 Good afternoon everybody. It's my pleasure to be here, the first on the great panel. Probably I'll take charge to make sure that your lunch is well digested by listening to me. And this afternoon I'll talk to you about translation of the of the Draghi policies into practice and I'll talk to you about the comprehensive intervention for people who use drugs, particularly who inject drugs, and I will share with you our experience in Tanzania about the methadone program and NIDO syringy program for Draghi users. I am a medical personnel. I work as introduced work in the methadone clinic but I'm also a psychiatrist and mental health specialist and I also lecturing them in Billy University in Tanzania. So I'll just take you through if time allows me. Why did we start the methadone program and NIDO syringy program in Tanzania? Who are the key players? What are the implementation planning for methadone and the NIDO syringy program? I will share with you some data in terms of the current progress, the challenges we face during the implementation plan as well as the way forward from now. Coming from one of the sub-Saharan Africa, I hope you can see where Tanzania is. Sorry, it's the technology. Yeah, it is there. Alright. Sometimes they do not follow command and they do the other way around. It's a country of about 45 population and as it is for other countries, majority are children and in Tanzania the HIV prevalence in the general population is around 5.1%. So why did we start the methadone program and NIDO syringy program? Basically we had a huge problem of heroin injection use. I know that we have been talking about use of drugs, marijuana and other drugs but in eastern Africa, I hope my colleagues will also agree with me, we have a huge problem of heroin use but the worst part of it is the injection practice that is highly associated with a number of complications that include the high rate of tuberculosis because of their living environment, sexually transmitted infection. Most women are involved in commercial sex works in order to get money for drugs and also the heroin overdose, family disintegration, psychiatric disorders. There is also associated with increased rate of criminality and incarceration and all this data we got around 2000 when we did the first research in the country which involved the five zones and that's where we found that there is a huge problem. Initially people did not believe that this is a problem. We thought injection use is not our problem, it's somewhere else a problem, maybe in the US or in Europe but not our problem. We had to live with that fact when we kept on digging more details about the drug users. That's the time when we realized that this drug using behaviors not only associated with the criminality and the other consequences but also it was highly associated with HIV and the hepatitis among people who are using drugs and we knew that this was highly linked with sexual risk behaviors as well as increased risk for sharing injection equipment. And on top of that we had survey in 2003 which showed that almost all women who injected heroin they were sharing the injection equipment and 20% of men they did the same and this was one of the highest risk for the HIV infection and hepatitis inspection particularly hepatitis C which is more virulent in the blood bone. But in eastern Africa there is another practice which is new but very dangerous, people share blood. Immediately after injection of heroin someone will draw blood from a person of just injection in order to feel high and you can imagine injection of blood from one person it means 100% chances of getting HIV and blood bone infection. If you further look at the data that we continued to work on this one in 2006 we noted that for the 2% of people injected the drugs they were HIV positive and this HIV positivity was very high amongst women to the tune of 62% while at that particular point in time the average HIV infection on the general population was only 70% and further 2011 we did another study and it kept on telling us that the problem is increasing to the extent that the HIV prevalence among people who are injecting drugs they were 51% and the rate was very high among women this was around 72% amongst women who are injecting drugs to HIV positive and in that survey we did also check for hepatitis C and what we found again was really very amazing very scaring in a sense that more than 75% of people who injected drugs they were also infected with hepatitis C infection and the rate was even higher among women to the tune of 84%. So these are the data which that we found and we kept on asking ourselves why women are more affected than men is it because women as they do sex for drugs is it because women happen to women they I mean they sex for money in order to buy drugs or it just a female sex who happened to be drug user and at the end of the day does it matter because we knew that this population is bridging is bridging between general population and this population which is basically hidden and any fight against HIV and hepatitis if you do not involve this hidden population definitely you'll not succeed because there is a pool of HIV and hepatitis plus many other physical conditions like TB and STI which we needed to reach these people and make sure that we treat and for that matter we acknowledged that we needed to work and we needed to work fast and in so doing we joined our efforts the department of circuit and mental health where I'm coming from is the one which bring this evidence on table because we are the ones who did this surveys and and researchers and got this data and together with the drug control commission which is the border sitting in the ministry of health responsible for controlling drugs in the country it is an interministerial board which is also in which involves various ministries the minister of health the minister of I mean the prison the police prosecutors and judges as well as the minister of education we normally all sit together and address issues of the drugs in the country and on top of that