In this blog, Adebisi Yusuff Adebayo takes a critical look at the implementation of harm reduction measures to address the health risks related to injection drug use in Nigeria.
Despite the fact that there are numerous strong global proofs that support harm reduction strategies1,2, the coverage, adoption and implementation for people who inject drugs (PWID) is poor and Nigeria is not an exception to this. PWID constitute a considerable quota of people at-risk in Nigeria and 20% of people who use drugs are injecting drugs3. It has been reported that the most common drugs injected were pharmaceutical opioids, followed by cocaine and heroin. In Nigeria, the level of risky injecting practices and risky sexual behaviors among PWID is worrisome3. Particularly, women who inject drugs are more prone to engage in high-risk sexual behaviors compared to the male counterpart which further catalyze their risk of acquiring and transmitting HIV among other infections. This problem is doubly compounded by the criminalization of drug use and the non-adoption of evidence-based harm reduction strategies in the country. Even though numerous evidences and mathematical models revealed that combination of opioid substitution treatment (OST), Syringe Access Services (SAS) and Antiretroviral Treatment (ART) among PWID can reduce new HIV infections by more than 50%1, adoption of harm reduction globally is still abysmally low.
Injecting drug use is known to be associated with serious drug-related distress, including but not limited to potential transmission of HIV and viral hepatitis, overdoses, and injection sites infection among others. According to the Global State of Harm Reduction 2018, the HIV prevalence among PWID in Nigeria is 3.4%; the Hepatitis C prevalence is 5.8% and the Hepatitis B prevalence is 6.7%4. Unsafe injection practices such as sharing contaminated needles are a major risk factor for transmission of blood-borne infections such as hepatitis B, C, and HIV. Access to interventions such as SAS and OST is known to be effective in reducing harms and reducing morbidity and mortality among PWID. Having knowledge about injecting practices and behaviours of PWID is an important first step to effectively target such interventions. Even though, the recently released report3 revealed a lot of information about the state of injection drug use in Nigeria, the total number of overdose deaths remains unknown.
While the incidence of HIV infection experienced a decline between 2011 and 2017 by 22% for all ages globally, HIV infections among PWID appear to be uprising. HIV incidence among PWID rose from an estimated 1.2% in 2011 to 1.4% in 20175. Nigeria, with over 180 million people, has been identified by the United Nations as high priority country for HIV prevention among PWID. The worldwide attestation in support of HIV prevention for PWID is entrancing 1,2. The Drug Use Report 2018 states that about 50% of PWID reported that they had used a needle or syringe after someone else had used it or another person had injected with their used needle or syringe3. Non-performance of the government to implement harm reduction programs to prevent HIV, hepatitis C, and overdose deaths among PWID has been a major factor extenuating against progress of the nation’s public health sector. This calls for systemic interventions to address scathing communal, legislative, governmental, and environmental facilitators of HIV risk among PWID.
Harm reduction interventions include symbiotic biomedical, behavioral, and organizational interventions, which are not only evidence-based but also rights-and-community-based. It is therefore important for the Nigerian government to endorse and develop a package of HIV prevention intervention for PWIDs, including, access to SAS, OST, ART, sexual behavior change communication, and community outreach. The majority of PWID in Nigeria do not know what Naloxone is for and how/when to use it. Many stakeholders hesitate to adopt harm reduction services because they fear drug use may increase as a consequence, although this has not happened elsewhere. At this point, adopting harm reduction and reforming drug policy in the country is a matter of urgency. The need to engage and equip the stakeholders with the right knowledge base is pertinent.
The Global State of Harm Reduction 2018 has shown that Nigeria is politically resistant to implementing SAS and OST, despite convincing evidence4. Political resistance and poor funding of the health sector due to little or no budgetary allocation for setting up and sustaining rehabilitation centers in the country complicate the process. Placing a ban on codeine without a provision to rehabilitate people that are already addicted is a further concern. It is therefore pertinent for the country to start establishing rights-based, adequate, effective and affordable rehabilitation and substance use treatment centers in the country. As affirmed by the World Health Organization (WHO), the United Nations Office on Drugs and Crime (UNODC), Harm Reduction International (HRI), International AIDS Society (IAS), Students for Sensible Drug Policy (SSDP), Youth Initiative for Drug Research, Information, Support and Education (Youth RISE) and other reputable partners at the heart of science, an all-inclusive package of harm reduction interventions has been demonstrated scientifically to support the prevention and spread of HIV and the reduction of other harms and distresses among PWID.
Nigeria could follow Mauritius, another African country which has successfully achieved a high coverage of harm reduction services for PWID. It would not be surprising if Mauritius would be the first country in Africa to achieve zero new HIV infection among PWID. It is time for Nigeria to adopt harm reduction intervention among PWID towards UNAIDS 90-90-90 target in 2020 and invest in setting up affordable and high-quality centers that offer rehabilitation and other substance use treatment services. This should be more than just a policy recommendation as the successful and actual implementation of services is much-needed. In addition to this, it is important to bridge the knowledge and awareness gaps about harm reduction among healthcare professionals in Nigeria. Harm reduction works!
About the author
Adebisi Yusuff Adebayo is the associate director for research at Global Health Focus with interests in global public health on issues concerning drugs ranging from licit and illicit ones with specific interests in harm reduction, substance use disorders and antimicrobial resistance. He is also interested in research and practice relating to HIV/AIDS, health promotion, emerging/re-emerging diseases, drug harm reduction and drug policy, access to medicines, health systems strengthening, human resources for health, and translation of health research into policy and practice. You can contact him at adebisiyusuff23[at]yahoo.com .
- Degenhardt, L., Mathers, B., Vickerman, P., Rhodes, T., Latkin, C., & Hickman, M. (2010). Prevention of HIV infection for people who inject drugs: Why individual, structural and combination approaches are needed. Lancet; 376:285–301. [↩]
- MacArthur, G., Minozzi, S., Martin, N., Vickerman, P., Deren, S., Bruneau, J., et al. (2012). Opiate substitution treatment and HIV transmission in people who inject drugs: Systematic review and meta-analysis. British Medical Journal; 345:e5945. [↩]
- United Nations Office on Drugs and Crime (2018). Drug use in Nigeria 2018. Available from http://www.unodc.org/documents/nigeria//Drug_Use_Survey_Nigeria_2019_BOOK.pdf. Accessed: 10/08/2019 [↩]
- Harm Reduction International (2018). The Global State of Harm Reduction 2018. Available from https://www.hri.global/files/2019/02/05/global-state-harm-reduction-2018.pdf. Accessed: 10/08/2019 [↩]
- UN AIDS (2019). Injection drug use. Available from https://www.unaids.org/en/keywords/injecting-drug-use-idu. Accessed: 10/08/2019 [↩]