Is the promise of methadone Kenya's solution to managing HIV and addiction? A mixed-method mathematical modelling and qualitative study.
OBJECTIVE
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.
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.
Centre for Research on Drugs and Health Behaviour, London School of Hygiene and Tropical Medicine, London, UK.
Tim
T
Rhodes
Centre for Research on Drugs and Health Behaviour, London School of Hygiene and Tropical Medicine, London, UK.
Andy
A
Guise
Kenyan Consortium of AIDS Non-Government Organisations, Nairobi, Kenya.
James
J
Ndimbii
Division of Global Health, School of Medicine, University of California at San Diego, San Diego, USA.
Steffanie
S
Strathdee
Centre for HIV Prevention Research, University of Nairobi, Nairobi, Kenya.
Elizabeth
E
Ngugi
Centre for Research on Drugs and Health Behaviour, London School of Hygiene and Tropical Medicine, London, UK.
Lucy
L
Platt
Institute for Global Health, College of Nursing, New York University, New York, USA.
Ann
A
Kurth
Institute for Global Health, College of Nursing, New York University, New York, USA.
Charles
C
Cleland
Centre for Research on Drugs and Health Behaviour, London School of Hygiene and Tropical Medicine, London, UK.
Peter
P
Vickerman
D000328:Adult; D005260:Female; D015658:HIV Infections / Q000453:epidemiology / Q000517:prevention & control*; D040261:Harm Reduction; D006556:Heroin Dependence / Q000188:drug therapy* / Q000523:psychology; D065026:Hope; D006801:Humans; D015994:Incidence; D007407:Interviews as Topic; D007630:Kenya / Q000453:epidemiology; D008297:Male; D008691:Methadone / Q000627:therapeutic use*; D008875:Middle Aged; D008962:Models, Theoretical; D009294:Narcotics / Q000627:therapeutic use*; D058850:Opiate Substitution Treatment; D036301:Qualitative Research; D015819:Substance Abuse, Intravenous / Q000188:drug therapy* / Q000523:psychology; D055815:Young Adult
D009294:Narcotics; D008691:Methadone
HIV prevention; Implementation science; Kenya; Methadone; Modelling; QUALITATIVE RESEARCH