we have this program that took lead or took charge to provide intervention within the country but also we got technical assistance from uh Pangea Nobel Foundation from USA and University of Texas as well as working with other local partners and international NGOs like Medicine de Mundo who are experienced in providing community-based ham reduction especially in the strange program in the country and also the university and other local NGO partners so all of us we sat together and say what are we going to do about this problem after uh knowing that we we uh I mean after planning that we needed to go that one then we started the process slowly initially by lobbying and advocacy the little data that we managed to capture from the previous studies are the ones that we use as a scientific evidence to show that we have a problem and people need to act if you don't do it now at the end of the day we are going to lose the nation and in that we also we took the message together with the primary secondary level of pressure of prevention and in primary we focus more to the education and public uh uh I mean to the schools and the public health education about the issues to stop using and to stop or not starting to use drugs for the for the secondary we we uh talk about intervention that were available within the country as well as providing a rehabilitation for people who are affected but also we had to talk about the uh the police uh police makers and also the concessors with the law enforcement because currently in the country harm reduction is not acceptable in a sense that if you are found with any paraphernalia related to drug use you are allowed for punishment in 10 years in jail so not the attempt to take a need on syringe to give to a drug user in your attempt to to prevent HIV and hepatitis uh infection so the law are still there but at that point in time we started to talk and we had a mutual agreement between the law enforcement and the we health enforcement that let's work together towards the fight against HIV and hepatitis and the do not fight the drug user so after agreement that after that agreement that's the time when we move forward and now we had to balance between supply reduction demand reduction which is commonly been talked about but at the same time we had to minimize uh the risk that were associated with use of drugs and for that matter we were able to establish the national strategic framework for HIV prevention for people who are using drugs uh this is the is the document that we've been using it is it is based on the recommendation made by the UN agencies as it was presented by WHO uh agent about the nine comprehensive package that should be available for people who are using drugs so that is the model uh we are using and therefore develop a number of local documents to make sure that we were well guided through the process so these are the some of the documents that we developed to make sure that our services are well provided thereafter we did a number of uh capacity building remember this was a new uh problem in the country and we were not experienced in doing that one so we had support from various agencies including UNODC who uh chose Tanzania to be part of the threatening training plan and we send our people for training ours amongst the first batch who were trained and they and thereafter we did a lot of training um and also trained uh community outreach workers and involvement of police we trained the police officers to understand the concept of addiction to understand that addiction is not always a criminal offense but people are sick and because of their sick they need to be treated and once we are we were understood we made the innovations of some of the areas uh these are the first and second two methadone clinics they are based on the government hospitals the first site is at the national referral hospital where I'm working the second one is the municipal hospital and these are all public institution and the services are within the public services in the ministry of health we establish a community outreach strategies because we needed to reach these people these are the people who will not come for the sick for for services but we are the ones who are going out looking for them where they are and starting to talk about uh treatment options available and if they agree then we give them an escorted referral to the hospital to start uh treatment but at the community we provide a number of services uh including uh um income generating activities schooling etc and at the hospital once they come in we not only provide the methadone but we also treat them as a whole all the problems that they have tuberculosis infections etc they were treated within the hospital and all these services you are free of charge because it came from the health police of the country addiction and mental health uh it's one of the chronic illnesses that treatments has to be done uh has they have to be exempted from uh paying the services we also use the mobile clinics to reach out them this including access to hepatitis and HIV testing cancelling so when you go out with these caravans will have a camp they'll come we talk to them we test HIV hepatitis for those who are ready to receive treatment we go with them to the hospital to start the treatment we are also working with MDM the medicine demonro who are an expert to the needle syringe program in the country and this is the one of the advanced they are using for outreach program so what have we done so far we are using the comprehensive provision model which is WHO recommended and UN agencies the UN AIDS as well as the UNODC it has got a nine package I'm glad to announce that Tanzania currently we are providing almost almost all the nine packages as recommended by WHO for people who are using drugs we are using the uh the hospital we are using the dropping incentives at the community levels we are also using the van to reach out the population and provide these services with an exception of number nine which talks about vaccination diagnosis and treatment of