and men living with HIV in Zambia limited time to access ART, and that rigid daily paths could constrain or facilitate HIV management practices (Bond et al., 2018). Though these studies demonstrate the utility of examining HIV treatment from the perspective of daily paths, little attention has been paid to the daily paths of people who use drugs.

In this paper, we draw from time geography to examine spatial, temporal, and social factors along the daily paths of heroin-using women living with HIV in Dar es Salaam, Tanzania, that constrain or provide opportunities for HIV treatment engagement.

METHODS

Study Setting

This study was conducted in Dar es Salaam, the largest city and commercial center of Tanzania and one of the fastest growing urban cities in the world (Group, 2014). With an estimated population of 6.7 million people, Dar es Salaam is expected to continue to expand and will likely achieve “megacity” status—10 million residents or more—by the early 2030s (Thomas et al., 2016). Alongside this rapid urbanization, Dar es Salaam is considered a hub for drug trafficking, particularly heroin (McCurdy & Maruyama, 2013). An estimated 300,000 people use drugs in Tanzania (NACP, 2014).

Certain neighborhoods in Dar es Salaam are known for hangout spots where drugs are sold and used and/or sex is traded, referred to as “maskani” or “drug camps” (McCurdy et al., 2005). Drug camps may have groups of people, typically younger individuals, who sit around and use drugs such as marijuana and heroin. In Dar es Salaam, these drug camps are often physically located in informal, low-income residential communities in areas with abandoned or unfinished buildings, near bus stops, or along main roads, and are mainly dominated by men (Commission, 2015). Some of the surrounding buildings may have rooms where people can use drugs covertly (Commission, 2015). People who use drugs might spend various amounts of time in the camps then move to other parts of the city to find work or look for sources of money for drugs.

Data Collection Procedures

Data for this paper are from a broader study examining HIV prevention and treatment among heroin-using women in Dar es Salaam, Tanzania. We conducted in-depth interviews with 30 women who used heroin and were living with HIV in Dar es Salaam, Tanzania, between January and March 2019. As part of the broader study, a cross-sectional survey was administered to 200 women who were aged 18 years or older and reported heroin use in the past 30 days. Survey participants were recruited through respondent-driven sampling methods through recruitment “seeds,” heroin-using women identified by community outreach workers affiliated with community-based organizations offering harm reduction services to people who use drugs. Among the 56 women who reported being diagnosed with HIV in the survey, we selected 30 to participate in qualitative interviews (see Table 1 for a summary of demographic and drug use characteristics of the women living with HIV who participated in the survey from which our final sample was drawn). We purposively sampled women for the interviews based on their reported level of ART engagement, from ‘never initiated ART’ or ‘discontinued ART’ to ‘currently using ART’. Interviews were conducted by local researchers with backgrounds in medicine and sociology using a semi-structured interview guide divided into four modules: 1) life history, which focused on high points, low points, and turning points in their lives; 2) using drugs; 3) living with HIV, including HIV treatment experiences; and 4) social support systems. Each interview lasted between one and two hours and was audio-recorded with the participant’s permission.

Table 1.

Demographic and drug use characteristics of heroin-using women living with HIV from the parent study (N=56).

Characteristic % (n)
Age category
 28 years old or younger 14% (8)
 29–39 years old 59% (33)
 40 years or older 27% (15)
Educational level
 Primary school or less 88% (49)
 Secondary school or higher 12% (7)
Years spent using heroin
 Less than 5 years 46% (26)
 5 years or more 54% (30)
Daily heroin use 80% (45)
Ever injected drugs 23% (13)
History of transactional sex 93% (52)
History of incarceration 80% (45)
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Analytic Approach

