Dvision of Global HIV/AIDS, Kenya

Heroin Crisis in Coastal Kenya

HIV and health related consequences for persons who inject drugs (PWID) and Kenyan national and provincial

response

Dr. Frank NjengaGovernment of Kenya, NACAADAMercy MuthuiCenters for Disease Control & Prevention, KenyaJuly 27, 2012

Authors

Dr. Frank Njenga Dr. David Kiima Dr. Maurice Siminyu Ernest Munyi Reychad Abdool Mercy Muthui Barrot Lambdin Jessie Mbwambo

Emma Mwamburi Sheryl McCurdy Gillian Anderson Sasha Mital Billy Pick R. Doug Bruce Richard Needle

Heroin Crisis in Coastal Kenya:Precipitating Factors

Heroin becomes scarce (Dec 25, 2010 -Feb 26, 2011)Heroin trafficking from Pakistan and Iran to East AfricaNov 2010: Key leaders in Kenya makes statement

describing trafficking patterns and drug baron profitingMid-Dec 2010: Drug traffickers/users go underground.

Drug peddlers arrested3rd -4th week Dec 2010 to Jan 2011: Communities mobilize;

public demonstrations26,000 estimated PWID affected by heroin shortageMethadone and Needles and Syringe Programs not

available

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

USG, GoK, UNODC assessment of heroin scarcity, it’s impact, and response

July 2011Chairman of NACADAA wrote to Ambassador Goosby of

PEPFAR for assistance

March-April 2012Ethical approvals of rapid assessment research

Kenyatta National Hospital ERCCDC Atlanta IRB

Rapid assessment field work began

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

Methods/Analysis (1) – Qualitative Study

Cross-sectional descriptive studyQualitative

98 Key informant interviews (KIIs) among Coastal Province PWID

Male: 75; Female: 2317 Focus Group Discussions (FGDs) among Coastal

Province PWID Male:14; Female: 3

Qualitative analysis performed by research team, coding performed using ATLAS.ti software

Methods/Analysis (2) – Clinical records review

Clinic registries – details basic information regarding clients seeking drug addiction treatment services (DATS) at facilitiesCollection

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

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

Study Sites

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”

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.”

Results: thousands seek and use drug addiction treatment services

PWID Voices: Drug use and HIV Risk

“Chemists will not sell syringes”

“If am in arrostos, I do not care even if [it] is a used needle”

“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”

“I usually share [needles] with my friends when I experience high levels arrostos”

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

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

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

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

Thank you