viral hepatitis this is the only one we still have uh challenges it is the worldwide problem the only thing we can do now is just to test it for hepatitis B and hepatitis C otherwise we do need a syringe program we provide methadone HIV testing and cancelling we provide ART at the old methadone clinics and other government receptors we provide treatment for STI we have condom programs we provide uh targeted materials that uh talks about uh use of drugs and consequences related to use of drugs as well as tuberculosis as I will show in some of the data so we had our first site in February 2011 the second site was opened in a year later and the third site in the following year so at least we have three sites and what have we done so far we've been able to reach uh this is Tanzania's prevention program we've been able to reach about 8,578 individuals these are people who are drug users are injection of drug users who are these are the men who sex with men and female sex workers who would not easily come forward to seek for services and these are the people who are hidden we were able to reach out them 22 percent of these people were injectors and female contributed only about 80 percent so we have problems with the females because we see a very minimal number of women when you go out for the outreach we know the reasons one is that men African women they have responsibilities during daytime and the majority of women as we showed earlier they could be involving in sex work and sex work business takes place during the night so unfortunately when we do our programming during the daytime they are probably at home or sleeping and when you go to sleep that's the time when they go out and we kind of don't meet each other most of the time by October I did not update uh I should have said earlier this this was my earlier slide the latest version did not open here so I'm using the letter I mean the earlier version we currently have about 1200 who are on methadone program currently and all these 1200 people they were heroin injectors we have not yet touched for those who are smoking or snorting only we are focused on the injectors our primary aim was initially to deal with the HIV and hepatitis issues the women population contributes about 110 percent as I said earlier the same reason and this table tries to say the distribution where we have as young as 16 individual enrolled in the program and 53 years a person also in the program at enrollment and I know that this for many people 16 years is considered as a is under age but at the end of the day we say this is not a program this is intervention and everybody from zero years to wherever they deserve to get treatment okay so I might need to need to jump but I'm just about to finish so far the retention is 80 percent that means almost all people who are on they're still on program and 80 percent are drug free they stopped using drugs for few who stop continue to use the drugs majority are still using cannabis is this cannabis has nothing to do with methadone is more behavior and is one of the difficult drugs to stop so we see the trend is just like anywhere else but for the program 30 percent of those who were tested with HIV positive 32 percent hepatitis B positive and if 58 percent were hepatitis C positive so these are the ones who are on program and also we have managed to give 41 percent of those who deserve to get of those who are HIV to start on ART in other language those who are not initiated ART their CD4 count is still high and we're still using 200 as the cut off point we've been treated 11 percent of the population for tuberculosis this is very high as compared to the general population we are 0.2 percent of the general population they are treated for TB but for this population we found the rate is very high at 11 percent we lost the two clients after having multi-drug resistant tuberculosis and this called upon a very risky for even health providers because we do not know who is having multi-drug resistance etc for MDM they were able to reach 9,000 people were using drugs two-third were injectors and they they they are able to reach about 850 using their community outreach workers they provided the 30,000 syringes each month and also they are able to recruit about 1,500 police officers so that they are sensitized on the issues of harm reduction and give us support and give support to the drug user rather than incarcerating them there was a number of challenges the the commonest challenges were we had is the misconception that methadone is another addiction and giving needle syringe to people who are using drugs is will I mean it was interpreted as will encourage people to continue injecting although our primary aim was to focus on the prevention of HIV and hepatitis in the community so we had to have a leverage between this supply reduction and harm reduction problems where some group consider think that supply reduction is the answer to the drug user problem while in the health sector we think both will work and each one has got his own role health professionals should play their own and also law enforcement should play their own but you all need to sit in one table discuss how are you going to manage that one lack of resources of course is the cross cutting issue for the staff we find ourselves having a heavy work which was not there before and also safety and security of the of this program because you are bringing together a number of people who unfortunately they had a number of personality problems in a survey we found 77 percent of them they had personality disorder which includes antisocial personality disorder so bringing all these people together creates somehow attention amongst staff and clients themselves but also the cost of traveling to the clinic is still very expensive many people lives below the poverty line and this is one of the reasons why 20 percent could not continue being in the program because they are not able to they are not able to pay for their transport otherwise we think women as one of the areas that needs to be considered the only