Results of the Access to Care Study implemented by the Kenya AIDS NGOs Consortium (KANCO) and the London School of Hygiene and Tropical Medicine (LSHTM) in partnership with Nairobi Outreach Services Trust (NOSET), Teenswatch and The Omari project show the need of reaching people who are not injecting drugs with harm reduction interventions. The study describes factors influencing transitioning to injecting – such as the costs of heroin and fluctuations in heroin supply, challenges of poverty, isolation of drug users and stigma. 
To get a deeper understanding of the issue of transitioning to injecting and assess the needs of people who use drugs but do not inject at the moment, we analyzed results of 10 focus group discussions (FGD) with people who use drugs and staff of harm reduction projects in Nairobi and Kwale (Ukunda), Kenya. These FGDs were organized by colleagues from MdM office in Nairobi, NOSET, KeNPUD and Teenswatch.
And what did the key findings tell us?
Methadone appeared to be a topic raised during all focus group discussions by clients and staff of harm reduction projects.
Clients expressed concerns that methadone is offered only to male injecting drug users and women living with HIV who use drugs through the other routes of administration. People who were not injecting drugs at the time of data collection felt they were excluded from the methadone programme and harm reduction project staff were expressing their regret as well. Overall people who use drugs participating in FGD had quite high expectations from the methadone programme and most of them considered it as a way to quit drug use and help with withdrawal symptoms.
All findings show a great need to provide educational and informational support regarding opioid substitution therapy (OST) both to PWUD and staff of harm reduction programme through developing informational, educational and communicational materials capturing the aspects of methadone, as well as group and individual counselling and advice regarding methadone programme. There are many questions and misconceptions on methadone, especially among users which can be provided by availing information.
As there are only anecdotal evidences about transitioning to injecting in order to be enrolled in harm reduction interventions, including the methadone programme, there is a need to study this issue understanding if there are risks leading to transition to injecting because of current eligibility criteria. There is a need to document the cases of transition to injecting because of desire to enter methadone programme properly and initiate studies assessing this issue in order to plan advocacy activities aiming to change the current eligibility criteria for MAT.
Types of drug and methods of use
Most of respondents preferred smoking mixture of tobacco, cannabis and heroin (“a cocktail”). Using different methods of drugs administration was widely spread. People can move from one route of administration to another through their history of drug use - would be chasing one day, then smoking and injecting.
“…was chasing, then smoking, then injecting…” PWUD, Nairobi
Most of the respondents mentioned they were injecting heroin at some point, with some reporting alternating from time to time because of either the quality or availability of money, while others had tried and stopped, without injecting again. Diazepam or rohypnol would be mixed with saliva and applied on the cigarette “for a greater high” for the smokers.
Chasing was not a very common way of heroin use. Those who reported chasing said heroin can be chased using the foil which can be obtained at the shop, but it was more common to use foil from cigarette wrapping; the foil can be preserved and reused several times.
“when chasing, after you are through, you fold your foil, put together with a pipe and store in a safe place”. PWUD, Nairobi
Sniffing, though considered an easy method of drug administration was uncommon as well. Respondents mentioned the use of sniffing pipes made of the banknotes, paper or bamboo (not too common).
“sniffing – it’s easy, you don’t need anything, put into nose and sniff it”. PWUD, Nairobi
Services provided to non-injectors
People who use drugs but do not inject at the moment can receive access to all harm reduction services except of the package of commodities. Staff of harm reduction projects encouraged them to continue chasing or smoking and not to transition to injecting, they have access to Hepatitis B vaccination in organisations where this is included into the package of services; they also received bio-medical services, HIV testing, condoms and health talks. Programme staff and PWUD mentioned people who do not inject drugs at the moment felt they were excluded from the programme because commodities were given only to injectors.
Reasons for shifting to injecting
There are different reasons why people shift to injecting: when they not have enough money to buy drugs; when the demand is high, but the quality of drug is low; increase in tolerance. In coastal part season also makes an impact – during high tourist season people have more money and can afford smoking or chasing, during low tourist season when money goes down, they may start injecting. These findings resonate with the Access to Care Study.
Stress and personal problems were also mentioned as reasons for injecting.
“Stress was from separation from family, then the guy decided to inject because he thought that it was the way to cope with stressful situation”. Outreach worker, Nairobi
Peer influence and curiosity to try something new which is done by peers who enjoyed it were also mentioned as possible reasons for shifting to injecting. There are sites dominated by injectors and the ones where there are more smokers and the preferred method of drug use can be chosen based on the group you enter.
“When area is dominated by those who inject, you gradually start injecting because of peer influence”. Outreach worker, Nairobi
Reasons for shifting to other methods of drug use than injecting
Many respondents (both clients and outreach workers) mentioned they were injecting at some point in their lives. Some people quit injecting after friends’ death related to injecting, and perhaps overdosing. Others considered it easier to smoke because this could be done in public without other people being aware that one was smoking heroin as well. This was especially the case where it was only cigarette and heroin, without bhang.
“Smoking is discrete, nobody knows what you are using”, PWUD, Nairobi
Having serious health problems can also lead to changing behavior – an overdose, wounds, HIV, other health problems.