We used an iterative approach to analysis. The study team held weekly meetings to discuss emergent themes, refine interview guides, and address recruitment and logistical issues in data collection. Interviews were transcribed in Swahili, translated to English, and then verified for accuracy and completion by the original interviewer. We adopted a grounded theory approach (Charmaz, 2006) to analyze transcripts. We closely read all transcripts to explore the sequence of events in participants’ lives and broader themes. Next, we conducted initial, line-by-line coding of a small sample of transcripts, which resulted in a comprehensive list of codes. We then performed a second cycle of coding to construct focused codes, which we used to develop a codebook that was applied to all transcripts using NVivo 12 (QSR International) for coding and data management. We used constant comparative methods to identify similarities and differences across participants. Themes related to spatial, temporal, and social constraints to HIV treatment engagement naturally emerged from participants’ narratives in response to a series of questions around drug use (mainly heroin use) and HIV treatment experiences. This prompted us to interpret findings through the lens of time geography, and to organize findings around key concepts of time-space constraints and daily paths.

Ethical Considerations

We obtained informed oral consent from all participants. To protect confidentiality, we use pseudonyms when presenting findings. Ethical approval was granted by the ethical review bodies at the Muhimbili University of Health and Allied Sciences, the National Institute for Medical Research in Tanzania, and the Johns Hopkins Bloomberg School of Public Health.

RESULTS

Unstable housing, high mobility, unpredictable daily paths due to drug use (specifically heroin use) and sex work, and social support emerged as key factors that influenced HIV treatment engagement of heroin-using women. The risks of HIV status disclosure, including subsequent HIV stigma and the loss of financial resources and housing due to discrimination, was an overarching theme that strongly emerged as an influencer of daily paths. Below, we describe how these factors constrained or provided opportunities for HIV treatment engagement.

The spatial constraints of unstable housing on HIV treatment engagement

Housing instability played an important role in HIV treatment engagement among participants. Participants’ experiences included sleeping outside, sleeping in communal rooms in camps, or shifting from one relative or friend’s home to another. In a few cases, episodes of unstable housing were preceded by migration from upcountry to Dar es Salaam from another region, and placed women in particularly vulnerable positions. One participant described her experience when she first moved to Dar es Salaam:

When I arrived in Dar es Salaam, there was this place where I lived. I was working for this woman [as a housemaid], but she started abusing me, so I could not stay with her for long. I decided to move in with friends. I became someone who just lived in the camps, no particular place to live. Sometimes you are just roaming around. I would sleep anywhere, even along the roads. I would meet someone who would take care of me for some time. My life has been like that since.

After losing her job, the participant formed relationships with people who used drugs, started smoking marijuana and then heroin, and continued to alternate between staying with friends and sleeping outside. Though housing instability was a common occurrence described by the women in our study, a few participants reported currently living with relatives or friends, some of whom were aware of their heroin use and HIV status and others who were not aware.

Not having a stable place to live or co-habiting with other people who were unaware of the participant’s HIV status posed time-space constraints to initiating or adhering to ART. As one participant described when asked why she had not initiated ART following her HIV diagnosis:

I don’t have permanent place to live. If do get [a place to stay], I would be sure that even if I am out, once I come back, my medications are in my room. At that point, it would be easier for me to start taking ART.

Another participant explained how housing and her inability to hide ART medications affected her decisions around HIV treatment:

“If I take [ART], is it not necessary for me to take them home? They would just find out. Where would I hide them, like where do I keep them? I don’t have a place to put them.”

Not having a place to discreetly store their ART medications in their current living arrangement was viewed by many participants as a barrier to initiating ART and adhering to ART as prescribed. Inadequate housing and stigma were often spoken of in tandem by participants. For many, the lack of privacy due to inadequate housing arrangements placed them at an increased risk of HIV status disclosure and, consequently, HIV stigma. The lack of privacy in living arrangements, such as living in drug camp surrounded by other people who use drugs, made it difficult for these participants to conceal their ART pills, which contributed to missed ART doses. Participants feared the consequences of having their status discovered, including the potential loss of social and housing support. Some participants reported hiding their ART pills to conceal their HIV status and thus avoid the social stigma and risks associated with being HIV positive. One participant said:

I stay in the camps but [I don’t have my own room]. I stay with friends. My [ART] medications are at Mama Naima’s place…I don’t want people to know that I’m infected [with HIV].

