Mozambique has around 28 million inhabitants, of which 68% live in rural areas and 60% along the 2.700 km coastline. Poverty in the country is very high, with up to 46.1% of the population living below the national poverty line in 2014/15. By 2016, only 24% of the population had access to electricity and less than half had completed primary studies.  Livelihoods in Mozambique depend to a large extent on natural resources, such as rain-fed agriculture and fishing. At the same time, the country ranks 10th in the most vulnerable to natural disaster risks such as floods and droughts. With climate change and the expected increasing frequency of natural disasters, national development may suffer serious constraints. Trade is also an important economic source in the country, via three strategic seaports in the cities of Nacala (north), Beira (centre) and Maputo (south), as well as regional transport corridors.

The same relative facility for trade, coupled with population’s poverty and low capacity of law enforcement at the coastline possibly facilitates the involvement of Mozambique in the illicit drug market. Mozambique is known as a transit country, above all, from heroin coming from the middle-east in direction to the European market. Produced in Afghanistan, heroin passes through Pakistan and is brought by sea to East Africa, particularly via the coastline in Northern Mozambique. From there, it goes by road to South Africa, to be sent to Europe. This route has remained unchanged for 25 years. It is estimated that every year between 10 and 40 tons of heroin are moved through Mozambique, with an export value of 20 million US$ per ton. It is estimated that at least US$ 2 million per ton remains in Mozambique, in the form of profits, bribes and payments to senior Mozambican figures. Heroin is estimated to be  the second largest exported product in Mozambique, just after coal.

Mozambican regulations criminalize the use and possession of drugs, which challenges people who use drugs and harm reduction programs. There is, nonetheless, an increasing trend towards a public health and human rights perspective to tackle drug use, including the creation of new policies and plans for policy reform. 

The National Drug Policy in Mozambique dates from 1997, and it establishes specific penalties for drug consumption. The so-called “consumer trafficker” can get 1 to 2 years of prison plus a fine of up to 10 million meticais for illicit drugs, and up to 1 year prison  plus up to 5 million meticais fine for prescribed medicines (articles 33, 35, 36).  Consumers can get  up to 1 year prison  plus fine, but those considered to be ocasional consumers or committing to engage into drug treatment can be exempted (article 55). Habitual consumers can be obliged to undergo medical examination (testing) and voluntary treatment (article 58). The law also allows for the application of compulsory treatment when people get a prison sentence beyond 2 years (article 75).  Mozambican National Drug Policy has a specific article (44) dedicated to “abandoning drug use paraphernalia in a public place”, punishable with a 1-2 years prison in addition to a corresponding fine. According to key informants, law enforcement does arrest people for syringe possession, which may contribute to people discarding syringes instead of collecting them. “Inciting drug use” is punishable with 2-8 years prison and 10-40 million meticais fine (article 43). Syringe distribution and other harm reduction activities may be understood as incitement, endangering the activities of outreach workers.  According to key informants, the National Drugs Cabinet was willing to decriminalise drugs in 2018. Civil Society Organisations were able to comment on a draft between 2018-19, as there was an ante project circulating. Nevertheless, no changes or official proposals occurred until now.

In 2003, the Policy and Strategy of Drug Prevention and Combat was approved.  It described that the major drug-related problems  to be tackled were school dropouts by youth, domestic and community violence, increased car accidents, and increased transmission of HIV, STIs, TB and HCV. The policy explicitly mentions harm reduction as a strategic option to protect people who use drugs from blood-borne diseases and TB (p.158). In 2019, the Central Office of Drug Prevention and Combat published a statement mentioning the need to revise the old drug policy. According to the statement, the revised law should include better coordination of trafficking fight efforts, recognition of the human dignity of people who use drugs, decriminalization of drug use, and access to treatment and harm reduction (p. 3).  Within this context, the WHO hired a consultant to make a National Harm Reduction Plan for Mozambique. According to key informants, the "medical" part of the plan has been approved, reflecting the strategies advised by the WHO comprehensive package for Harm Reduction. The community part is still in draft form, and waiting for approval by the Health Ministry and the Central Office of Drug Prevention and Combat.  

