Heroin Scarcity in Coastal Kenya

1. Heroin Scarcity in Coastal Kenya HIV and health related consequences for persons who inject drugs (PWID) and Kenyan national and provincial response Dvision of Global HIV/AIDS, Kenya Dr. Frank Njenga Government of Kenya, NACAADA Mercy Muthui Centers for Disease Control & Prevention, Kenya July 27, 2012

2. Authors • Dr. Frank Njenga • Dr. David Kiima • Dr. Maurice Siminyu • Ernest Munyi • Reychad Abdool • Mercy Muthui • BarrotLambdin • Jessie Mbwambo • Emma Mwamburi • Sheryl McCurdy • Gillian Anderson • Sasha Mital • Billy Pick • R. Doug Bruce • Richard Needle

3. Heroin Crisis in Coastal Kenya:Precipitating Factors • Heroin becomes scarce (Dec 25, 2010 -Feb 26, 2011) • Heroin trafficking from Pakistan and Iran to East Africa • Nov 2010: US Ambassador makes statement describing trafficking patterns and drug baron profiting • Mid-Dec 2010: Drug traffickers/users go underground. Drug peddlers arrested • 3rd -4th week Dec 2010 to Jan 2011: Communities mobilize; public demonstrations • 26,000 estimated PWID affected by heroin shortage • Methadone and Needles and Syringe Programs not available

4. GoK Emergency Response • 1st week Jan 2011: Emergency drug dependence ward set up. Drug dependence treatment decentralized (12 Public Health Clinis and 2 hospitals) • 4th week Dec 2010: • Provincial Commissioner asks Ministry of Internal Security for help • NACADAA organizes the rapid response including Community Service Organizations (CSOs) • Medical staff from 36 PHCs in Mombasa were trained on drug dependence treatment • 2nd week Jan 2011: • UNODC and Kenya Red Cross procured codeine

5. USG, GoK, UNODC assessment of heroin scarcity, it’s impact, and response • July 2011 • Chairman of NACADAA wrote to Ambassador Goosby of PEPFAR for assistance • March-April 2012 • Ethical approvals of rapid assessment research • Kenyatta National Hospital ERC • CDC Atlanta IRB • Rapid assessment field work began

6. Rapid Assessment Objectives • To understand changes in drug use HIV risk practices before, during and after heroin scarcity in Mombasa • To identify the availability and effectiveness and use of drug treatment clinical services, other services provided by CSOs • To determine the capacity and barriers to rapidly scale-up HIV services to PWID • To inform recommendations for scaling up high-volume, high-quality, evidence-based opioid treatment and NSP services

7. Methods/Analysis (1) – Qualitative Study • Cross-sectional descriptive study • Qualitative • 98 Key informant interviews (KIIs) among Coastal Province PWID • Male: 75; Female: 23 • 17 Focus Group Discussions (FGDs) among Coastal Province PWID • Male:14; Female: 3 • Qualitative analysis performed by research team, coding performed using ATLAS.ti software

8. Methods/Analysis (2) – Clinical records review • Clinic registries – details basic information regarding clients seeking drug addiction treatment services (DATS) at facilities • Collection • Monthly # of client visits accessing DATS from Aug 2010 –Feb 2012 abstracted from MoH registries • All facilities involved in heroin crisis response (n=14) • Disaggregated by: • Inpatient & Outpatient • Male & Female

9. Role of Community Service Organization • Provided trusted access to PWID • Identified study sites and participants • Assisted in coordinating KIIs and FGDs • Accompanied research team to interview sites (mainly PWID hotspots) • Conducted KIIs

10. Study Sites

11. Results: What happened during the crisis (1) • Heroin scarce: price inflated, quality low with drug additives (e.g. caffeine, chalk) • “During the shortage they started reducing the size and hiking the price” • “He was sold chalk powder; it was bad stuff. People took advantage of the shortage of unga to do such things. Some people used to take medicine from hospital; they pounded it, packaged it and sold it to unsuspecting drug users” • Changes in how drug was used: smoking to injecting • “Smoking has no equal strength as injecting. I had to change from smoking to injecting so as to have a maximum use of the scarce drug” • “I used to smoke cocktail (marijuana and heroin), then I shifted to injecting…and currently I am still injecting”

12. Results: What happened during the crisis (2) • Changes in drugs used or used heroin mixed with other drugs to supplement low quality • “During the shortage, people used beer, others bhangi and others used cocaine” • Traveled great distances in search of heroin to avoid pain of withdrawal • “We had to walk long distances in search of heroin that was scarce and expensive at the same time” • Thousands sought treatment • “I went to hospital. When we went there, we were given some tablets that were allegedly meant to reduce the cravings, but since there was not enough of them, we would be told to get more from Makadara. This we did several times.”

13. Results: thousands seek and use drug addiction treatment services

14. PWID Voices: Drug use and HIV Risk “I usually share [needles] with my friends when I experience high levels arrostos” “Chemists will not sell syringes” “They first draw their blood, mix it with heroin and re-inject themselves with the same contents one after the other. [They] contributed money to buy heroin collectively, one of them then proceeded to inject himself while the other was busy drawing blood from his partner to inject himself with it” “If am in arrostos, I do not care even if [it] is a used needle”

15. After the crisis: Heroin becomes available • Heroin becomes widely available • Prices dropped dramatically • Quality of heroin improved • Those switched to injecting continue injecting • PWID relapsed and suffered overdose • Few continue to use drug treatment services • Methadone and NSP not yet available contributed to increased risk for HIV

16. Conclusions (1) • The GoK, Coastal Province and partners mobilized quickly to respond to the heroin scarcity on PWID in Coastal Kenya • CSOs were critical to the assessment ownership of the study findings as well as building the capacity of staff in research methods and providing services

17. Conclusions (2) • Codeine dosing was inadequate given the tolerance of patients. Key: Pharmacological therapy works, but it has to be the correct medication (e.g., methadone) and at the correct dose. • Unavailability of Methadone and NSP during and after the heroin crisis contributed to increased risk for HIV, and pain and suffering related to acute opioid withdrawal

18. Implications: Crisis Results In Robust Policies and Programs • GoK developing policy and currently planning to introduce Methadone and Needle and Syringe Programs • Expect high volume, low-threshold, accelerated start up of programs

19. Thank you