High mobility and flexible and unpredictable daily paths as time-space constraints to HIV treatment behaviors

Participants described time-space constraints along their daily paths that affected their ability to consistently take ART. Most participants described living or spending a significant amount of time in drug camps. Daily paths were anchored by buying and using drugs during the day, often in the drug camps, and earning money through sex work at night. Heroin use posed time-space constraints on participants’ ability to adhere to an ART regimen because of the significant amounts of time spent managing withdrawal symptoms. Frequent movements between sleep locations, places where participants buy and use drugs, and locations where transactional sex takes place, coupled with not knowing in advance the duration of time spent in these places, deterred some participants from initiating ART and others from adhering to their ART regimen. Even participants who did not live in a camp often described spending days in camps, which made it difficult to adhere to ART. As one woman not on ART explained:

Imagine in my current condition, I have been out of the house, you move from one camp to another, you are at Magomeni, Manzese, Kagera [neighborhoods in Dar es Salaam], and you left your [ART] pills at Mwananyamala. The whole week in the camp. Are you going to take your medicine properly? It’s difficult.

This participant recognized the instability in her life and the unpredictability of her daily path as a barrier to initiating ART treatment.

Sex work was a common income-earning activity in participants’ daily paths; nearly all women interviewed reported engaging in some form of transactional sex. Participants reported that the consequences of unintentional HIV status disclosure extended beyond their social support systems and social networks and that the risks of disclosure can have deleterious effects on income earned through sex work. When asked about challenges that heroin-using women living with HIV face in the drug camps, one participant explained: “People in the camp who know someone is infected [with HIV], no longer like you. Men no longer want you. They know you’re infected. Who is going to want you?” Similar concerns around HIV stigma by those in the camps and places where they solicit clients were echoed by participants who had never initiated or had discontinued ART.

Some participants described strategies they used to adhere to their ART regimen even with unpredictable daily paths and concerns around HIV status disclosure. For example, some reported carrying their ART pills with them when moving from place to place:

I used to walk around with my purse keeping both my ART pills and [HIV clinic] card. I was keeping my purse myself, walking with it everywhere I go. No one was aware. I didn’t want anyone to know [that I’m HIV-positive] because someone might think that you will infect them. They might stigmatize you.

A few participants also reported storing their ART medications with relatives or friends to prevent others, particularly peers in the camps, from discovering their HIV status. Storing ART medications with trusted others facilitated ART adherence, but also presented a constraint when they were unable able to travel to their relative or friend’s home at scheduled ART dosing times. One participant who reported alternating between staying at her sister’s home and sleeping in camps explained how she was often unable to make it to her sister’s home where her ART medications were stored in time for scheduled dosing:

Even now, I have not taken [ART] for three to four months. Sometimes I’m busy with my activities with peers in the streets and my [ART pills] are at home. Three, four days I’m not at home. I miss the [ART] dose, you see? I used to take my [ART pills] every night, but sometimes I’m not at home. I might not be home for a week, two weeks, even a month.

For participants like the one mentioned above, maintaining a fixed ART dosing schedule posed a time-space constraint. Participants spoke of running out of time, losing track of time, or missing designated times to take ART medications.

Conversely, for other participants, having set times to take ART medications made it easier for them to incorporate ART dosing into their daily routines. For them, ART dosing served as time-space anchors along their daily paths. Describing what makes it easy for her to take her ART medications “on time”, one participant who reported living with friends in a camp stated:

Mama Naima’s place and the camp aren’t far from each other, so my medications are at Mama Naima’s place. I know my [scheduled] time [to take my ART medication]. When a certain time approaches, I go to take them.