Furthermore, people who inject drugs are among the Key Populations mentioned at the  National Strategic Plan to combat HIV/Aids (2020-2024), together with Men who have Sex with Men (MSM), Female Sex Workers (FSW) and people in prisons. The previous plan (2015-2019) included people who inject drugs for the first time. The population is referred to as having much higher HIV and Aids prevalence than other (key) populations, being key to the maintenance of the HIV epidemic in the country. 

The first and last IBBS conducted in Mozambique was published in 2015, and is still the main source of information for drug use in the country. The data, collected between 2011-14, gathered information on HIV prevalence, risk behaviors, access to and use of health services in people who inject drugs, FSW, and MSM. The IBBS was coordinated by the Mozambican Ministry of Health (MoH), through the National Institute of Health (Instituto Nacional de Saúde - INS), with technical, implementation and financial support from CDC via PEPFAR. 

The 2015 IBBS focused on the cities of Maputo and Nampula, and estimated the population of people who inject drugs at 2.200. The most commonly injected drug at the time was heroin in both cities (82.2% of the people injecting drugs in Maputo and 73.3% in Nampula/Nacala). Cocaine came in second, with much lower rates (17% in Maputo and 14% Nampula/Ncala). The IBBS also demonstrated high risk injecting behaviours.  Close to half (50.3% in Maputo and 42.4% in Nampula/Nacala) of people who inject drugs had ever shared a needle or syringe. Users would rather rent, share or borrow injection equipment at shooting galleries than purchase them due to stigma, fear of criminalization, transportation and purchase costs, restricted pharmacy hours, personal preference for needle sharing, and immediacy of drug need. Not surprisingly, the HIV prevalence among people who inject drugs in Mozambique was found to be high: 50% in Maputo and 20% in Nampula/Nacala. A good portion of the population (31% in Maputo and 41% in Nampula/Nacala) had never tested for HIV. Prevalence for HCV was also high at the time: around 45% in Maputo and 7% in Nampula/Nacala, while for Hepatitis B, prevalence was slightly above 30% in both cities. Despite the needs, people who inject drugs had very poor access to health and social services. Challenges included limited availability of programs targeted to the population, distance, lack of knowledge of the few programs that exist, and concerns about the quality of care provided by health providers.

By mid 2022, anecdotal evidence refers to heroin as the main injected drug in the country. Heroin is also often smoked on foil or with cannabis, and an increasing use of smoked crack cocaine was mentioned by key informants, especially among young populations. The use of crack cocaine had already been documented in 2018/19 by MSF, who then run the harm reduction project in Maputo. According to key informants, programatic data from that time revealed that virtually all service beneficiaries used heroin and around half also used crack cocaine.  Indicators on availability of and access to testing and treatment for HIV among people who inject (or use) drugs are not yet available. Hepatitis C treatment is available on a very limited basis via MSF activities in Maputo (only). Indicators regarding Tuberculosis are also missing for this population. 

According to key informants, another IBBS is currently being coordinated by the INS. The initiative is very welcomed since the previous IBBS can be considered very outdated due to several changes in the drug scene. The new IBBS will have a bigger scale in terms of number of cities and components being measured when compared to the first one. 

People who inject drugs have had access to HCV treatment since 2016 via a clinic from Medecins Sans Frontieres (MSF) in the capital Maputo. In 2017, negotiations between MSF and the Mozambican government started to set a harm reduction pilot program in Maputo. MSF intensely advocated to convince the relevant health and law enforcement authorities of the gains to public health, raising awareness among the police, national and local health authorities, AIDS and civil society organisations, and the community in the area. With the government authorization, a Drop in Centre and  outreach work started in Maputo’s Mafalala slum in May 2018. Later that year, the Minister of Health also authorised the start of a Needle and Syringe Program (NSP). The centre was established as a first entry point to healthcare services, with the aim to help fight the HIV/TB epidemic and control hepatitis C transmission in Maputo. The Mafalala pilot, as it is known, also provides access to hygiene services (laundry, shower), STI testing and treatment, HIV, HBV, HCV and TB testing, linkage to care, and adherence support, distribution of condoms and lubrication, social work support, family reintegration and basic nursing care. Since 2020 the pilot also counts with an Opiate Agonist Treatment (OAT) and with the distribution of Naloxone. MSF implemented the pilot together with UNIDOS, the National Harm Reduction Network.