“I shifted from injecting to smoking because of the wound and an overdose – was in coma for three days”. PWUD, Nairobi
Getting from jail where there was limited access to drugs also may lead to the shift to smoking.
PWUD mentioned severity of withdrawal symptoms as key in deciding the method of administration.. The fear or pain and strong withdrawal effects from injecting were mentioned as reasons for shifting to smoking. Sniffing was also reported as having severe withdrawals, which made it less preferred.
Advice from outreach workers about the risks of injecting and discovering about the risks of HIV related to sharing injecting equipment were named among the reasons contributing to transit from injecting to other methods of drug use. This opens a big potential for harm reduction programmes which may support people who inject drugs with shifting to less risky methods of drug use.
Equipment and safety of use
Among equipment used for drug use and preparation respondents mentioned rosters (tobacco cigarettes), rizlers (rolling paper) for smoking cocktail, glass and razorblades to cut drug into portions, foil for chasing (cooking foil or from the packs of cigarettes).
Among the risks associated with the use of equipment for drug use and preparation there are the following: the glass can burst when you heat it; sharing of cigarettes can increase the risks of TB because of saliva as they pass the cigarette from one to another. Also, smoking the cigarettes up to the end, often PWUD burn their fingers.
Cigarettes are shared because PWUD often do not have enough money to contribute to the portion and buy drugs together. Friendship and close relationship are other reasons for sharing.
Equipment for drug preparation and use is usually taken from drug dealers at drug dealing sites. Cigarettes and smoking paper is bought from shops, but is also available at the dens.
Risks for PWUD
People who use drugs share the same risks with those who inject drugs except of blood born infections transmitted though sharing injecting equipment and skin infections: Hepatitis B and C, TB, often they are jobless, involved in petty crimes and suffer from police harassment, some people (more common women) engage in sex work and transactional sex to get money which makes them at risk of HIV and other STIs. In addition they can have family problems and suffer stress. Sniffing drugs can cause nose bleeding and infections when sharing sniffing equipment.
“They are homeless, live in the streets. When they start using heroin, wife goes, and this brings psychological problems because their lives stagnate”. Outreach worker, Nairobi
Relationship between people who inject drugs and those who do not
Groups of people who inject drugs and those who use other methods of use (smoking, chasing, etc) do not communicate much and try to avoid each other’s company.
Participants of FGDs mentioned that smokers stigmatize injectors though many PWUD participating in discussions confessed they were injecting at some point of their life. When people injecting drugs are seen injecting by the rest of the community, they are chased away and end up doing it in hiding. If community members see people injecting in public, they can call the police who often harass injectors. People who smoke drugs can do this openly without fear of being chased away. Smokers also tended to look at injectors as selfish, because they could not share their drugs with others.
People who use drugs participating in FGDs mentioned the following needs: help with getting back to school, assistance with reintegration into community, income generation and employment programmes, food provision, housing (especially during rainy season) face-to face and group counselling, especially with coping and managing drug use.
The other important need identified was educating community and police to be more tolerant towards people who use drugs.
“They have burnt a food kiosk because they sold food to drug users”. PWUD, Nairobi
“Ask police to stop harassment, one of us broke his leg, because of being woken up and beaten at night while sleeping”. PWUD, Nairobi
PWUD also mentioned the need to provide methadone to those who do not inject at this moment, assist with rehabilitation and provide opportunities for outing – like games, gym.
Topics for informational materials mentioned were: risks of injecting and alternative ways of drug use.
A separate self-support group for those who use drugs but do not inject at this moment was also mentioned as a needed activity.
PWUD discussed the need for the provision of medical services and mentioned the need to have a nurse at the drop-in centres and the need to provide medical services not only to PWUD, but to their children as well.
Staff of harm reduction projects commented on the need of income generation activities to occupy their clients and keep them from stealing, talks with police and community to stop harassment, health talks and informational materials for clients about methadone, harm reduction, safer sex, and hepatitis.
Female drug users, in a FGD held exclusively among them, also highlighted that they faced more disadvantages in their drug use, as they also had to cope males who would harass them from time to time
“These lazies, those who just stay at the maskanis, sometimes they wait for us to hustle, then as you take your stuff they can snatch it from you”. Female PWUD.
The most used device for drug use was cigarette, but outreach workers raised some concerns about providing cigarettes which can bring challenges with the community who may also want to get cigarettes for free and also public health concerns. Harm reduction package for non-injectors can consist of plastic filters for cigarettes, rizlers (smoking paper), foil for chasing, matchboxes, glass for hitting, spoons, plastic pipes for sniffing.
Findings from the group discussions will be used for development of a pilot intervention targeting at preventing transition to injecting in Kenya. While considering the intervention, it will also be necessary to ensure that the unique needs of female drug users are considered.
The authors of this blog, Maryna Braga, Regional Technical Support Hub for Eastern Europe and Central Asia and James Ndimbii, KANCO.
 Guise, A., Dimova, M., Rhodes, T., Ndimbii, J., Turnbull, P, Clark, P, Ayon, S. “A synthesis of qualitative studies exploring the social and structural context of transitions to injecting heroin in Kenya: implications for HIV prevention and harm reduction”. Not published.