AN OVERVIEW OF PROGRAMS FOR PEOPLE WHO INJECT DRUGS

AN OVERVIEW OF PROGRAMS FOR PEOPLE WHO INJECT DRUGS Helgar Musyoki MARPs and Vulnerable Groups Program National AIDs/STI Control Programme November 2012

Background Injection of heroin in Kenya reportedly increased a er late 1990s as white crest became more available; Coast Province and Nairobi identified as largest geographic areas of use. Programs have been conducting prevention and treatment programming for injecting drug users (IDUs) since approximately 1997, PEPFAR Kenya began funding programs in 2004. Government of Kenya has since prioritized IDUs in the National AIDS Strategic Plan (KNASP). Heroin shortage in Kenya from December 25, 2010 to February 26, 2011

KNASP 2009/10 2012/13 Impact and outcome targets Impact 1: No. of new HIV infections reduced by 50% by 2013 Outcome 1: Reduced risky behaviour among the general, infected, most at risk and vulnerable populations Indicator 20.0.4: Percentage of injecting drug users who reported using sterile injecting equipment the last time they injected

Historical data DataSource Year Location Findings HIV Prevalence Data Ndetei,D.M. 2004 Mombasa 49.5% HIV positive; sample arameters unknown Odek Ogunde, M. et al. 2004 Nairobi 36.3%HIV, 42.2% HCV among 146 IDUs; sampling method not stated Deveaux, C. et al. 2006 Mombasa 31.2% HIV among 142 IDUs accessing VCT at a drop in centre Population Size Estimates Unpublishedestimate 2007 Kenya >12,000in Nairobi; >5,000 in Coast using focus group multipliers Unpublished estimate 2009 Coast ~100 in Mombasa and Malindi; using community mapping methods Needle and Zhao 2011 Kenya 30,000in Kenya, derived from Aceijas C. et al., estimation of population percentage

Why focus on IDUs 1/3 of all new HIV infections are attributable to MARPs 4% by IDUs Bridge population for HIV to general public HIV prevalence higher than general population. (Ranges 20 50% prevalence) 8.8% of IDUs are women of age 15 49 HIV prevalence for women 44.5%(IBBS 2011) 80% of IDUs do not know there HIV status IDUs account for 17% of new HIV infections in the coastal region Estimated 49,167 PWID in Nairobi and Coast Provinces 5

2011 Nairobi IDU Surveillance: HIV Total HIV Prevalence (n=269) Crude Unadjusted % RDSAdjusted % (95% CI) 21.2 18.7 (12.2 26.7) HIV prevalence by needle sharing Ever used needle 33.1 30.7 (20.4 42.7) after somebody else Never shared needle 5.9 5.1 (1.2 11.8) Of HIV positive IDUs (n= 57): Lent their needle to other users in past month 61.4 61.4% (CI=43.6 80.6)

IDUs: Recruits Larger circles = HIV positive No sharing Shared

2011 Nairobi IDU Surveillance: HIV Crude Unadjusted % RDS Adjusted % (95%CIs) (n=269) Sex Male 92.2 92.7 (86.0 97.8) Female 7.8 7.3 (2.2 14.0) Age Mean (median; IQR) Injected heroin within past month Injected drugs every day in past month Number of injections in day (median; IQR) Number of times uses needle before disposal (median; IQR) Has ever used needle after somebody else used it 32.4 (31; 27 37) 95.9 96.5 (93.3 99.0) 79.6 77.3 (70.5 84.9) 2.4 (2; 2 3) 5.4 (3; 2 7) 56.1 53.8 (45.4 62.2)

The practices

Needle sharing and other injecting equipment

Poor disinfection practices before re use hence use of contaminate d needles

Needle Sharing Blood flushing Vipointi

A woman injecting drugs on the thigh

9 WHO INTERVENTIONS FOR PWIDs Needle and syringe programmes (NSP) Medically Assisted Therapy (MAT) & Other drug dependence treatment HIV testing and counselling (HTC) Antiretroviral therapy (ART) Prevention and treatment of sexually transmitted infections (STIs) Condom programmes for IDUs and their sexual partners Targeted information, education and communication (IEC) for IDUs and their sexual partners Diagnosis and treatment of and vaccination for viral hepatitis Prevention, diagnosis and treatment of tuberculosis (TB)

Medically Assisted Therapy ( MAT /OST) Methadone is the commonly used drug for MAT Methadone hydrochloride is a synthetic opiate (opioid) which was first marketed as an analgesic (a painkiller) for the treatment of severe pain. Nowadays methadone is primarily used for the treatment of narcotic addiction. Methadone's effects can last up to 24 hours, thereby given only once a day for the treatment of people dependent on heroin and other opioids.

Medically Assisted Therapy ( MAT /OST) Methadone relieves withdrawal symptoms and reduces the opiate craving Improves quality of life by helping IDUs to integrate normally family, jobs,social etc. Reduces criminality It is a maintenance or long term program, which may last for months or years. Min: 6/12 Methadone is available in liquid and tablet forms. Liquid form will be used in Kenya to minimize diversion

NEEDLE EXCHANGE PROGRAMS

OBJECTIVES OF NSP PROGRAMS Reduce the HIV transmission rates among IDUs Reduce co infections associated with IDU Increase access of drug users to effective and supportive services use NSP as an entry point

Do NEPs make good public health sense??? NEPs reduce transmission of HIV, Hepatitis B virus (HBV), hepatitis C virus (HCV) and other blood born pathogens among IDUs Reduce unsafe drug use and sexual behaviors associates with the transmission of HIV, HBV, HCV and other blood borne pathogens Reduce the number of used needles discarded in the community

Do NEPs make good public health sense??? NEPs do not encourage initiation of injection drug use Do not increase the duration The frequency of injection drug use or decrease the motivation to reduce drug use The lifetime costs of providing treatment for IDUs living with HIV greatly exceeds the costs of providing NEP services

Do NEPs make good public health sense??? At any given time, most individuals who inject drugs are not receiving drug treatment and NEPS are often the only contact these people have with health or social service providers (Strike C and Leonard L, 2006)

Why promote NEPs Equipment access programs are associated with selfreported reductions in (Wodak et al. 2005; IOM 2006): Sharing needles, syringes, and injection equipment Unsafe injection and disposal practices Frequency of injection No evidence exists that equipment access programs increase the frequency of drug use

NSP KIT

Program successes Coordinated response TWGs Development of program tools service guidelines, policy documents,sops, M&E tools Training of health care workers, peer educators,provincial administration, religious leaders among others. Engagement of program beneficiaries at all levels Generation of strategic information to inform programming Creating an enabling policy environment Resource mobilization GF, Dutch government, PEPFAR among others

Challenges Lack of supportive legislation for implementation of NSP Resources for scale up of service provision across the country. Commodity Supply Possible political interference Balancing evidence based and right based approach Negative media publicity Dilemma on the use of the auto disabled/non re use needles and syringes or the reusable

Evaluation of Program Impact Change in program outcome With program Without program TLC IDU Program start TIME-> Program end

ASANTENI SANA!