BACKGROUND AND OBJECTIVES:
Promoted
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 PARTICIPANTS:
We
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.
RESULTS:
The
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.
CONCLUSIONS:
Methadone
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.
Below: Projected impact of opioid substitution treatment (OST) on HIV prevalence and incidence at varied coverage levels
1Centre for
Research on Drugs and Health Behaviour, London School of Hygiene and Tropical
Medicine, London, UK
2Kenyan
Consortium of AIDS Non-Government Organisations, Nairobi, Kenya
3Division of
Global Health, School of Medicine, University of California at San Diego, San
Diego, USA
4Centre for HIV
Prevention Research, University of Nairobi, Nairobi, Kenya
5Institute for
Global Health, College of Nursing, New York University, New York, USA
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