I arrived back in London yesterday from a two week visit to Kenya to see drug policy in the UK news. The purpose of my visit was to meet with people who use drugs, HIV and drugs NGOs, health service providers and government officials to assess HIV and drug use situation in Kenya, and to work with KANCO (the Alliance’s Kenyan national civil society partner) to plan a programme of HIV prevention and care for people who use drugs and their families, as part of the Alliance’s five country CAHR programme.
As I hear the debate in the UK, the situation in Kenya’s coastal province – where the largest prevalence of drug use occurs – is uppermost in my mind. So too is the looming UN High Level Meeting on AIDS next week, where governments will be asked to account for their HIV responses, and commit to renewed attention to and investment in HIV/AIDS.
Drug users in Mombasa and Malindi, on the coast of Kenya, will be on my mind when I watch what happens. Lots of us are worried that governments will back away from a commitment to a harm reduction, or a health-based, approach to HIV and drug use. It’s a moment of truth for the Kenyan Government.
The Kenyan Government has a lot to be proud of in recent years in terms of its general response to HIV/AIDS. We observed a deeply ‘AIDS competent’ health service, leadership and civil society. Access to HIV testing is widespread, access to antiretroviral treatment is improving and a culture of HIV prevention in communities and in medical settings is very evident. Leadership on HIV is strong and exists across sectors, and the national planning processes are robust and inclusive.
But when it comes to drug users, everyone talks about abstinence. Drug users have to stop using drugs. There is not (yet) a strong commitment to evidence based harm reduction approaches to HIV and drug use in Kenya. Except that there are a small number of advocates and officials who are working hard to try to improve the health of people who use drugs in Kenya, by advocating and supporting harm reduction approaches. Even amongst drug users, it seems that the only option that they see for themselves is continuing drug use and poverty, or abstinence. For those of us working to stop HIV in communities of people who use drugs in Kenya, we need to address this issue of abstinence.
All of us want services for drug users that help them to abstain from drug use. When people who use drugs are ready and able to abstain, let’s all make sure there are good quality and effective services available. Good rehabilitation services, good support networks. But if you have an opiate dependency, or if you are socially excluded because you’ve been in and out of jail, or if you’re stigmatised as dirty or as evil, or if you feel shame in your family because you’ve been told that you have not been a good wife and mother or a good husband and father, or if you have a mental illness, or if chronic unemployment and poverty plagues your community….for these and many other reasons, abstaining from drugs might not be possible.
So, people keep using drugs, and keep being incarcerated, or forced to pay bribes to police to keep out of jail, and feel shame and powerlessness because they and their families are poor and stigmatised. And as these cycles of poverty and stigmatisation go round and round, HIV transmission occurs. So the cycles of poverty and illness deepen. And what do we do? We put those people in jail – removing them from their families, from the possibility of work and education, from feeling like their part of a community. Or we say ‘stop using drugs’.
A very useful background paper by the Global Commission on Drug Policies is available. It is helpful for Kenyan officials who right now are coming to terms with the HIV epidemic amongst injecting drug users in Kenya. Written by Dr Alex Wodak, it provides an account of the effectiveness of abstinence based drug treatment, of drug prevention education and of harm reduction responses such as opiate substitution treatment such as methadone.
Wodak sets out the evidence base for the effectiveness of these various responses. The evidence base for the effectiveness of abstinence based treatment is weak, especially in terms of its effectiveness at preventing HIV transmission.
For a Government such as Kenya’s who understands already the importance of focusing scarce resources on interventions that work, investing in abstinence based drug treatment will waste a lot of resources in a resource poor health system. And for a Government who is committed to health care for all its citizens, getting the most effective health care to drug users with HIV or at risk of HIV is part of its right to health agenda.
Opiate substitution treatment – the provision of methadone or buprenorphine to people with opiate dependency – is an intervention with a very strong evidence base. Its effectiveness in preventing HIV transmission – because it stops or reduces injecting – has been proven over and over in many different countries and many different settings. Methadone works. And it’s cheap. Opiate substitution treatment also reduces crime, and takes away a lot of the chaos in the life of a dependent user who spends his or her day trying to buy drugs, trying to raise money to buy drugs and trying to find a syringe that’s clean and a place to use drugs where the police won’t see you or your family won’t know. And when that chaos is reduced, then it’s much easier to look for work, or feed your family, or go back to college, or otherwise participate in community life. And it’s much easier to prevent HIV transmission, and to go to a clinic and ask for treatment, and take medicines and to care for others around you.
The report from the Global Commission on Drug Policies immediately prior to the High Level Meeting on HIV at the UN next week is good timing.
The Commission calls for an end to the ‘war on drugs’ approach to drug use that results in the incarceration of hundreds of thousands if not millions of young people around the world for the simple act or crime of using drugs. Many of these same people will be very poor, and will be dependent on drugs. When these people are sent to jail, most will continue to use drugs in these prisons or detention centres, though they will have less access to clean syringes, health care and information about the different harms associated with different drugs, or how to avoid HIV or hepatitis C transmission.
As AIDS activists, harm reduction advocates and people who care about human rights and international development, we’ll be watching how governments commit to – or retreat from – effective and rights-based approaches to HIV, such as harm reduction. For the Kenyan Government, the Global Commission on Drug Policies report couldn’t be more finely timed. Kenyan citizens care about HIV and AIDS, and worry about growing drug use in Kenya. They are right to worry. We are all hoping that the commitment to evidence based approaches to HIV more generally in Kenya extends to HIV and drug use. And when it does, the Kenyan Government will be a leader in East Africa and amongst its own people, educating others that people who use drugs are people like us, and that is people who have a right to HIV and health care that will stop HIV transmission, that offers people choices based on what will work for them, that keeps people out of jail, and most importantly, that works.