Drug dependence as time-space constraint to HIV treatment engagement

Participants who reported being on ART elucidated how heroin dependence affected their ability to adhere to ART. Women made tradeoffs between using heroin and buying food, using money to buy heroin instead of food. Participants reported that health care providers often communicate messages on the importance of eating nutritious food and the potential side effects one might experience if ART medications are taken on an empty stomach. Not having enough food or the right types of food, because they spent their money on heroin instead of food, were common reasons for missing ART doses. A few participants also recounted forgetting or not having time to take ART medications, especially when their focus was on the immediate physiological need to relieve withdrawal symptoms. Drug dependence is a direct temporal constraint to ART adherence.

Personally, I sometimes miss [my ART dose]. I go do my activities in the evening, maybe I doze off. When you wake up and look at the time, it’s already time to look for money. When I come back from looking for money, I might forget to take my medicine or not remember to eat and just rush to smoke the drugs.

Spending large amounts of time in the camps and soliciting clients for transactional sex was also a time-space constraint to taking ART medications as scheduled. Participants commonly reported forgetting to take ART medications when they are in spaces where they use drugs or sell sex.

Participants expressed a number of stressors and challenges that inhibited their ability to engage in HIV treatment. Managing withdrawal symptoms took precedence over taking ART medications. Furthermore, dealing with feelings of hopelessness, stigmatization, and marginalization against drug users led some participants to neglect their ART regimen:

It’s not that we don’t know [that we should take ART medications]. We know, but we neglect it seeing that the community has given up on us. They don’t care about us. They give us [HIV] medication instead of money for food. We have no place to live; we have no relatives; some are from outside regions. You think, ‘I don’t care what happens to me,’ and as a result you go to the road [to sell sex]. You’re tired, no time to rest or sleep. You only think of money all the time for drugs. You find an [HIV-positive] person sick [from not taking ART] for a long time. Like [my friend] got sick, and in only four days his health got a lot worse.

In this case, the participant’s friend died and they discovered that he had not been taking his ART medications.

In addition to drug dependence as a constraint to maintaining ART, drug use interfered with ART initiation and also led to discontinuation of ART. A few participants expressed concerns about harmful drug interactions between heroin and ART medications. The fear of mixing what they perceived to be two “strong” medications led some participants to delay initiating ART because they were not ready to stop using heroin. One participant recounted not returning to the HIV clinic after testing positive for HIV because a health provider told her that she had to stop using heroin in order to initiate ART:

After I received the [HIV test] result, they told me to come in the next day, but I didn’t go back because I was afraid. I was told to stop drugs, then they would help me to start [ART]. Others told me that I couldn’t take ART with [heroin]. I thought, maybe it’s like that. I was confused.

Another participant described initiating ART when she was pregnant and reducing her heroin use during pregnancy. However, after giving birth, she stopped taking ART medications to continue smoking heroin as she feared adverse health effects from taking both concurrently:

I felt it better to stop taking ART. I stopped ART and continued with just smoking [heroin]…I felt like I’m mixing drugs, which could make things worse, like I could die before it’s my time. Because I enjoy and feel stronger when I smoke heroin, I had no reason not to continue using [heroin], so I decided to stop ART.

The belief that heroin makes one feel strong in the context of living with HIV was echoed by other participants. Some even believed heroin could treat HIV and other diseases. This was a common misconception among women in our study, and which they attributed to widely held beliefs within their drug-using social networks. As one participant described:

There in the camps we tell ourselves, ‘Even if you have AIDS, when you smoke heroin the illness doesn’t manifest,’ so I was believing that…That is how we lie to each other in the camps.

The participant questioned the validity of the view held by those who frequent the camps about heroin being a cure-all, yet acknowledged that she used it to rationalize her decision not to initiate ART.

Overcoming time-space constraints to HIV treatment engagement through social support and social role performance

Social support emerged as a key factor that allowed participants to overcome time-space constraints to HIV treatment engagement. Participants described the range of supportive behaviors offered by friends and family, including being offered a safe place to store ART medications, having someone accompany them to HIV appointments, being reminded to take ART medications at scheduled times, and in one case, being observed by a family member while taking ART medications.

