A qualitative analysis of transitions to heroin injection in Kenya: implications for HIV prevention and harm reduction

Abstract

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.

The experience of initiating injection drug use and its social context: a qualitative systematic review and thematic synthesis

“…Friends (41, 44, 47, 48, 50, 51, 55, 56, 60, 68, 70, 73, 77), family (41, 43, 44, 51, 52, 55, 68, 70–73), intimate partners (42, 48, 49, 52, 57, 59, 60, 64, 68, 70–72, 77), acquaintances (37, 43, 77), gang members (63), elders (65) and drug dealers (41, 42) were all described as influential. Different types of social interactions shaped injection initiation.…”

“…Some studies referenced the idea of ‘exposure’ to drug injecting behaviors within particular social networks and locations (e.g., street drug scenes) (44, 61, 70, 72). More precise conceptualizations identified witnessing or observing others injecting (38, 47, 50, 52, 55, 70), which can generate awareness and curiosity (44, 52): “He would sit in the back [of the car] and start shooting himself. And I was watching him as he was nodding out, much more than I was, and I started getting jealous” (Woman, 21 years old, USA (48)).…”

“…Studies suggested that people who already inject may encourage injection initiation, enthusing about the benefits of drug injection linked to pleasure or cost-efficiency (37, 47, 48, 51, 52, 70, 72, 73) (e.g., “ people were telling me, ‘you’re wasting it by sniffing’ ” (Man, USA (70)). This advocacy is then linked to providing injection initiation assistance, including administering an individual’s first injection (47, 72).…”

“…This advocacy is then linked to providing injection initiation assistance, including administering an individual’s first injection (47, 72). Encouragement by people who already inject could extend to peer pressure (37, 66, 68) and more direct coercion (38, 52, 55).…”

Preventing Injection Drug use Initiation: State of the Evidence and Opportunities for the Future

“…Further, the efficiency afforded by injection vs. non-injection of drugs has been identified as a key motivator for transitions into initiation, particularly among individuals experiencing endemic poverty and during periods when the price of illegal drugs increases [26][27][28][29][30][31].…”