BY NLM WRITER
The Nairobi Outreach Services is a community-based outreach programme that responds to HIV among drug users – especially indigent injecting drug users in Nairobi – by reducing the bio-medical, psychological and social harms from their drug use. NOSET employs controversial yet successful methods such the distribution of syringes to drug users. This has seen them targeted by law enforcement agents and biased reporters who misunderstand their efforts.
Despite concerted efforts by organisations the State and other concerned agencies, drug abuse persists as a destructive phenomenon. The Nairobi Law Monthly spoke to NOSET’s Caleb Angira to find out why.
Your offices are located in the suburbs, not the city centre or upmarket, as most would assume. Any reasons why?
Our office is “a Drop In Centre (DIC)”, which offers user-friendly services to the targeted drug user on a five-day week between 8 am and 5 pm. One aspect is that it is within an easy reach of the targeted drug user, with little or no harassment by the police, city council askaris or general public. The drug users and staff form a therapeutic community in a drug-free and safe environment to become a substitute home and family for the target population. The services offered here include nursing care for various common conditions, HIV testing and counselling, comprehensive care centre for those identified HIV positive, outpatient drug dependency treatment, and provision of shower and laundry services.
Apart from being unaffordable, city houses and their environment stigmatise, discriminate against and criminalise drug users, and generally see them as a public nuisance. The drug user is unwelcome to this environment.
Nairobi Outreach Services Trust (NOSET) responds to HIV among drug users, particularly indigent injecting drug users in Nairobi. Why HIV and why Nairobi?
The choice for HIV and Nairobi are based on HIV evidence that inform prevention interventions. There is evidence that intravenous injecting drug use is a sure way of spreading HIV among injecting drug users, because they share injecting equipment and drug preparation paraphernalia. Therefore, injecting drug use is one of the drivers of new HIV infections in Kenya. The sex partners of injecting drug users are also at a high risk of contracting HIV. The Kenya AIDS Indicator Survey (KAIS) 2008 indicated that at national level, injecting drug users contribute 3.8 % new HIV infections, of which 5.8 % are in Nairobi and 6.1 % in the Coast of Kenya.
In 2012, the United Nations Office on Drugs and Crime (NUODC) had estimated 49,167 injecting drug users at national level of whom 22,500 were in Nairobi Province and 26,667 in the Coast Provinces.
On my last visit, I noticed a number of posters, which suggested a certain bias for the gay and lesbian community. I could be wrong but, if not, kindly elaborate the reason and extent for this bias. Does NOSET encourage same sex relations?
The sex workers, men who have sex with men, lesbians and injecting drug users are drivers of HIV that are often referred to as key populations – previously they were referred to as “most at risk population”. NOSET does not encourage same sex relations or sex work, but helps those who have chosen such behaviour to deal with bio-psycho-social harms that are consequences of their behaviour in HIV prevention, treatment and care.
In your experience, who are the people most affected by drugs? Is social class a contributing factor?
Some people who use drugs have a problem with their use of drugs. This depends on how their bodies respond to drugs. We target those who have problem with using drugs that expose them to bio-psycho-social harms. The social class, environment, age, sex, type, amount and frequency of using drug do not matter. The problem is explained briefly by this equation:
PAIN + ALCOHOL/DRUG = IMMEDIATE PLEASURE + LONG-TERM PAIN, LEADING TO ALCOHOL/DRUG… AND THE EQUATION CONTINUES IN VICIOUS CIRCLES
Bio-medical harms are medical complications that may affect vital body organs such as heart, liver, brain and reproductive organs, and diseases such as acquired immune deficiency syndrome (AIDS), sexually transmitted infections (STI), hepatitis; drug overdoses and death. Psychological harms are mainly guilt-complex, acute self-recrimination, self-doubt, self-pity, unworthiness, and loss of reality. Others are shame, depression and anxiety. Social harms include loneliness, rejection, family abuse, broken marriages, homelessness, stigma, discrimination, crime, and so on.
People always use drugs to respond to some pain that may be physical, psychological and social. The onset is simple but the body response to the drug will determine the next stages
Kindly take us through the various programmes you have. I have heard about the Needle and Syringe Programme (NSPs); Opioid Substitution Therapy (OST) and other evidence-based drug dependence treatment programmes; HIV testing and counselling (HTC); Antiretroviral therapy (ART); Comprehensive Care Centre (CCC); Prevention and treatment of sexually transmitted infections (STIs) and the Condom programmes for people who inject drugs and their sexual partners. What is their importance?