HIV care providers often work with patients to identify a treatment supporter who can help monitor HIV management and pick-up ART medications when needed. Treatment supporters can offset time constraints that emerge along the daily paths of women. This type of support is not guaranteed and depends on the willingness and availability of supportive persons to perform this role and of clinic staff to provide medications.

I have [ART] pills, but I have not gone to the clinic. I give someone my clinic card and they pick up the pills for me. But this time, they refused to give the medications and ordered that I go myself.

Additionally, supportive persons in participants’ lives provided emotional support that motivated them to take their ART medications. One participant contemplated discontinuing the use of her prescribed ART medications because of side effects, she explained:

A friend of mine said, ‘Don’t stop taking ART because you already started to use them. Starting ART and then stopping it will cause you other problems. The important thing is to go back to the hospital and tell the doctors. They will know what is going on and what to do.’

A few participants reported that their motivation to initiate and continue ART medications was rooted in a desire to manage HIV for the sake of their children, to both reduce the risk of transmitting HIV during pregnancy and breastfeeding and to be in a better position to rear their children. This motivation, rooted in their identities as mothers and the social responsibilities associated with this identity, highlights the importance of caretaking roles even while managing a drug use problem. When asked what motivates her to take ART medications every day, one participant explained:

Because I know that it’s life to me. If I don’t use it, I will get sick. When I get sick, I’ll be bedridden, right? Who would take care of my child? I have to make every effort so that my child can live. And since she is breastfeeding, I have to take my medication on time. I have to take the medicine so that she doesn’t get HIV.

Participants also described reducing heroin use while pregnant or breastfeeding to avoid adverse medical effects on their children.

DISCUSSION AND CONCLUSIONS

In this study, we found that aspects of the time-space context affect the ability of women who use drugs to adhere to an ART regimen consistently. For the majority of participants in this study, daily life paths were dictated by buying and using drugs during the day and earning money through sex work in the evening. Movements between places to sleep, buy and use drugs, and sell sex contributed to time-space constraints to HIV treatment engagement. While unstable housing and unpredictable daily paths constrained participants’ ability to incorporate HIV treatment behaviors into their daily lives, social support and newfound identities as mothers helped women overcome these temporal and spatial constraints

Housing instability and high mobility hindered ART initiation, adherence, and sustainment among the women in our study. Not having a place to discreetly store ART medications was expressed by multiple participants and led some participants to delay ART initiation or frequently miss ART doses. Inadequate and unstable housing among people who use drugs can carry particularly destabilizing effects on their daily paths and ART regimens, inhibiting privacy and medication storage (Palepu et al., 2011).

Housing instability has been cited in the literature as a critical barrier to HIV treatment engagement, from ART access and adherence to HIV viral load suppression (Aidala et al., 2016; Leaver et al., 2007). However, few studies have examined mechanisms through which housing instability affects HIV treatment and outcomes (Cornelius et al., 2017), particularly in low-income countries. Research has demonstrated that evidence-based supportive services can help people living with HIV mitigate the challenges associated with unstable housing (Hawk et al., 2019; Leaver et al., 2007; Rajabiun et al., 2018). A study conducted in several cities in the U.S. with unstably housed people living with HIV with co-occurring substance use and mental health disorders found that patient navigators provided critical support to transition participants to more stable housing and improve HIV outcomes (Rajabiun et al., 2018). Though housing assistance to improve HIV treatment engagement has been explored in high-income countries (Leaver et al., 2007), it is unclear what it might entail in places like Tanzania—though a community-led drop-in center for female sex workers in Iringa, Tanzania has been shown to improve HIV outcomes and could be a model to build on (Kerrigan et al., 2019). Given the importance of housing on peoples’ ability to store ART medications and adhere to ART, structural interventions that mitigate the effects of housing instability for people who use drugs should be further explored in this context.

