Designing and Implementing a Harm Reduction Program for People Who Inject Drugs in Kigali, Rwanda
Dr. Jean Olivier Twahirwa Rwema, 2021-2022 IIE Centennial Fellow
I am Dr. Jean Olivier Twahirwa Rwema, a Rwandan medical doctor, currently completing my PhD in Infectious Diseases Epidemiology at Johns Hopkins School of Public Health (JHSPH). My career trajectory took a turn in 2016 when I was completing a Master of Public Health at JHSPH as a Fulbright Scholar. During that year, I joined the Center of Public Health and Human Rights at JHSPH and got involved in Key Populations’ research. Key populations include men who have sex with men, transgender women, female sex workers, and people who inject drugs (PWID). Members of these groups are at higher risk of HIV, other sexually transmitted infections (STIs), and other blood-borne infections (OBBI) compared to the general population. Additionally, these groups are criminalized, marginalized, and face substantial stigma, sexual and physical violence, and discrimination from their communities – all of which limit their engagement with health services in many settings. As a result, these groups not only have higher risk of diseases, but also have poorer health outcomes compared to the general population. Since then, I decided to focus my research on understanding the gaps and challenges in health programming for these groups in Rwanda and across sub-Saharan Africa.
The project supported by my IIE Centennial Fellowship will focus on People who Inject Drugs (PWID). I plan to work with Health Development Initiative (HDI), the community of PWID in Kigali, Rwanda, and other local partners to design and implement the first harm reduction project for PWID in Rwanda. I believe that lessons learned from this project will inform national and regional efforts to offer health and social services to PWID.
Scope of the problem
Globally, about 15 million people report injection drug use (IDU) (1, 2). IDU constitutes a major public health issue because it is associated with an increased risk of acquiring HIV and other STIs, hepatitis B virus (HBV), hepatitis C virus (HCV), OBBI, and mental health issues(2, 3). PWID also face significant social and economic challenges with high burden of homelessness or unstable housing and high incarceration rates (1). Given this high burden of disease and social challenges, the World Health Organization recommends that countries design and implement programs to address the unique needs of PWID.
Rwanda does not have a national program to address the health and social needs of PWID. This is mainly due to a lack of epidemiological data and the criminalization of injection drug use which complicate health programming for PWID in the country. However, I recently collaborated with HDI, a local non-governmental organization and other partners to conduct a study among PWID in Kigali.
This study, published in the Harm Reduction Journal, provided valuable data to inform programming for PWID in Rwanda (4):
- We found a prevalence of HIV among PWID that was three times the national average.
- We found a high prevalence of opioid use, with 98% of participants reporting heroin to be their primary drug of injection.
- We found high levels including needle sharing and reuse, with 91% of participants reporting ever sharing needles with an injecting partner and a third reporting reusing needles in the six months preceding the study. Needle sharing and reuse are practices associated with increased risk of transmission and acquisition of infections.
- We also documented other unsafe injection practices including use of inappropriate injection equipment and use of non-sterile and dirty syringes and needles.
- Finally, 43% of participants reported knowing someone who died from a drug-related overdose.
These data showed that PWID are at high risk of morbidity and mortality, and that there is an urgent need for implementation of evidence-based harm reduction strategies.
The objective of this project is to design and implement the first harm reduction program in Kigali, Rwanda. I will collaborate with the community of PWID in Kigali, HDI, and other local partners to accomplish the following goals.
First, given the high level of needle syringe sharing, needle reuse and other unsafe injection practices found in our study, we will design and implement a syringe services program (SSP) for PWID in Kigali. SSP programs are evidence-based interventions recommended by the World Health Organization for all countries (5). These programs provide sterile needles, syringes, and other drug paraphernalia to PWID and have been shown to be effective in reducing unsafe injection practices and injection frequency. Additionally, they facilitate linkage of PWID to overdose prevention, substance use treatment programs, and other medical services while being cost effective (6-8). Second, given the high number of drug-related overdoses reported by participants, the program will also include an opioid-related overdose prevention program that will include naloxone distribution.
- Degenhardt L, Peacock A, Colledge S, Leung J, Grebely J, Vickerman P, et al. Global prevalence of injecting drug use and sociodemographic characteristics and prevalence of HIV, HBV, and HCV in people who inject drugs: a multistage systematic review. The Lancet Global Health. 2017;5(12):e1192-e207.
- World Drug Report 2020. 2021.
- J G, S L, A P, S C, J L, M H, et al. Global, regional, and country-level estimates of hepatitis C infection among people who have recently injected drugs. Addiction (Abingdon, England). 2019;114(1).
- Twahirwa Rwema JO, Nizeyimana V, Prata NM, Okonkwo NE, Mazzei AA, Muhirwa S, et al. Injection drug use practices and HIV infection among people who inject drugs in Kigali, Rwanda: a cross-sectional study. Harm Reduction Journal. 2021;18(1).
- Organization WH. Consolidated Guidelines on HIV Prevention, Diagnosis, Treatment and Care for Key Populations – 2016 Update 2016. Available from: https://www.ncbi.nlm.nih.gov/books/NBK379694/.
- Strathdee SA, Celentano DD, Shah N, Lyles C, Stambolis VA, Macalino G, et al. Needle-exchange attendance and health care utilization promote entry into detoxification. Journal of urban health: bulletin of the New York Academy of Medicine. 1999;76(4):448-60.
- Hagan H, McGough JP, Thiede H, Hopkins S, Duchin J, Alexander ER. Reduced injection frequency and increased entry and retention in drug treatment associated with needle-exchange participation in Seattle drug injectors. Journal of Substance Abuse Treatment. 2000;19(3):247-52.
- Riley ED, Kral AH, Stopka TJ, Garfein RS, Reuckhaus P, Bluthenthal RN. Access to sterile syringes through San Francisco pharmacies and the association with HIV risk behavior among injection drug users. J Urban Health. 2010;87(4):534-42.