In 2005, NOSET determined the drug using hotspots in Nairobi, estimated the sizes by male and female and personal needs, set performance targets, obtained a funding from UNODC, set a work plan, understood demographics, evidence-informed interventions, recruited and trained outreach workers to initiate Project K108. In 2013, the Ministry of Health developed Standard Operating Procedures (SOPs) for Needle and Syringe Exchange Programme (NSEP) and Medically Assisted Therapy (MAT) to help NOSET to set NSEP in Nairobi in 2014.
The provision of sterile injecting equipment through NSEP is highly effective in reducing transmission of HIV and Hepatitis B and C among injecting drug users. Intravenous injecting drug use is a sure way of contracting and spreading HIV if the injecting equipment and drug preparation paraphernalia are shared among HIV positive injecting drug users. NSPs facilitate the use of sterile needles and syringes and reduce the number of injections with unsterile or used equipment. NSPs also serve as an important point of entry for people who inject drugs to other health and social services, which they might otherwise be reluctant to use.
The annual progress report for October 2015 to September 2016 revealed that 2,400 (811 Female and 1,589 Male) were engaged in the following services: Needle and Syringe Exchange Programme (NSEP), 800; Methadone Maintenance Therapy (MAT) – Inducted 235, Active 175; Screened for Hepatitis B and C, 418 and; Tested for HIV and given test results, 1,112
The main challenge is that Outreach Worker to Client Ratio is 1:400 instead of 1:40.
The success of your work requires a lot of resources – financial, syringes, substitute drugs and personnel. How do you get these? Do you demand payment for the services you offer?
All our services are “free of charge” because they are paid for by the donors from development partners who give us both technical and budgetary support based on our evidence of estimated injecting drug users, identification of the drug using scenes, drugs used and mode of use, times and days of use, accessible services if any, our capacity to implement the evidence-informed interventions, and registration in Kenya to carry out the work and the understanding of evidence-informed interventions for HIV preventions, treatment and care among people who inject drugs in Nairobi.
When interviewed, recovering addicts severally cited the equally addictive nature of the substitute drug
Methadone as well as the health ramifications that come with withdrawal; how true is this statement? Is this not substituting one illness/vice for another?
Methadone is a synthetic opiate that works by “occupying” the brain receptor sites affected by heroin and other opiates. Methadone blocks the euphoric and sedating effects of opiates; relieves the craving for opiates, which is a major factor in relapse and; relieves symptoms associated with withdrawal from opiates; It does not cause euphoria or intoxication itself (with stable dosing), thus allowing a person to work and participate normally in society. It is excreted slowly so it can be taken only once a day. Methadone maintenance treatment, a programme in which addicted individuals receive daily doses of Methadone, is a multi-component treatment program that also emphasizes re-socialisation and vocational training. The benefits of Methadone Maintenance Treatment (MMT) to addicted individuals are numerous and they include reducing or eliminating illicit heroin and other drug use by those in treatment; improving the health and well-being of those in treatment; facilitating the social rehabilitation of those in treatment; reducing the spread of blood borne diseases associated with injecting opioid use; minimizing the risk of overdose and other medical complication, as users switch from illicit drugs to legal drugs dispensed under the care of a health professional, and; allowing health professionals to keep in contact with drug users, which aids in keeping them in treatment, making relapse unlikely.
In our previous discussion, you cited the insincerity of mainstream media in reporting of the activities of NOSET and like organizations. Please elaborate.
Mainstream media organizations do not take time to do literature review and relevant in-depth interviews with the main stakeholders on HIV prevention, treatment and care among people who use drugs. In other words, they do not understand the subject they are reporting on. They end up distorting the whole issue by creating negative response by public health care and law enforcement agencies. There are three internationally agreed interventions, according to UN statutes, which are signed by all member countries. These are drug supply suppression, demand reduction through drug dependency treatment and harm reduction. The details are contained in literature by WHO, UNODC and UNAIDS
What other problems do you encounter?
In many instances, mainstream media want record their details secretly with hidden cameras and tape recorders. This is dishonest.
Has government been of any help in your quest? How would you rate their cooperation?
