title: Heroin shortage in Coastal Kenya: A rapid assessment and qualitative analysis of heroin users' experiences.
abstract: BACKGROUND
  While relatively rare events, abrupt disruptions in heroin availability have a significant impact on morbidity and mortality risk among those who are heroin dependent. A heroin shortage occurred in Coast Province, Kenya from December 2010 to March 2011. This qualitative analysis describes the shortage events and consequences from the perspective of heroin users, along with implications for health and other public sectors.
  
  
  METHODS
  As part of a rapid assessment, 66 key informant interviews and 15 focus groups among heroin users in Coast Province, Kenya were conducted. A qualitative thematic analysis was undertaken in Atlas.ti. to identify salient themes related to the shortage.
  
  
  RESULTS
  Overall, participant accounts were rooted in a theme of desperation and uncertainty, with emphasis on six sub-themes: (1) withdrawal and strategies for alleviating withdrawal, including use of medical intervention and other detoxification attempts; (2) challenges of dealing with unpredictable drug availability, cost, and purity; (3) changes in drug use patterns, and actions taken to procure heroin and other drugs; (4) modifications in drug user relationship dynamics and networks, including introduction of risky group-level injection practices; (5) family and community response; and (6) new challenges with the heroin market resurgence.
  
  
  CONCLUSIONS
  The heroin shortage led to a series of consequences for drug users, including increased risk of morbidity, mortality and disenfranchisement at social and structural levels. Availability of evidence-based services for drug users and emergency preparedness plans could have mitigated this impact.
authors.affiliation: Division of Global HIV/AIDS, US Centers for Disease Control and Prevention, 1600 Clifton Road, MS E-04, Atlanta, GA 30329, United States. Electronic address: smital@cdc.gov.
authors.forename: Sasha
authors.initials: S
authors.lastname: Mital
authors.affiliation: Division of Global HIV/AIDS, US Centers for Disease Control and Prevention, 1600 Clifton Road, MS E-04, Atlanta, GA 30329, United States.
authors.forename: Gillian
authors.initials: G
authors.lastname: Miles
authors.affiliation: Division of HIV/AIDS Prevention, US Centers for Disease Control and Prevention, 1600 Clifton Road, MS E-45, Atlanta, GA 30329, United States.
authors.forename: Eleanor
authors.initials: E
authors.lastname: McLellan-Lemal
authors.affiliation: KEMRI Complex, Mbagathi Road off Mbagathi Way, PO Box 606-00621, Village Market, Nairobi, Kenya.
authors.forename: Mercy
authors.initials: M
authors.lastname: Muthui
authors.affiliation: Division of Global HIV/AIDS, US Centers for Disease Control and Prevention, 1600 Clifton Road, MS E-04, Atlanta, GA 30329, United States; Office of the Global AIDS Coordinator, SA-29, 2nd floor, 2201 C. Street NW, Washington, DC 20522-2920, United States.
authors.forename: Richard
authors.initials: R
authors.lastname: Needle
mesh_terms: D055030:Drug Users / Q000523:psychology / Q000706:statistics & numerical data*; D005260:Female; D017144:Focus Groups; D003932:Heroin / Q000600:supply & distribution*; D006556:Heroin Dependence / Q000453:epidemiology*; D006801:Humans; D007407:Interviews as Topic; D007630:Kenya / Q000453:epidemiology; D008297:Male; D015819:Substance Abuse, Intravenous / Q000453:epidemiology; D013375:Substance Withdrawal Syndrome / Q000453:epidemiology*
chemical_list: D003932:Heroin
keywords: Drug treatment; HIV; Heroin shortage; KENYA; Medication-assisted treatment