From May 2018 through November 2019, a total of 1818 clients registered for services at the first visit to Mafalala DIC.By looking retroactively at the screening data collected, a study found that 92.6% of the clients were male, and the majority (85.1%) were non-injecting drug users. Most visitors consumed heroin (93.8%), which most common mode of administration was smoking (49.5%), followed by snorting (35.5%), and injection (15.3%). Prevalence of HIV (43.9%), HCV (22.6%) and HBV (5.9%) was significantly higher among PWID when compared to non-injectors. Half of the 380 people who use drugs living with HIV who were screened at the DIC, were enrolled in HIV care via the facility. Lack of peers to accompany users to appointments at HIV clinics, together with the large number of patients in these clinics were pointed as challenges to achieve a higher linkage to care. Both this study, published in 2021, and previous evaluations from MSF showed the need to expand the program in the city of Maputo, as well as to other regions in the country.  

The continuation and extension of the pilot has been agreed upon, and is planned to three other provinces between 2021-2024 (Maputo city, Maputo province, Beira and Nampula), via Global Fund (GF) support. Total GF funding is set to 4.5 million US dollars. Approximately 3 million will go to the principal recipient FDC and almost 2 million to the Mozambican Ministry of Health to procure paraphernalia (syringes), methadone, HCV rapid tests and reagents, HIV tests, condoms, lubricants, and sensitisation with law enforcement to be done by the National Aids Commission. In October 2021, MSF handed over the activities at community level (DIC and outreach) to UNIDOS as sub-recipient of the Global Fund grant and the OAT clinic in January 2022 to Maputo City’s Ministry of Health.

Despite the growth, harm reduction still finds challenges to get established in Mozambique. In March 2021 the local government banned syringe distribution in the community, motivated by complaints about syringes being left in public spaces. According to key informants, affected communities denounced the case to municipal authorities which decided, in a multi sectoral meeting, to stop the NSP until a new order. After negotiations to reopen the NSP, including a clear plan describing the criteria for syringe distribution and recollection, the distribution was re-authorised in mid-2022. Nevertheless, by the end of June 2022, syringes were not yet available due to delays in purchase. Other harm reduction services such as OAT were not affected by the NSP ban, but are still far from enough to cater for the demand. Key informants affirmed that OAT has currently a waiting list of about 1000 people in Maputo only. There are also doubts about to what extent there is an understanding of harm reduction principles regarding OAT, as stakeholders might perceive it as “not producing changes” when participants are still smoking crack but no longer injecting heroin, for instance. HCV care is currently done in a very small scale. The plan is to increase the offer of testing and treatment of HCV, along with an expansion of methadone. Resources for both will come from Mozambique's Ministry of Health as counterpart to the GF grant. Primary health care centres to run these interventions were already identified in Maputo and Beira, but current challenges are the purchase and delivery of methadone to the centres and to build the capacity of staff to deliver OAT. 

The restrictions related to the COVID pandemic have also affected some of the interventions in the DIC. To reduce the number of people in the DIC, food started being provided only to those people coming for TB Daily Observed Therapy or nursing services, as new clients felt more comfortable to approach when there was no crowds in the DIC. As these changes are still in place, some beneficiaries previously accessing food provision no longer have this benefit.

There are two networks identifying themselves as networks of people who use drugs in Mozambique: MozPUD and REAJUD. REAJUD was formed in 2018. The organisation is connected to INPUD, SANPUD, EuroNPUD, and AfricaNPUD. REAJUD members have been previously hired to work on research related to people who use drugs in Mozambique. They worked on mapping main drug scenes, the population of people who use drugs and their drug using habits. They are, however, not involved in implementing the harm reduction program. 