Government, through National AIDS Control Council (NACC), National AIDS and STI Control Programme (NASCOP) in the Ministry of Health and National Authority for Campaign Against Alcohol and Drug Abuse (NACADA) in the Ministry of Internal Security, does facilitate and coordinate HIV prevention, treatment and care among people who inject drug in Kenya. The three government agencies provide technical support that includes evidence-based interventions, policies and funding or funding channels to civil society organizations (CSOs). Government does what it can, but it is development partners that play the lead role. Government should seriously think about sustainability of the work initiated by the development partners by allocating taxpayers income to meet the budgets. The GOK should put in place helpful legal and policy environment that supports harm reduction interventions
How would you describe the government’s war against drug abuse? What is your view on the available legislation?
This is always drug supply suppression war, but it wrongly targets the drug user instead of the drug baron – often untouchable. The Narcotic Drugs and Psychotropic Substances (Control) Act, 1994, is used to oppress the downtrodden drug user against prevention and treatment interventions and so war against drug abuse is actually war against interventions targeting the drug user. This Act has two sides that target the drug user both negatively and positively. But the truth is the positive side has always remained untouched in practice.
Kindly describe what it is like dealing with addicts…you know, walking with them through their struggles? How difficult is it to quit substance abuse?
I start by understanding how they feel about their drug use, knowing that they feel bad about it but they do not know what to do about it. They need understand what it (drug use) is all about: a negative way to escape from problems. The step-by-step approach is to motivate the drug user to use the drug safely, then to manage his use and move towards abstinence. This is a process without a fixed time frame because it often involves making two steps forward and five backwards. This is a process of empowering the drug user to understand oneself and analyse how a drug use has interfered with the vital areas of one’s life, then use that knowledge to decide what to do about it. A user must realise that s/he must take charge.
What are the recovery steps and what should the environment be like to prevent relapse?
Drug supply suppression deals the criminal aspect of drug production and supply. Drug demand reduction through drug dependence treatment helps the drug addicts to recover from drug addiction. Harm reduction is HIV prevention, treatment and care among people who inject drugs and not drug dependence treatment. The interventions have been proved to help the drug user to prevent contracting and spreading HIV and AIDS, to live positively with HIV and delay the onset of AIDS and get treatment for psychiatric complications from drug use, STIs, TB, hepatitis B and C, reduce social harms from drug use. It is about safe drug use through NSP, managed drug use through opioid substitution therapy, which finally leads to abstinence through exiting from maintenance therapy.
Are there any self-support programmes you set in place to aid in the economic recovery of recovering addicts? If not, how else do you assist them to be self-dependent responsible citizens?
This is starting from a wrong premise – that an individual uses drugs because he has no economic activity, to sustain his livelihood; that drug use is a full time job that cannot allow any time for economic activities. Drug using becomes a problem in all vital areas of the user’s life. So, without mixing two equally difficult issues, deal with drug use first and the rest will follow. GOK has no capacity to undertake quality drug dependence treatment, and so it is difficult to see how it will deal with the economies of the recovering drug users! The concept of the economies of successfully recovering drug users can be part of quality drug dependence treatment. The development partners are not funding drug dependence treatment but HIV prevention, treatment and care among drug users, and more specifically injecting drug users
How successful has this endeavour been? Any statistics?
Methadone Maintenance Therapy (MMT) and Needle and Syringe Programme (NSP) complement each other; as MMT clients increase, those on NSP reduce. This is safe drug use and maintained drug use which ultimately leads to abstinence from substitute drug and initially injected drug.
Since December 2014 to date NOSET has inducted 262 heroin addicts to methadone maintenance therapy and 195 (74.4 %) are still in MMT, with a few having exited successfully.
A petitioner recently approached Senate clamouring the legalisation of Marijuana for health and industrial purposes. Should marijuana be legalised? Does it qualify as a drug? How often do you deal with cases of marijuana addiction?
This was a positive approach to the right Senate Committee although it is not the right time to consider his petition. He gives examples of countries like Australia which have the best treatment for drug addiction unlike Kenya which has none because the GOK has yet to set quality treatment for drug addiction. He failed to explain the fact that those who have negative consequences of using cannabis are allergic to it and that it is that allergy that processes to dependence on it. This was a sign of a citizen thinking beyond what is happening in Kenya instead of starting from the Kenyan economy – where political will cannot sustain quality treatment based on research.
In conclusion, what would be your message to the government and Kenyans as far as your fight is concerned?
The Government of Kenya, through her lead agencies – the National AIDS and STI Control Programme (NASCOP) and National AIDS Control Council (NACC) – should involve other GOK ministries, the legislature and law enforcement agencies to include harm reduction interventions in the HIV laws, so that the national government and county governments can include them is their development or work plans and budgets.