Informal assessment of drug use and NGO-based services in Kenya and Tanzania

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

2. 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

3. 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 1990s “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.

4. 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

5. 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.

6. 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

7. 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)

8. 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]

9. 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

10. 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

11. 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

12. Possible research themes • Link between law enforcement practices and risk behaviors of drug users • Link between law enforcement practices and health-seeking 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)