The Access to Care Study in Kenya: PWID experiences of care and the risk environment


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  • Sylvia
    The Access To Care research project is a qualitative study which aims to understand the environmental factors which influence access to HIV prevention and treatment for people who inject drugs (PWID) in Kenya.
    It is a collaboration between the International AIDS Alliance, KANCO and the London School of Hygiene and Tropical Medicine, and is supported as part of the CAHR programme.
    [Introductions from the group]
  • Sylvia
    Context – detail in slide
    A key feature of the study is that it is capturing access to HIV prevention and care in a period of change, with the development, implementation and scale-up of harm reduction interventions supported by CAHR as well as by other initiatives.
    Key topics investigated by the study include: perceptions of risk and safety, especially regarding syringe use and sharing; access to services and HIV prevention materials; access to, and experience of, drug and HIV treatments; access to informal help and the role of peer support; transitions in drug injecting; relationships with community, including police, mob justice etc; and the lived experience of HIV.
    Theoretical approach of exploring the risk environment for PWID, develop that more in the next slide
    An important part of the study approach is that it is longitudinal, where we follow-up on a sub-sample of those in the study a further two times after baseline, approximately at 6 months intervals. This enables us to capture change, as well as to follow-up in depth on particular life stories and experiences.
    Three sites – working with outreach projects, with combination of outreach, KANCO and LSHTM team involved in collecting data through ion-depth interviews, observation and stakeholder interviews
    [Here, reporting on emerging analytical themes – not final analysis – and so welcome comments]
  • James
    Before discussing findings, briefly reflect on the importance of qualitative harm reduction to HIV care and harm reduction for PWID in Kenya
    Based on how, qualitative work, especially qualitative longitudinal work is under utilised in this area
    Four key elements to the importance of qualitative work to compliment quantitative work
    1 longitudinal element so important because of the fast pace of policy change and development in Kenya – allowing us to engage with these innovative policies as they develop and see them change over time – harm reduction
    2 Being a qualitative study which relies primarily upon in-depth interviews, it seeks to generate detailed narratives from participant perspectives, thus giving voice to people who inject drugs about their own experiences and views.
    Photo gives some insight in to this – photo is a location for some interviews by the team – in the community, trying to collect data in natural settings
    3 Power of these narratives and accounts is in understanding the micro-scale social processes that i) adapt and change national and global policy and ideals as they are implemented at the local level
    And 4 how people are shaped and limited in their actions by the broader structural environment
    A key theoretical basis for the study – based on thsi approach of engaging with experience, local processes and the pathways of strucvture – is the Risk environment. Key analytical approach that seeks to move analysis on from focus on the individual, and a consequence focus on individual level blame and interventions – and instead seek to identify the environmental factors – social, political, economic, cultural – and the pathways through which individuals’ actions are made; and consequently in which individuals experience harm from drugs. Come back to this perspective through the presentation
  • Sylvia
  • Reduced sharing since the inception of NSP (expected). During second wave interviews, most PWID reported reduced sharing, directly linked to the ease of access to clean injecting equipment.
    Heightened awareness of sharing risks are also evident, associated with NSP outreach
    Photo 2- PWID displays used needles and syringes waiting to be returned to an outreach worker to receive new ones
    Sharing in the context of NSP
    However, accounts of sharing under specific contexts have been reported
    Withdrawal is a key factor shaping post-NSP sharing. when experiencing withdrawal, perceptions of risk are significantly overshadowed by the urge to get over the withdrawals.
    Shortage of injecting commodities- interrupted supply of commodities, during the weekend when harm reduction projects are closed
    Delivery vs PWID livelihoods- the structure of care versus the PWID livelihoods also influences access to NSP, and in turn sharing. The informal nature of employment makes them mobile, whereas outreach structure is organized to be flexible (no specific time for outreach contact)
    NSP Programs should make considerations on how to make access of commodities easier, considering the unique lifestyles of PWID. These should be addressed to cater for time spent, distance and cost of accessing NSP
    Targeted messages on risks of sharing addressing intimate relationships among PWID should be communicated
  • The study design, being a longitudinal, qualitative study, has provided an opportunity to document the perceived changes as needle and syringe program is being implemented.
    Wave one interviews conducted just before introduction of NSP, thereby capturing narratives of needle and syringe sharing in the absence of harm reduction initiatives
    Across the sites, self reports of sharing, or reporting other people who share. [elaborate on this] – shame and stigma attached to it
    Restrained access to needles and syringes significantly impact on risk perception,
    Pharmacy – key point of access – but refudsing to sell
    BUT no other piont of access
    Explain Photo 1- Incinerator at a hospital where PWID used to access discarded needles and syringes (before NSP). Sharing before NSP mainly linked to constrained access, costs of needles and syringes,
  • NSP perceived as a much-needed intervention, ease in access of needles and syringes.