MozPUD is the Mozambican Network of People who Use Drug. The network was created in 2019 and has its headquarters in Maputo. The organisation advocates for the human rights and well-being of people who use drugs and has as mission to maintain this population alive and protected from harms. Among their objectives is the promotion of harm reduction, health access, and legal assistance to people who use drugs, and contributing to the improvement of quality of services. The network works with referral and awareness regarding to HIV, HCV, TB, STIs for the community, besides distribution of condoms, education on COVID and safer injection, and referral to basic health care and SRHR services. The network has, among others, made an intervention in the CND thematic intersession in October 2020 highlighting the need for more health care access to people who use drugs in Mozambique, and expansion of harm reduction in the country, outside Maputo. 

MozPUD is currently a grantee for the Love Alliance, with a two-year grant that will focus on advocacy activities in Maputo. The network mentions to have still several challenges to assure the voices of people who use drugs are heard in Mozambique. These include stigma and discrimination and criminalisation of drug use, lack of funding to dedicate more time to the network, as well as to have proper headquarters for the work, lack of funding for harm reduction projects, difficulty to officially register the organisation, lack of education in human rights, and lack of experience exchange with other countries, specially Portuguese speaking countries such as Portugal and Brazil, where harm reduction is more advanced.

In the new extended pilot, Global Fund will give grants to both networks to do technical advisory roles in the implementation of projects. According to GF the organisations will act in different areas, with MozPud supporting implementation in Maputo and REAJUD in the other provinces. 

UNIDOS, the National Harm Reduction Network, works closely with MozPUD. They are also a Love Alliance grantee, with a two-year grant that will focus on strengthen the contacts among key population using drugs – sex workers, transgenders, MSM, people in prison settings, and people who use drugs in general. They also plan to use the grant to advocate for policy reform, since the current drug policy does not reflect the national strategic plan for harm reduction. UNIDOS sees this as a favourable moment to discuss harm reduction and policy reform in Mozambique. A challenge, nevertheless, is the lack of common understanding of harm reduction among the different stakeholders. This requires good communication and dissemination of harm reduction nationally. UNIDOS is also involved in running the harm reduction program in Mozambique, via a GF grant.  

Regarding civil society involvement in general, Civil Society Organisations have previously voiced their concerns that the government (NAC and the Ministry of Health) do not enable meaningful participation from their representatives in planning and decision-making regarding HIV prevention, and that their engagement is tokenistic. They reported that government institutions have sometimes involved CSOs at the end of a process to legitimise it, rather than involving them in the decision-making itself.

According to Human Rights Watch, the human rights situation in Mozambique deteriorated in 2020 largely as a result of the ongoing conflict in the north of the country. An Islamist armed group has continuously attacked villages, killing civilians, kidnapping women and children, and burning and destroying properties. State security forces were implicated in serious human rights violations during counterterrorism operations, including arbitrary arrests, abductions, torture, use of excessive force against unarmed civilians, intimidation, and extrajudicial executions. The conflicts left least 732,000 people displaced as of April 2021, forcing the authorities to set up camps for internally displaced people across the province. About 1 million people are in critical need due to food insecurity. A report from UNODP published in 2020 analysed the perception of Mozambican citizens about human rights. The top 3 rights perceived as the most disrespected in the country were: the right of freedom, the right of freedom of (political) expression and in third place the right of life.

More specifically regarding people who use drugs, the National Drug Policy in place establishes the possibility of both enforced drug testing as treatment in certain cases. Habitual consumers can be obliged to undergo medical examination (testing) and voluntary treatment (article 58). For those getting a prison sentence beyond two years, compulsory treatment can also be applied (article 75). According to key informants, there are also unlawful arrests, with police arresting people for carrying syringes and arrests based on profiling. These are considered structural barriers to the rights of people who use drugs. Access to health for people who use drugs is also constrained. The IBBS from 2014 showed that despite the needs, people who inject drugs had very poor access to health and social services. Challenges included limited availability of programs targeted to the population, distance, lack of knowledge of the few programs that exist, and concerns about the quality of care provided by health providers. Such conditions, unfortunately, still linger.

