The missing middle: harm reduction in East Africa
At around 11:30 every morning, Chiku begins her work day. Carefully gathering her syringes and needles, she'll work steadily preparing doses for her clients -- all of whom wait inside her tin-roofed shack in the slum known as Nigeria: one of Nairobi, Kenya's toughest neighborhoods. The money she earns will be enough to pay her rent, and feed her own heroin habit. After every fix, she drops the dirty needle into a box branded with two logos: one for SAPTA, a local non-government organization , the other for the Global Fund.
Needle exchange and opioid substitution therapy programs are a small but resourceful response to a growing threat of injected drug use (IDU) in sub-Saharan Africa, which is beginning to drive the HIV epidemic and threatens to undermine the investment in reducing the burden of disease.
Kenya, Tanzania and Mauritius are among a handful of countries on the continent with needle-exchange programs in place. But these are often run by small grassroots organizations drawing on international support -- without the buy-in of national governments or an overarching policy framework to support harm reduction.
2014 estimates by Kenya AIDS NGO Consortium put the number of PWIDs at 30,000 people. Around 18.3% of them are HIV positive, according to estimates generated by Harm Reduction International (IHRA).
Reaching this group and preventing the spread of HIV through unsafe sex or sharing dirty needles requires a nuanced approach in many ways different from harm reduction work at the global level.
Initially, Kenya drew much of its approach from the Ukrainian model in establishing needle and syringe exchange programs for at-risk communities in 2012. This ad hoc approach was necessary in large part due to funding shortfalls, which were ultimately the result of an unsympathetic policy environment. Delays and logistical challenges have plagued the roll-out of Kenya's harm reduction activities; a planned piloting of methadone-assisted therapy (MAT) in August 2014 has yet to begin. Phased trials for opioid substitution therapy have also been plagued by delays and logistical challenges.
In looking for locally sourced solutions to emerging public health problems posed by injected drug use, Kenya would do well to adopt some of the innovations currently being implemented in next-door Tanzania. To respond to a population size estimated at around 25,000 people, Tanzania was the first country in sub-Saharan Africa to implement needle exchange and methadone therapies. There are two PEPFAR-funded methadone clinics in Tanzania, and plans are in place to open two more in the Temeke and Illala districts of the capital, Dar Es Salaam.
Mauritius is also providing a regional model for harm reduction. The country has a high HIV prevalence rate among injected drug users, who form the bulk of the country’s HIV population (UNAIDS figures place the estimate at 9,600). In 2005, the figure was 92%. By 2013, it had fallen to 44%: the result of a massive harm reduction campaign at the center of its HIV response.
Both formal needle exchange programs and methadone-assisted therapy have been available in the country since 2006, provided by both NGOs and as part of government policy. However, the public health approach has had little impact on how Mauritius sees drug use. As a result there has been little progress in efforts to decriminalize drug use, which has kept many drug users underground.
Representatives from the Kenyan HIV advocacy community and government agencies travelled to Mauritius in early 2012 to observe some of the activities underway. What was happening in Mauritius was eye-opening and fueled considerable momentum in Kenya to open dialogue at all levels. Community engagement and policy discussions drawing in both government and non-government voices took place in September 2012. These discussions ultimately set the ball rolling toward engagement by both NGOs and government institutions with the challenge of substantive harm reduction work.
That said, the risk for Kenya, as for countries on the East African region and beyond, is that investment in controlling the spread of HIV among the general population may be undermined if a proportionate investment is not made in responding to the emerging threat posed by injected drug use.
In a July 2014 report, IHRA noted that in low- and middle-income countries, an acute funding crisis was jeopardizing even the modest harm reduction activities currently in place. And while national governments were spending more on HIV than ever before, "these increased state commitments have yet to benefit people who inject drugs and other key populations".
As East African countries develop their HIV concept notes to submit to the Global Fund, advocates both at the grassroots and the global level are pushing hard to develop an investment case and evidence base for harm reduction to be included as part of prevention activities funded by the international community. In the meantime, a comparable push is being made to encourage governments to hold policy discussions to create a more conducive environment for a sustained engagement in harm reduction at the national and regional level.
In the interim, KANCO is continuing to pilot harm reduction services including MAT, and is working toward the creation a regional harm reduction network of service providers and recipients Eventually, the hope is for drug users or drug users in recovery to become part of the policy discussions, instead of just part of the supply chain, like Chiku. But that, like everything else, will take time and money: resources that are in short supply.
SAPTA spends around $1 on each of the NSP kits they give to Chiku and the 30 other peer educators in the program in Nairobi. Their budget estimates hover around $100 for each of the 1,355 recipients of harm reduction services -- a negligible number when the estimated size of the injected-drug population in Kenya is around 30,000 people.
Still for people like Chiku, who was diagnosed as HIV+ in 2013 and is currently receiving treatment for tuberculosis, that $1 kit is helping her do her own small part in stemming the epidemic.