    The narrative of sharing shifting to a more risk-aware, less likely to share narrative
    Outreach-led NSP providing heightened awareness of sharing risks
    There are still some contexts that enable sharing among PWID
    [pharmacy still a key role]
    [peer distribution]
  • Wavw 2 interviews – July 2013
    Assumed positivity or being HIV positive- low risk perception on account of HIV status- potentially creating a possibility of new infections for those assuming positivity
    NSP costs-the structure of NSP in relation to PWID lives and livelihoods-outreach time, DIC-based NSP,
    Withdrawal- low risk perception when experiencing withdrawal-higher chances of sharing since focus is on getting over the pain of withdrawal
    Trusting relationships-Relationships considered ‘trustworthy’ among PWID perceived less risky in relation to sharing needles and syringes.
    Storage of needles and syringes a potential difficulty for PWID based on using places, risk in losing and hence sharing in the absence of own injecting equipment* (still thinking about whether necessary to include)
  • Key point- beyond provision of injecting equipment, there are contextual factors that need to be addressed to ensure NSP success.
    The availability of injecting equipment through NSP has loopholes that create an environment that could potentially be blind to sharing. [risk environment]
    Weekend delivery- is it possible to have outreach happening throughout?
    Consider collaborations with willing retail outlet pharmacies known to PWID on NSP
    Targeted messaging on intimate relationships and sharing-can these be included in outreach messaging/curriculum?
  • [Sylvia ]
  • The Access to Care Study in Kenya: PWID experiences of care and the risk environment

    1. 1. Supporting community action on HIV & AIDs and TB The Access to Care Study in Kenya: PWID experiences of care and the risk environment NOPE Conference Prof Tim Rhodes; LSHTM Sylvia Ayon, KANCO; Dr Andy Guise, LSHTM James Ndimbii, KANCO; Dr Sobbie Mulindi, NACC with and the Access2Care Outreach project partners – Omari Project, Teenswatch, NOSET Friday 20th June 2014
    2. 2. Supporting community action on HIV & AIDs and TB The A2C study  Context  Est 18,327 PWID, est HIV prevalence 18.3% (44.5% for women)  Introduction of harm reduction services – needle and syringe exchange  Study aim – understand the risk environment  Understand impact of new services, and experience of PWID, to support ongoing development of harm reduction services
    3. 3. Supporting community action on HIV & AIDs and TB A2C study: methodology  Three sites – Malindi (Omari Project), Ukunda (Teenswatch), Nairobi (NOSET)  Qualitative: In-depth interviews with PWID, observation, stakeholder interviews  Longitudinal: 4 waves of data collection, ongoing Baseline 6 mths 12 mths 24 mths NAIROBI PWID: N=30 PWID: N=12 PWID: N=12 PWID: N=12 Stakeholders: N=7 Stakeholders: N=7 MALINDI PWID: N=50 PWID: N=16 PWID: N=16 PWID: N=16 Stakeholders: N=7 Stakeholders: N=7 UKUNDA PWID: N=30 PWID: N = 5 PWID:N = 5 PWID: N = 5 Stakeholders: N=7 Stakeholders: N=7
    4. 4. Supporting community action on HIV & AIDs and TB Qualitative perspectives on harm reduction and HIV in Kenya ∗ The role of qualitative research ∗ Engage with change and dynamism ∗ Accessing detail of experience ∗ Understanding local processes and adaption ∗ Identify pathways from structure to individual
    5. 5. Supporting community action on HIV & AIDs and TB Emerging themes in analysis ∗ Changes in Sharing following NSP ∗ Access to HIV care for PWID ∗ Drug Treatment ∗ Changes in the HIV and harm reduction policy environment ∗ Effective Government policy
    6. 6. Supporting community action on HIV & AIDs and TB Syringe sharing in the context of harm reduction  Pre-NSP  Accessing injecting equipment-challenges  Sharing-inevitable, normative and acceptable  Reflections on NSP  The gains, perceptions and challenges  Sharing avoidable, rather than inevitable  Sharing becomes situational  Priorities  How to improve and maximize
    7. 7. Supporting community action on HIV & AIDs and TB Syringe sharing – pre-NSP ∗ Wave 1 interviews conducted just before implementation of NSP ∗ Massive accounts of sharing ∗ Limited access to needles and syringes-restricted sale by retail outlets, costs, places of access versus using sites and legal environment
    8. 8. Supporting community action on HIV & AIDs and TB Reflections on NSP ∗ Outreach and DIC based NSP ∗ Improved access to needles and syringes ∗ Decline in accounts of sharing ∗ Heightened awareness in relation to sharing risks- outreach-led NSP ∗ Social facilitators enhancing post NSP sharing
    9. 9. Supporting community action on HIV & AIDs and TB Context for continued sharing ∗ HIV Status ∗ Costs of accessing NSP ∗ Withdrawal ∗ Social/intimate relationships among PWID
    10. 10. Supporting community action on HIV & AIDs and TB Implications and social interventions  Specific contextual factors play a significant role in enhancing sharing, and go beyond availing needles and syringes  How can current interventions be constructed to cater for these specific contexts?  Weekend delivery, linking to pharmacies?  Targeted messaging for PLHIV? Links to HIV care?
    11. 11. Supporting community action on HIV & AIDs and TB Asante Sana – Thank you