Informal assessment of drug use and NGO-based services

Informal assessment of drug use and NGO-based services in Kenya and Tanzania Joanne Csete, Ph. D, MPH Dept. of Population and Family Health

Informal assessment • Objective: identify grantmaking opportunities to strengthen NGO services for people who use drugs in Kenya and Tanzania (including Zanzibar) • In 3 weeks (July 2008) spoke with 110 people who use illicit drugs (mostly heroin), as well as many health professionals (including in PEPFAR-supported work), high-level HIV and drug control policy-makers, local authorities, NGO service providers; briefed by ICAP on Zanzibar work • Visited several NGO-run “rehab” facilities

Illicit drug situation: Previous research • Estimated 130, 000 [30, 000 -230, 000] people who inject illicit drugs in Kenya alone (Mathers et al. , Lancet 372(9651): 1733 ff. , 2008) • Kenya an important transit point for heroin – functioning ports with lax regulatory regime • Local consumption: late 1990 s “brown” heroin largely displaced by white heroin suitable for injection • Heroin injection in context of generalized HIV • Law allows for very long prison sentences for possession of very small amounts of illicit drugs; state may “take all such measures as it deems necessary or expedient” to control illicit drugs.

Previous study of drug treatment, Kenya • Clearly inadequate services for treatment of drug dependency to meet the need • One free government service, 15 beds, others NGO -run and unaffordable for most people • Symptomatic treatment, sometimes with 12 -step; virtually no doctors, and no one trained in addiction medicine; high relapse rates • No opiate maintenance therapy • Inadequate link to HIV testing and treatment • Conclusion: failure to address drug use threatens the national HIV response LE Sullivan et al. , Afr. J Drug & Alcohol Studies, 6(1): 17 -26, 2007

HIV, HCV among drug users: previous research • Mombasa: 31. 2% HIV prev among drug users referred to HIV testing in outreach programs [i] • Nairobi, n = 332, HIV prevalence of 36. 3% and hepatitis C prevalence of 42. 2% among injectors. [i] • UNODC-supported rapid assessment of 103 heroin injectors, Nairobi, 2004: 60% HIV prevalence • Dar es Salaam, 58% HIV prev. among women injectors, 27% among men [ii]; highlights need for attention to women drug users [i] Deveau et al. (2006), Afr J Drug & Alc Stud 5(2): 95 -106. [ii] S Timpson et al. (2006), Afr J Drug & Alc Stud 5(2): 158 -169.

Selected findings: experiences of drug users • High awareness of HIV and HIV-related risk among drug users, yet almost all reported being constrained to share and reuse needles • Practice of “flashblood” • Most said they had been arrested or had seen friends arrested because of syringe possession (even though possession of syringes is not illegal) • Most said they regularly hid shared needles in bushes or in a discreet indoor location • Many feared seeking HIV testing or other health services because of risk of being turned in to the police • Some said health facilities did not welcome active drug users

Selected findings: experiences of drug users • Most recounted experiences of police extortion, often including planting of drugs • Many recounted being interrogated by police in a state of drug withdrawal • Several credited NGOs with helping them to reduce jail sentences by sending someone to accompany them to the magistrate or probation officer • A few had been treated for drug dependency in residential facilities (with financial assistance of families) or in the home-based “rehab” offered by one NGO; high relapse rates • Most had seen many friends die of HIV (by their own accounts)

Selected findings: health professionals • Some apparently unaware of track record of methadone or other medically assisted treatment of opiate dependency • Those aware of methadone: enormous frustration over the limited treatment tools • Recognition of need for training of health workers at all levels in good practices for HIV prevention and care among drug users [possibility of buprenorphine trial at Muhimbili Hospital, Dar es Salaam]

Selected findings: policy • Methadone and other opiates used for treatment of heroin dependency are not authorized for use • Needle exchange is illegal • Legality “on paper” of syringe possession is belied by law enforcement practices • Recognition by some policy-makers of deep need for health work training on drug use • Not clear that harm reduction outreach themes – such as encouragement to switch from injection to smoking – are allowable under abstinence-based national drug policy

In their own words…. • “I am ashamed that I stole from my mother to get drugs, even when my mother is so poor…. I took the door off the hinges in her house and sold it in the market. ” Joseph O. , 23 years old, Lamu • “The police are ready to plant drugs on you if you have needle marks on your arms. Then you have to buy your way out…. I was taken in several times and never sent before a magistrate; they only waited for money. ” Mahmoud K. , 21 years old, Malindi

Law enforcement, drug use and HIV Findings from outside Africa: • Police actions linked to shift from smoking to injection • Police actions displace drug users to less safe locations, disrupt normal networks, and disrupt ability to seek health care • Fear of carrying syringes leads to unsafe storage and disposal of syringes, increased sharing • Fear of police causes hurried injection, leading to vascular accident and other risks • Frequent incarceration is associated with high HIV risk and lack of access to health services

Possible research themes • Link between law enforcement practices and risk behaviors of drug users • Link between law enforcement practices and healthseeking behaviors of drug users --Could inform ongoing policy development --Could help PEPFAR, other important donors to be more effective policy advocates (J. Csete et al. , Lives to save: PEPFAR, HIV and drug use in sub. Saharan Africa. Lancet, forthcoming)