Slava Kushakov recently travelled to Kenya where he visited Mombasa and Nairobi to learn more about drug use and HIV in the country. Here he shares his impressions of the issue.
Mombasa, Nairobi, Kiev, May-June 2011
Kenya is a country where drug use is becoming a significant factor in the HIV epidemic. My first impressions of the country were of the incredible warmth and welcoming nature of the people, the shocking extent of social differentiation, the rich diversity of the traditional tribal cultures, the pitiless pressure of globalization, the imposing beauty of the landscapes and wild life, and the pervasiveness of the funeral industry, which is closely associated with AIDS.
Growing availability of antiretroviral treatment has led to a significant decrease in AIDS related mortality. Consequently a vast majority of the coffin makers had to shut down. But the remaining number is still large. Over 70,000 AIDS related deaths are reported in Kenya each year.
The focus of this article is HIV, drug use, and the prospects for the development of programmes aimed to reduce the harm drug use can cause.
1. Drugs on offer in Kenya
The most characteristic features of Kenyan drug scene are the surprisingly ‘boring’ menu of consumed substances and the appallingly low level of drug awareness. Apart from alcohol, which is becoming an increasing public concern, and traditionally tolerated bhang (a preparation from the leaves and flowers or buds of the female cannabis plant) and miraa (khat), the only other popular substance is the ‘white crest’, crystalline form of heroin. The latter is probably the only illicit drug that is injected in Kenya.
The level of experimentation with substances is relatively low and includes occasional use of painkillers and Roche’s Rohypnol. Relatively low level of active exploration of new substances is likely to be linked to the fairly stable supply of heroin relying on several complementary routes. The only reported interruption of supply happened at the end of 2010 and affected a relatively small proportion of heroin users.
However, significant strengthening of the supply reduction measures, supported by a number of politicians, agencies, and public opinion, can lead to unpredictable surges of interest in possible alternative substances, including various types of over-the-counter medicines which are becoming more and more popular among people who use drugs in other parts of the world.
2. Smoking or injecting?
Supply irregularities may lead to a significant increase in injecting, a much more cost-effective mode of administration which significantly increases the risk of HIV transmission, along with the whole range of other harms associated with injecting practices.
The risk relates to another important feature of the drug scene in Kenya: the close interaction between two groups of people who use heroin who are very different in terms of their vulnerability to HIV infection – those who smoke the white crest (mostly in cocktail with tobacco and often marijuana) and those who inject the stuff.
Injecting has been reported to decrease in Kenya since 2004-2005, but has never been eliminated. Currently between 10 and 20% of all heroin users are reported to inject the drug. This puts four fifths of all heroin users at risk of transitioning from smoking to injecting and dramatically increasing their vulnerability to HIV and the whole range of harms associated with this route of administration of the drug.
Any intervention designed to reduce harms associated with the use of drugs should be thoroughly analysed in terms of its potential influence on the rate of transitions between smoking and injecting. Making clean needles widely available may encourage some of the smokers of white creast to shift to injecting, which would significantly increase their risk of HIV and expose them to the other negative impacts of injecting. HIV and drug use programmes should introduce adequate measures to avoid transitions to injecting and also encourage those who inject to revert to safer modes of administration.
There are other patterns of social interaction between various sub-populations of drug users, which should be carefully considered during the development of interventions aimed to reduce drug related harms. One example is restricted communication between older people who use drugs and those between 15 and 25 years of age. Complex patterns of social mixing may be affected by the relationship with the police and local law enforcement patterns, family and other cultural norms that need to be understood and taken into account in HIV and drug use programming.
3. ‘All pull together’
Another feature which is particularly interesting is the intrinsic solidarity and mutual appreciation, openness and helpfulness of Kenyan people. The culture still retains its incredible bonding power, which can and should be relied upon in HIV programming. This feature is illustrated by the idea of Harambee (‘all pull together’ in Swahili) – a Kenyan tradition of self-help events, which has become a national motto, and can be instrumental in the development of community mobilisation, drug user activism, mutual help movements, anti-stigma programming, volunteerism, and behaviour change communication aimed to reduce harms associated with the use of psychoactive substances.
4. Kenya’s AIDS response
Another important characteristic is the generally high level of AIDS awareness and the existence of community-focused and community-based programmes experienced in facilitating access to HIV treatment and care.
The long and complex history of HIV epidemic, and the response to it, has also resulted in relatively low levels of HIV associated stigma. This means that for a drug user living with the virus, drug use is a source of greater stigma than their HIV status.