Prison population in Mozambique has grown exponentially since 2005, without the development and improvement of the physical and structural conditions of the country's Penitentiary Establishments. Overcrowding is a serious problem. Data from 2020 shows that occupancy level (based on official capacity) is at 232,8%. The prison population made up of 18378 inmates, compared to the normal capacity of 8,498 inmates. Taking into account the total population of Mozambique, there are 57 prisoners for every 100,000 inhabitants. 93% of the prison population is male, mostly young. Besides overcrowding, other problems in the Mozambican prison system which stand out are lack of adequate infrastructure to house detainees, pre-trial detention periods largely expired, poor hygiene and medical care, the inclusion of minor prisoners in adult facilities, the sharing of cells between convicted and awaiting trial prisoners, and inadequate nutrition.

One evaluation study of the health care of inmates in Mozambique was found, for the Provincial Penitentiary of Maputo. The case study, published in 2020, found that the Maputo penitentiary has a precarious structure, lack of supplies and insufficient professionals for health care. No laboratory, blood collection room or material sterilisation room are available. In addition, there is no running water. In the clinical treatment room there is not enough material to make wound dressings. The favourable conditions for the transmission of HIV are accentuated due to material shortages. Moreover, the service at the health care post is done without any privacy. Consultations are always accompanied by the "head of health", inmates trained as peer educators to support the activities of the medical post. If on one hand this generates the empowerment of the peers in prison, on the other it was evaluated that their presence inhibits inmates to expose their real problems. Moreover, it can also hinder access to health care for inmates who cannot afford to pay the peers for access. 

Prisoner health care in Mozambique is not the subject of debate and is not included in the policies of the National Health Service, which results in inadequate and insufficient care. Recognising the problems the attorney General of the Republic (PGR) referred, in a declaration in April 2021, to the need for "structural reforms" to ensure respect for the rights of prisoners. No specific information on people who use drugs and their access to health care in prison was found.

Data on women who use drugs in Mozambique is virtually non-existent. The only IBBS (from 2014) used respondent driven sampling methodology, and its sample ended up with 94% of males who inject drugs. No disaggregated analysis was made. Women are also underrepresented in the only harm reduction program in the country, where around 93% of the visitors are male. No female friendly or female only harm reduction activities are currently offered.  According to MozPUD, women who use drugs in Mozambique are extremely vulnerable, and lack access to health, legal support, and above all SRHR services. 

The available data on women in general shows a grim reality for Mozambican females. According to UNAIDS, only about half of the women aged 15-49 have their demand for family planning satisfied by modern methods. Prevalence of recent intimate partner violence among women aged 15-49 in the general population amounts to over 15%. Women also suffer from gender based violence in all its forms. As an example, in the current conflict in the north of the country, there has been reports of community leaders and some aid workers sexually abusing displaced women in Cabo Delgado in exchange for humanitarian aid (such as food or refugee shelter).

Women living with HIV suffer from high levels of stigma and discrimination in the communities and families they come from. A study made in Maputo found that, in dealing with stigma, women try to keep their diagnosis confidential, many times also from close family members. The strong gender inequality in Mozambique means that women are often blamed for HIV infection. The prevailing double morality allows men to be unfaithful and have several lovers without these behaviours generating masculine social depreciation. Women, on the other hand, can be unfairly accused of betraying their husbands, of leading a promiscuous life and even of prostitution.They can be abandoned by their husbands due to an HIV positive status, and lose all economic support for themselves and children. Stigma renders women more vulnerable to HIV and challenges their adherence to testing and treatment. Current policies and services do not sufficiently address women's empowerment or the reduction of HIV/AIDS-related stigma.

Information on women engaging in transactional sex in Mozambique is also scare. The only study found looked into prevalence of and factors associated with physical and sexual violence against female sex workers. From the 1,250 participants in the cities of Maputo, Beira and Nampula, prevalence of physical or sexual violence (defined as being hit or battered or raped or forced to have sex within the last 6 months) ranged from 10.0% to 25.6%. Strangers and acquaintances were the most frequent perpetrators of sexual violence, and often did not use a condom. Most of the women who experienced sexual violence did not seek medical care (66%) or police assistance (87%). Although sex work is legal in the country, acts defined as contrary to decency and public morals are not, leaving sex workers vulnerable to harassment and prosecution.

