Dr Olawale Maiyegun, African Union (Chair)

Africa Union is proud to welcome you to the launch of the AU Compendium of Good Practices – made possible by the East Africa Office of UNODC. In 2013, we launched the AU Plan of Action on Drug Control as a comprehensive frame for the continent to galvanise national and international collaborations. Drug dependence treatment has improved since then in several African countries. OST is now available in six or seven countries. National drug observatories also exist in several countries. The AU’s Standing Technical Committee on Health and Population met in 2017. Articles were collected by member states and evaluated on the basis of efficiency, relevance, community involvement, political involvement, replicability and sustainability. We also had an extensive internal debate over what comprises good practice – which led to these clear criteria. We hope that the publication will be useful for you all, and will look to improve on it and include more examples in the next editions.

Dr Jane Marie Ong’olo, African Union

Welcomed, and introduced the panelists as well as thanked UNODC who co-edited the document with us, and they supported this initiative.

Mrs Sylvie Bertrand, UNODC East Africa Office

It is an interesting time for the region, with treatment being scaled-up and delivered. Our focus is on drug use prevention, drug treatment, and the HIV needs of people who inject drugs. We did hope to have a civil society participant from Nigeria, with support from the European Union, but he was unable to attend sadly.

Dr Menan Abd-Imaksoud Rabie, Egypt

We have a problem of female drug use in Egypt – research in 2015 showed that rate of drug abuse amongst men and women was 7:1, and dependence 10:1. We need gender-responsive steps to address gender differences in dependence, mental health, risk factors and consequences, barriers to treatment, support needs, and relapse predictors, etc. Before 2011, there was no records if female addicts. Inpatients were treated in a psychiatric ward, mixed with males. Gender-specific programmes allowed for research on female socialization and pathways through the system. Phase 1 included a desk review of practices worldwide. Phase 2 was focus groups with experts. Phase 3 as a quantitative survey. Phase 4 was a workshop. Phase 5 was the pilot. Phase six was evaluation. Phase 7 was the final report. Key elements of the approach included a relational approach, a strengths-based approach and a trauma-based approach. Barriers included childcare, lack of motivation, finances, fear of legal problems, etc. Need included special activities for females, special services for childcare, female health providers, etc. So we built the therapy team to run the project. The service was based in Heliopolis Hospital, in a separate building with a special entrance. The management team was all female. We work to provide safety to our clients, and include post-trauma therapy in the treatment plan. In the inpatient ward, we provided fixed daily schedules including individual psychotherapy and group therapies, book reading, etc. Other elements including couple and relationship counselling, family sessions, cooking, art, planting, and themed days – such as “A Day Without Smoke”. We continue to follow-up with clients after they leave, with telephone calls etc to support their completion. Feedback is improving, and services were spread to other centres in Cairo and Alexandria. The numbers engaging are increasing since 2014, showing that this approach was acceptable to the target group in Egypt. All stakeholders were involved and supportive.

Dr Hussein Manji, UNODC East Africa Office

I am here today to introduce some of the responses in Kenya. In 2014, after a consensus assessment was done, we identified nearly 20,000 people who inject drugs – 50% of whom were in the Coast Region. In 2010, there was a heroin crisis but a weak response – resulting in overcrowded hospital responses etc. In 2014, we finally had the Medically Assisted Therapy (MAT) programme – a comprehensive programme to prevent HIV among people who use and inject drugs. It has four prongs: adopting policies and strategies, increasing access to HIV prevention services, strengthening political and community support, and evaluating the programmes. We had strong engagement with government and non-government partners through regular meetings. The MAT clinics have monthly meetings within their local area to discuss best practice, lessons learned, and share data. Every four or three months, they also have an inter-county meeting. Twice a year, there was also a national meeting hosted by NASCOB in Nairobi. We did study tours for key individuals to learn lessons from Mauritius, Spain, UK, USA and Tanzania. A national policy on HIV prevention for key populations was developed. We conducted structured feasibility assessments, and to ensure sustainability the government paid for some elements and international donors paid for others. In Kenya, a network of CSOs reach out to engage clients. A range of services are provided at each facility as well as MAT – including care for comorbidities. There are now more tolerant attitudes towards those accessing MAT programmes in the community and among law enforcement. We also had an increase of referrals to the programme as an alternative to incarceration. We developed the evaluation indicators and tools, and now all MAT programmes report to one platform to resolve communication difficulties. Kenya’s MAT programme is a good practice model. The low threshold approach, client-centred approach and rapidly scaled-up approach ensures that people who inject or use drugs are being reached. Adherence to ART and other medical treatments has benefited. We hope that others will replicate this model too. The next step is to reach 9,000 people in the coming years – including through mobile vans and take-home doses, and the introduction of naltrexone.

Dr Cassian Nyandindi, Tanzania

Tanzania’s programme started in 2011, and the community programme began as early as 2008. We did research and found HIV prevalence of more than 50% and HCV prevalence of more than 70%. So policy makers established a response, and we started the first programme for methadone. In 2017, we had 5,885 clients across six sites, and we noted high levels of multi-drug resistance tuberculosis. We adopted the UNODC, WHO, UNAIDS comprehensive package – including the methadone, but also HIV testing and counselling. People can receive their ART in the same site as the methadone clinic. We also provide information, education and other medical services. We also provide vocational training. We provide needle and syringe exchange in different sites. We developed guidelines and SOPs for these services, and soon we start with take-away doses (as it is currently a directly-observed therapy). This is a cornerstone for people to get into treatment, and allows people to get HIV, HCV and TB treatments as well as for other medical and mental conditions. The programme also has a lot of benefits for pregnant women, and has very good outcomes. It has decreased mortality and morbidity related to drug use, and drug-related crime has also gone down. Despite the fact that we have had a lot of success – but we need to expand further, we need to do more capacity building and training, and need to have a well-integrated aftercare programme. We are also exploring the use of other medications alongside methadone, such as buprenorphine and naltrexone. The advocacy is very important, starting from the high and low levels. It needs a multisectoral approach – government agencies, academia etc. Research is very important. We have a scale-up plan.

Questions:

• I want to ask about monitoring and evaluation – so we can show what we have been doing.
• How do you do assessments of the clients accessing the programmes?
• Does the African Union have a policy on harm reduction?
• What strategies are in place to ensure that those on methadone are taken off of it as much as possible?
• Will countries also look at heroin-assisted treatment?

Tanzania response: We have adopted our M&E systems from PEPFAR. For our methadone programme, we use community outreach workers and peers to do an initial assessment of clients in the street. They then are assessed by professionals using specific tools designed to assess drug use behaviour, medical and mental conditions. Some clients have been supported to exit the programme, but we need to understand that addiction is a chronic condition with common relapses. The key is to assess the clients needs, to help them to exit the programme in the best way. It is also important that family and friends are involved in the recovery process, to provide as much support as possible. The presence of comorbidities is also an extra complication, and impacts on how a person succeeds with methadone, and for how long.

Kenya response: We have representatives from all community organisations to develop the tools – starting with paper-based tools, but now also on Excel. The tool you use depends on the resources and context you are in. We even have a system that works on mobile phones, so that it can be used in communities.

Africa Union: The AU policy on drug issues is balanced, comprehensive – so it encompasses everything. The AU also came up with a common position that outlines this balanced approach, and it is available for everyone to see. Plus the compendium that we are launching today.

Question: Why is the Africa Group position so much different?

There is no difference between the AU position and the position of the AU Group in Vienna. However, we should not forget that there is Group Politics among regional groups at the UN”.