Furthermore, lack of privacy and the absence of discreet places to store ART medications were often linked to fears of HIV status disclosure and the stigma associated with being found HIV positive. HIV stigma has been shown to affect ART adherence through concerns about unintentional disclosure of HIV status when accessing or consuming ART medications (Robles & Canoy, 2019; Sweeney & Vanable, 2016). Deprioritizing and avoiding HIV treatment behaviors, such as taking ART medications, was a strategy to prevent being stigmatized for living with HIV, particularly in drug camps where many women in our study reported spending large segments of time along their daily paths. HIV stigma can affect daily paths as people living with HIV avoid taking ART medications in spaces where they may encounter stigma and discrimination. The women in our study faced multiple layers of stigma. They faced discrimination from the wider community because of their heroin use and thus became reliant on their drug-using peers and fellow sex workers in the drug camps—who did not stigmatize them for their drug use—for social support and friendship. However, HIV remained highly stigmatized even within their drug-using networks. The fear of isolation and loss of support, including income from sex work, from those who accepted them despite their heroin use appeared to outweigh the stigma perpetrated by the wider community against people who use drugs. Thus, maintaining their social support network took precedence over adhering to ART, particularly when it risked accidental HIV status disclosure. Multilevel HIV stigma reduction interventions can play an important role in reducing constraints posed by enacted and anticipated stigma to support women who use drugs to effectively manage their HIV.

The immediate need of participants to stave off heroin withdrawal symptoms came at a cost to their ability to manage HIV. In her ethnographic research with pregnant women addicted to cocaine in San Francisco, Kelly Ray Knight describes how women experienced multiple temporalities that were often in opposition (Knight, 2015). Similarly, to our findings, she wrote of the conflict between “addict time,” the repetitious cycle of drug-seeking and scoring behaviors fueled by the crisis of withdrawal and cravings, and “treatment time,” time accessing and adhering to medical treatment. In our study, earning money to buy heroin, often through transactional sex, was often prioritized over buying food to take with their ART medications, attending regular HIV clinic appointments, and consistently taking ART. For the women in our study, heroin use was seen as essential to their livelihood and a physiological necessity, which posed particular temporal and spatial constraints to ART adherence in their daily lives.

Mobility patterns linked to drug use and sex work contributed to flexible and unpredictable daily paths among participants. Mobility is well established in the literature as a barrier to ART adherence (Camlin et al., 2019; Camlin & Charlebois, 2019; Davey et al., 2018; Taylor et al., 2014). A study conducted in Kenya and Uganda, demonstrated that people living with HIV tend to be more mobile than the general population (Camlin et al., 2019). In Swaziland, mobility resulting from economic and social circumstances triggered a chain of events that led to ART discontinuation among people living with HIV (Shabalala et al., 2018). Sex workers tend to have high levels of mobility in their daily paths, such as staying overnight in places other than their usual residence, which affects their ability to access HIV care and adhere to ART (Davey et al., 2018). Participants’ daily paths clashed with the demands of HIV management activities, including ART regimen schedules and attending medical appointments. Daily paths were flexible and often dictated by sex work to generate income and heroin use. Though the process through which sex work and drug use interact to affect HIV treatment engagement has not been well established, we believe that findings from this study illuminate potential mechanisms that could be examined in future research.

The structure of HIV care services and ART dosing schedules require rigid, predictable routines and strict adherence, which conflicts with the lived experiences of heroin-using women. At the health care level, more flexibility in HIV care delivery and treatment regimens for people living with HIV with high mobility will be critical to improving ART adherence and HIV outcomes (Bond et al., 2018). Efforts at the individual level to support people living with HIV, including particularly vulnerable groups such as women who use drugs, to establish consistent and regular paths could prime their memories to take ART medications and help to establish habits of taking medications. Long-acting ART, such as injectables or implants, and broadly neutralizing antibodies, i.e. the intermittent infusion of antibodies every 6 months to replace daily ART, hold the potential to alleviate the effects of mobility and instability on ART adherence and HIV viral load, and will move countries forward in improving HIV outcomes (Caskey, 2020; D’Amico & Margolis, 2020).