Key populations such as men who have sex with men (MSM), female sex workers (FSW) and their clients, people who inject drugs (PWID) are population groups disproportionally infected with HIV relative to their size. Early modelling exercises have estimated that KP and their partners account for about one third of all new infections in Mozambique. Based on the last IBBS research, a study mapped the engagement of these three key populations in HIV testing, care and treatment services. All key populations fell below the 90% target for the global Fast Track Targets for knowledge of HIV status, as well as treatment enrolment. This was most stark among MSM where only 8.8% had knowledge of their HIV status prior to the survey. Of the MSM, FSW and PWID participants who were aware of their status, only 40.0, 52.6, and 47.2%, respectively reported being on treatment at the time of the survey. 

Most MSM (80%) and FSW (72%) in Mozambique are young and under 24 years of age; for people who inject drugs, the rate is around 18%. Nonetheless, young people are not being explicitly included in the new Mozambican Harm Reduction Plan, nor are there “youth-friendly” or youth focused interventions targeting this important sub-group. The media, as well as the government, portrait the use of alcohol and other drugs among young people in Mozambique as a very serious problem. School education around drugs when existing, in general is related to encouraging saying no to drugs. A partnership with the Ministry of Education and Human Development of Mozambique (MINEDH) and the British Consulate in Mozambique, runs a program called “smashed” (quebrados),  which aims to inform about the risks of alcohol consumption among adolescents from 12 to 13 years old. Alcohol consumption is seen as very worrying and compromising pedagogical attempts in schools. Religious youth groups also run campaigns for youth to “learn to say no”, warning young people about the negative aspects of choosing drugs, sex, and violence.

Based on data gathered via desk research and key informants, and on the validation meeting with Love Alliance grantees and other key stakeholders from Mozambique, we propose the following recommendations:

Advocacy & policy reform

• Advocate for decriminalisation of drug use and possession for personal use, also removing penalties for “inciting drug use” and “abandoning paraphernalia”  

• Follow up on the National Drug use prevention and Harm Reduction Plan and hold the government accountable for its implementation

• Advocate for the authorisation and support to harm reduction activities (e.g., purchase and distribution of syringes) to be sustainable and officialised in documents

• Create a platform for interaction and information sharing between key population organisations (Key Population Network)

Awareness raising

• Support awareness-raising/capacity building among health care providers of harm reduction and OAT

• Support awareness raising/capacity building on harm reduction and human rights for people who use drugs among policymakers and policy implementers engaged in the drug field    

Community-based research and assessments

• Complement the new IBBS with community-based studies tackling specific topics and sub-groups of PWUD (e.g., needs assessments for women who use drugs, female sex workers and people who use crack cocaine, access to HCV testing and treatment, different settings of drug use besides the street scene, substances used in different settings, etc.)

• Support a size estimation study on the population who use drugs, with attention to different subgroups of users, so that SCOs and policy makers can make better informed choices for programming and activities

Harm Reduction services

• Develop gender sensitive services and interventions to guarantee access to women who use and inject drugs, including other key populations (transgender women and sex workers). The city of Beira could be a choice to pilot a women-specific service, given the large female population (anecdotal data) injecting heroin and engaging in sex work

• Incorporate SRHR into harm reduction programming (specially for women)   

• Develop harm reduction interventions for youth, and/or help new programs to be youth-friendly

• Develop harm reduction interventions for people who use stimulants and NPS

• Integrate harm reduction interventions in the humanitarian context, especially considering refugees in the north of the country (Cabo Delgado)

• Improve the involvement of people who use drugs in the planning, monitoring, and evaluation of services (not only delivery)

Capacity building (or learning needs)

• Build the capacity and financially empower CSOs and networks led by people who use drugs (organisational capacity + advocacy and representation)

• Support capacity building an exchange in harm reduction among countries of Portuguese expression (e.g., Portugal and Brazil) 

• Support shared learning and capacity building across services assisting different key populations (e.g., sex workers, LGBTQI, MSM, etc.)