There is limited data regarding women who inject drugs, and how harm-reduction services can be made more women-centered. This study explored experiences of Kenyan women who inject drugs, with regard to access to HIV, harm reduction and sexual and reproductive health (SRH) services. A total of 45 women who inject drugs and 5 key stakeholders participated in-depth interviews and focus group discussions. Thematic analysis of the data revealed that stigma, long distances, lack of confidentiality, user fees, multiple appointments, drug users' unfamiliarity with health facilities, disconnect in communication with healthcare providers, and healthcare providers' lack of understanding of women's needs were factors that impede women's access to health services. Community-based services, comprising of outreach and drop-in centers mitigate these barriers by building trust, educating women on their health and rights, linking women to health facilities, sensitizing health providers on the needs of women who inject drugs, and integrating women's SRH services into community-based harm-reduction outreach. Inclusion of SRH services into community-based harm-reduction activities increased women's interest and access to harm-reduction interventions. These findings underscore the need to strengthen community-based programming for women who inject drugs, and to integrate SRH services into needle and syringe exchange programs.
Background and objectivesPromoted globally as an evidence-based intervention in the prevention of HIV and treatment of heroin addiction among people who inject drugs (PWID), opioid substitution treatment (OST) can help control emerging HIV epidemics among PWID. With implementation in December 2014, Kenya is the third Sub-Saharan African country to have introduced OST. We combine dynamic mathematical modelling with qualitative sociological research to examine the ‘promise of methadone’ to Kenya.Methods, setting and participantsWe model the HIV prevention impact of OST in Nairobi, Kenya, at different levels of intervention coverage. We draw on thematic analyses of 109 qualitative interviews with PWID, and 43 with stakeholders, to chart their narratives of expectation in relation to the promise of methadone.ResultsThe modelled impact of OST shows relatively slight reductions in HIV incidence (5–10%) and prevalence (2–4%) over 5 years at coverage levels (around 10%) anticipated in the planned roll-out of OST. However, there is a higher impact with increased coverage, with 40% coverage producing a 20% reduction in HIV incidence, even when accounting for relatively high sexual transmissions. Qualitative findings emphasise a culture of ‘rationed expectation’ in relation to access to care and a ‘poverty of drug treatment opportunity’. In this context, the promise of methadone may be narrated as a symbol of hope—both for individuals and community—in relation to addiction recovery.ConclusionsMethadone offers HIV prevention potential, but there is a need to better model the effects of sexual HIV transmission in mediating the impact of OST among PWID in settings characterised by a combination of generalised and concentrated epidemics. We find that individual and community narratives of methadone as hope for recovery coexist with policy narratives positioning methadone primarily in relation to HIV prevention. Our analyses show the value of mixed methods approaches to investigating newly-introduced interventions.
BackgroundA tenth of all people who inject drugs in Kenya are women, yet their social contexts and experiences remain poorly understood. This paper reports how multiple forms of stigma are experienced by women who inject drugs in coastal Kenya and the impact that they have on their ability to access essential health services.MethodsIn 2015, in-depth interviews and focus group discussions were held with 45 women who inject drugs in two coastal towns. These data were supplemented with in-depth interviews with five individual stakeholders involved in service provision to this population. Data were analyzed thematically using NVivo.ResultsWomen who inject drugs experience multiple stigmas, often simultaneously. These included the external stigma and self-stigma of injection drug use, external gender-related stigma of being a female injecting drug user, and the external stigma of being HIV positive (i.e., among those living with HIV). Stigma led to rejection, social exclusion, low self-esteem, and delay or denial of services at health facilities.ConclusionHIV and harm reduction programs should incorporate interventions that address different forms of stigma among women who inject drugs in coastal Kenya. Addressing stigma will require a combination of individual, social, and structural interventions, such as collective empowerment of injecting drug users, training of healthcare providers on issues and needs of women who inject drugs, peer accompaniment to health facilities, addressing wider social determinants of stigma and discrimination, and expansion of harm reduction interventions to change perceptions of communities towards women who inject drugs.
BackgroundHeroin injection is emerging as a significant dimension of the HIV epidemic in Kenya. Preventing transitions to injecting drug use from less harmful forms of use, such as smoking, is a potentially important focus for HIV prevention. There is, however, little evidence to support comprehensive programming in this area, linked to a shortage of analysis of the social and structural context for transitions, particularly in low-income settings. We explore accounts of transitions from smoking to injecting in Kenya to understand the role of individual, social and structural processes.MethodsWe combine data from two separate studies conducted in Kenya: an in-depth qualitative study of HIV care access for people who inject drugs (study 1) and an ethnographic study of the political economy of the heroin trade in Kenya (study 2). In-depth interviews with PWID and community observation from study 1 are triangulated with accounts from stakeholders involved in the heroin trade and documentary data from study 2.ResultsPeople who inject drugs link transitions to injecting from smoking to a range of social and behavioural factors, as well as particular aspects of the local drug supply and economy. We present these results in the form of two narratives that account for factors shaping transitions. A dominant narrative of ‘managing markets and maintaining a high’ results from a process of trying to manage poverty and a shifting heroin supply, in the context of deepening addiction to heroin. A secondary narrative focuses on people’s curiosity for the ‘feeling’ of injecting, and the potential pleasure from it, with less emphasis on structural circumstances.ConclusionsThe narratives we describe represent pathways through which structural and social factors interact with individual experiences of addiction to increase the risk of transitions to injecting. In response, HIV and harm reduction programmes need combinations of different strategies to respond to varied experiences of transitions. These strategies should include, alongside behaviour-oriented interventions, structural interventions to address economic vulnerability and the policing of the drug supply.
Highlights Globally there is limited research concerning women who inject drugs. This paper reports important insights related to the experiences, needs and barriers preventing the utilisation of reproductive maternal, neonatal and child health services among women who inject drugs in coastal Kenya. Findings from this study will inform the development of equitable, comprehensive, and family-centered RMNCH interventions targeting women who inject drugs, including the integration of RMNCH services within harm reduction programs. ABSTRACT Introduction:The Kenyan government has committed to increasing access to comprehensive reproductive, maternal, neonatal and child health (RMNCH) services. However, inequalities still exist.Women who inject drugs are an important sub-population for public health interventions, yet their RMNCH needs have largely been overlooked. Additionally, there is a lack of research to inform RMNCH interventions for this sub-population. Methods:In 2015, we undertook interviews and focus group discussions with 45 women who inject drugs and five key stakeholders to understand these women's RMNCH experiences and needs. Results:Women' access to essential services across the RMNCH continuum was low. Two thirds of the women were not using contraception. Many discovered they were pregnant late, due to amenorrhea of drug use, and thus were unable to enroll for antenatal care early. Facilitybased deliveries were limited with many choosing to deliver at home. Following delivery, women's attendance to immunization services was sub-optimal. Stigma from healthcare workers was a major factor impeding women's use of existing RMNCH services. The prospect of experiencing withdrawals at health facilities where waiting times were long, deterred utilization of these services. Additionally, women faced competing priorities, having to choose between purchasing heroin or spending their money on health-related costs. Conclusions:Several barriers disrupted women's access to services across the RMNCH continuum.Consequently, there is a need to develop equitable, comprehensive, and family-centered RMNCH interventions tailored to women who inject drugs, through a combination of supplyand demand-side interventions. For optimal impact, RMNCH services should be integrated into harm reduction programs.
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