North Star has been implementing the Global Fund HIV programme in Makueni County, Kenya, targeting truck drivers and People who inject drugs (PWIDs). North Star Alliance is a sub-recipient of the Global Fund New Funding Model (NFM-3) for HIV through the support of the Kenya Red Cross Society, which is the non-state prime recipient. The programme provides a comprehensive package of HIV prevention, care, treatment, and support services to key and vulnerable populations (KVPs).
According to the World Health Organization (2018), people who inject drugs (PWID) are at increased risk of tuberculosis (TB), irrespective of their HIV status. TB is a leading cause of HIV-related mortality among PWID in Kenya.
The constraints in healthcare service provision in Kenya pose a major challenge to preventing the spread of HIV and TB among people who inject drugs.
Recognizing the need for a community-driven approach to curb the spread of HIV and TB among people who inject drugs, North Star Alliance adopted a peer-led and community-centred approach in Makueni County as per the Ministry of Health Key Populations HIV prevention and care and treatment services guidelines for Key Populations, including PWIDs.
The programme entails the inclusive participation of all stakeholders to develop new context-specific solutions for addressing HIV/TB risk behaviours among PWIDs.
The programme approach is based on a combined prevention approach that draws together behavioural, biomedical, and structural interventions. An essential service package for HIV prevention has been developed to ensure that PWIDs receive the services necessary to minimise risk and vulnerability to HIV, TB and STIs. The programme banks on peer educators drawn from the PWID cohorts to implement the interventions.
The peer educators are responsible for the weekly distribution of needles and syringes, dubbed the Needle Syringes Programme (NSP), supported by the Ministry of Health. This has helped in strengthening health education at the hotspots and curbing needle sharing among PWIDs. To know the number of needles and syringes needed by the peers, the peer educator, together with the project team, looks at the injecting episode a day. For instance, when a peer is injecting once a day, 30 needles and syringes are distributed evenly within the month. During the behaviour change communication sessions, the peers are also taken through condom demonstration and distribution, discussions on the importance of HIV testing, TB and STI screening, and the importance of safe disposal of needles and syringes.
“The programme banks on us. We are the link between the programme and PWIDs. As a peer educator, I help with mapping hotspots, planning and coordinating peer outreaches, health talks and distribution of needles and syringes at the hotspots.” Charles Kimathi, Peer Educator, Emali.
Peer educators also lead peer outreaches at the hotspots where the PWIDs are offered comprehensive clinical services. The peer educators develop a work plan, assess and determine the requirements of the cohorts in terms of commodities and services required. This informs the clinical outreaches conducted by locum clinicians and HIV Testing Services (HTS) providers who offer HIV testing and screening for TB and STIs. Peers identified to be HIV positive or in need of further laboratory investigation for Tuberculosis are linked for treatment services at the North Star Alliance roadside wellness centre located in Emali town or at the Ministry of Health facilities as per their preference. The peer educators visiting the hotspots to engage and assess the needs of the peers has led to more peers accepting the program.
To ensure safety at the hotspots, the program uses plastic safety boxes drilled into the hotspots. The peer educators regularly monitor these safety boxes and inform the project field officers when they are filled up. The project officer and peer educators, with the assistance of public health officers, dispose of the filled-up safety boxes and the peer educators replace the disposed plastic boxes with new ones.
“As PWIDs, we faced a lot of stigma and discrimination, and whenever we went to buy needles and syringes, we would be turned away. This meant that we had to share needles, putting us at risk of contracting diseases such as HIV. Through the Needle and syringe programme, we no longer share these commodities”. Jackson Mutua, PWID, Emali town, Makueni County
Additionally, peer educators play a key role in supporting PrEP services to peers at the hotspots. North Star has integrated ‘PrEP Labs’ at the hotspots. PrEP lab at hotspots entails hotspot-targeted PrEP messaging to create awareness and demand for PrEP uptake, including distribution of informational materials. It also entails ensuring access to and weekly dispensing of PrEP pills to PWID at hotspot level, including adherence monitoring. This has helped monitor adherence and side effects and ensure adherence is sustained.
“Over the programme period, we have seen stigma against PWIDs reduced; they walk freely into the clinics for check-ups, HIV testing, and STI screening, or to pick up commodities whenever they need”. Tumaini Nguma, Project Field Officer
Peer educators have played a key role in the programme. However, this has also had its fair share of challenges. Being the first programme providing HIV prevention services to PWIDs in the target locations, North Star has experienced community resistance. To remedy this, North Star used a community-centred approach to ease programme acceptance and community entry. This has had a slow-balling effect as peers enrolled in the programme have escalated the benefits to their peers. This increased the number of PWIDs voluntarily enrolling in the programme.
“At the start of the programme, it was challenging onboarding and enrolling the PWIDs into the programme as they thought we were spying on them. However, we adopted a community-centred approach to ease programme acceptance and community entry and there has been a slow-balling effect as peers enrolled in the programme have escalated the benefits to their peers. This increased the number of PWIDs voluntarily enrolling in the programme”. Dahlstrom Aloka Project Field Officer