The role of social relations in affecting how people perceive and react to time-space constraints is an important consideration when examining HIV treatment behaviors, or any health behavior, from a time-geographic framework. Supportive social relations can mitigate the effects of mobility and flexible and unpredictable daily paths on HIV treatment engagement. In the present study, supportive persons provided safe places for participants to store ART medications, fetched ART medications from the HIV clinic, reminded participants to take ART pills or attend HIV clinic appointments, and generally provided emotional support. In these cases, social support enabled participants to overcome time-space constraints related to unstable housing and unpredictable daily paths to adhere to their ART regimen. The social responsibility of motherhood, including its caretaking role, was critical for some participants to overcome temporal and spatial constraints to HIV treatment engagement for the sake of protecting children.

Many participants in our study expressed concerns related to the harmful effects of taking ART while using heroin. There were two main beliefs conveyed: 1) heroin treats HIV or reduces the physical effects of HIV and 2) heroin and ART medications negatively interact and can be harmful to one’s health. Research on pharmacological interactions between heroin and ART is not available due to ethical and study design challenges. However, even with the absence of research on interactions between heroin and ART medications, healthcare providers should not be deterred from prescribing ART to people currently using heroin, as the effects are likely minimal and not harmful based on previous research on methadone and ART medications (Bruce et al., 2013; Clarke et al., 2001). Instead, healthcare providers should counsel their patients on how to incorporate HIV management into their daily routines and prioritize ART adherence even in the context of active drug use.

There are limitations to this study. As in most qualitative inquiries, findings presented may not be representative of all women who use drugs in Dar es Salaam. Our intention was to understand different pathways, and contextual influences along these pathways, that affect HIV treatment engagement. Our sampling approach and recruitment strategy may have resulted in a sample of women highly engaged in transactional sex; nearly all participants in our sample reported engaging in transactional sex. It is possible that we under-sampled heroin-using women who were not directly involved in the sex trade economy. Furthermore, the interview guide developed for the study did not include explicit questions on daily paths, rather these themes emerged naturally from conversations when discussing ART engagement. Therefore, there were some issues related to daily routines that could have been more comprehensively explored had it been the focus of the study. Detailed examinations of daily paths to identify time-space constraints, such as through the use of global positioning system (GPS) technologies to track daily paths (Chaix et al., 2013) or ecological momentary assessment (Cook et al., 2018), will be key areas for future inquiry. This study, nevertheless, demonstrates the utility in applying time-geography concepts of time-space constraints in the context of daily paths to examine spatial, temporal, and social barriers to ART initiation and adherence among particularly vulnerable and mobile populations.

HIGHLIGHTS.

  • Time geography can identify barriers to antiretroviral therapy (ART) engagement

  • Multiple time-space constraints hinder ART initiation, adherence, and sustainment

  • Heroin-using women in Dar es Salaam have flexible and unpredictable daily paths

  • Housing instability, high mobility and stigma constrain HIV treatment adherence

  • Support systems and mother role performance may help women overcome barriers

ACKNOWLEDGMENTS

This research was funded by a 2017 developmental grant from the Johns Hopkins University Center for AIDS Research, an NIH funded program (1P30AI094189), which is supported by the following NIH Co-Funding and Participating Institutes and Centers: NIAID, NCI, NICHD, NHLBI, NIDA, NIA, NIGMS, NIDDK, NIMHD. The preparation of this article was partly funded by a career development grant through NIDA (1K01DA047142-01A1). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

Footnotes

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ETHICS APPROVAL

Ethical approval was granted by Institutional Review Boards at the Muhimbili University of Health and Allied Sciences and the Johns Hopkins Bloomberg School of Public Health, as well as the National Research Ethics Committee at the Tanzania National Institute for Medical Research.

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