A relatively rich variety of HIV related programmes and services may increase the chances of access for HIV-positive people who use drugs. Community-based organisations delivering services for HIV positive and other vulnerable people can be instrumental as a basis for the development and scale-up of services designed to reduce drug related harms.
There are also existing mechanisms for the delivery of support to front-line service delivery organisations, including the Kenya AIDS NGOs Consortium (KANCO), a Linking Organisation of the Alliance, which unites over 1,000 NGOs and is now actively developing its harm reduction capacity. The Kenyan political landscape is currently undergoing significant reforms and changes including important changes in the policies affecting HIV and drug use programming. The relevant government departments, including health and law enforcement agencies, are eager to collaborate on the development of locally appropriate HIV interventions including those related to drug use and harm reduction.
5. First steps in harm reduction
There are several civil society organisations in Kenya grounding their work in harm reduction principles. Although unable to implement needle/syringe programmes or to provide substitution maintenance treatment (two services usually considered to be the corner stones of harm reduction), organisations like Reach Out Trust, which operates from Mombasa, have developed effective outreach mechanisms, established close relationships and enjoy considerable authority and rapport among the local people who use drugs.
Most outreach workers are people with history of drug use and a large proportion of them are women, which makes the organisations well positioned to reach women who use drugs and develop services for women.
Outreach workers develop close relationship with the clients and know majority by name. The organisations provide a range of demanded services and creatively seek opportunities to expand the services offered in line with the needs of the people they serve.
Although in need of strengthening and significant expansion, these services present a rare example of genuine community focused harm reduction programming that is implemented before needle and syringe programmes and substitution maintenance are legitimised. For the time being the harm-reduction-ready organisations engage in advocacy efforts and awareness raising activities designed to prepare the ground for expedient introduction of needle programming and substitution maintenance treatment.
6. Tailoring services to fit the client
One particular characteristic of these NGOs is a rare application of case management approach to HIV prevention/harm reduction programming: a sophisticated system which includes an admission questionnaire, creation of individual development plan for each client and regular monitoring of progress. It also allows for tailoring of offered services for each client.
The admission questionnaire assesses various behaviours and factors that increase person’s vulnerability to harms associated with the use of drugs. Based on the assessment an individual development plan is designed, which may include measures to avoid using drugs by injecting, adoption of safer injecting or sexual practices, and counselling and testing for HIV and other issues.
With further scale-up of harm reduction efforts and introduction of a more comprehensive range of services the case management system will have to be adjusted to incorporate standardised planning options for various segments within the population of people who use drugs.
7. Understanding a changing drugs landscape
Apart from the groups of people already mentioned there might be many other sub-groups characterised by specific vulnerabilities, needs and challenges.
An important pre-requisite for tailoring services to specific categories of [potential] clients is better understanding of the status and the changes of the local context, dynamics of drug scene, changing needs and challenges faced by people who inject drugs.
Such understanding can be achieved through improved registration and service delivery monitoring system, as well as through research. Further research into the Kenyan drug scene, patterns of drug use and vulnerabilities will be required to inform further development and scale up of HIV and drug use programmes based on harm reduction principles.
An adequate research agenda can only be developed as a collaborative effort of stakeholders including people who use drugs, service providers, academic institutions, and key other players involved in HIV and drug use programme development. Research should also be used as an instrument for thorough implementation analysis and generating better evidence for HIV and drug use programming.
The indicative research agenda may include exploration of:
- Factors affecting transitions between drugs and modes of administration and detailed exploration of related behaviours.
- Geographic differences in the drug scene and communities of people who inject drugs in different geographic areas.
- Key segments of the drug using population including by the drug of choice, gender, age, vulnerability factors, in order to tailor outreach (e.g. reaching out to sub-population of drug users aged 15 – 25) and service delivery mechanisms.
- Relevance and appropriateness of prevention messages e.g. messages related to modes of administration.
- Mortality rates and causes of death among people who use drugs.
- Populations that may be associated with increased risk of injecting drug use e.g. fishermen who may be affected by the drug supply by sea, sex workers, homeless people.
- Bridging populations at most risk of HIV transmission from people who inject drugs (e.g. their spouses and sexual partners, truck drivers using services of sex workers many of whom inject drugs).
- Religious and cultural factors influencing the patterns of drug use and associated vulnerabilities.
These areas require more in-depth analysis, but the need for further research should not lead to any further delay in the scale-up of harm reduction services in Kenya. The required general course of action is as salient as the Kenyan drug scene.