thing that I'd like to say we are moving forward the government starting from the president prime minister and the member of parliament have basically agreed based on the work that we showed to them this program works and the government has given direction that from next government year they are going to finance the program so that you are able now to move throughout the country and this is just to show the beauty of harm reduction starting from injection to get married these are just two examples of course the beauty of Africa or not forget and I'm really very thankful for you listening and it as I said it is a multiple work of many individuals who have been doing work together with us thank you for listening good afternoon ladies and gentlemen and let me begin by thanking you very profoundly for hosting us or for having us at this very distinguished gathering I think the Portuguese speaking African countries have led the way in dealing with drugs in dealing with the drug issue and we can only hope and pray that the English and the French speaking countries will follow suits so that we can all be at the same wavelength in Africa I want to make a very short presentation on the work that we are doing basically providing legal aid for drug users in conflict with the law as the moderator introduced me earlier my name is Hussain Khalid I'm the executive director of Haki Africa but then I also partly lecture at the school of human rights and governance studies Haki Africa is an ungovernmental organization based in Mombasa Mombasa is at the cost of Kenya and it works basically to promote development and improve livelihoods with a particular emphasis on socio-economic rights so the whole idea behind Haki Africa is not to go out and defend people's rights but rather to build the capacity of the people to be able to champion for their own rights themselves so we don't expect to be there forever we want people to take the struggle for their rights on their own so that they can be the champions for their rights and we do this using various means you know public lectures talking to communities about their legal rights their constitutional rights and of course sometimes this means going out to the streets and demanding for justice whatever we feel that you know there has been some form of injustice anywhere then we do that what you see in the picture is a public lecture where we had the political leaders coming back to the public to explain what they've done in terms of implementing the constitution and then the other side is basically when a few Kenyans were renditioned to a neighboring countries to a neighboring country to face charges there and we felt that that was against the constitution so we took to the streets together with the people to demand for justice social economic rights in Kenya basically are guaranteed by the constitution of Kenya now article 43 of the constitution of Kenya guarantees these rights which include the first and the most important one for us the right to the highest attainable standard of health which includes the right to health care services including reproductive health care now the constitution of Kenya which was recently promulgated makes human rights justiciable which basically means if your rights are not guaranteed or if you don't in one way or another enjoy your rights you can actually go to court to sue the government for not having to enjoy these rights so this is something very very crucial the article 43 because it is within which the work that we are doing is based on it is the foundation of the work that we are doing as you will see later we have very many disabling laws you know that would not allow for example for drug users to get justice in courts or things like that but through the article 43 if there's any law legislation that contradicts the constitution of course that law is null and void to the extent of that contradiction so then this article becomes extremely extremely important in the work that we are doing to try and ensure that drug users have their right to health care besides that of course we also have other rights accessible and adequate housing freedom from hunger and to have adequate food of acceptable quality again this is crucial for drug users not just any food but adequate food of acceptable quality clean and safe water in adequate quantities social security and education these are all constitutional guarantees under the constitution of Kenya Kenya and the drug use well as is in most other countries it is illegal and punishable by a fine imprisonment or both if you are found in use or possession of any drugs in Kenya and this drugs range you know from marijuana heroin and all those so it is something punishable and unfortunately in Kenya even though we are neighboring Tanzania which has made huge strides in terms of dealing with the drug issue from a health perspective we still lag behind in that in that area in Mombasa where our organization is based at drug use is the worst in the country and children as young as nine years old are actually hooked on drugs many drug users find themselves in conflict with the law at one point or another and get caught up more often than not in the criminal justice system so many of those who use drugs at one point or another they will tell you that they've had issues with the with the police with the criminal justice system or something like that and approximately 70 percent of the total remand prison population are on drug related cases in Kenya the prison population at the moment we are housing over 300 percent of the capacity of our prisons our prisons are meant to take in just about 15 thousand that's the population that they're supposed to take in but we have on average 50 000 inmates at any given time in all our prisons now out of these 50 000 inmates over 50 percent just over 50 percent around 51 and 52 percent are remand yeah these are remand prisoners basically you know the law says you're innocent until proven guilty so if your case you've not been convicted then you're an innocent person but then we have over 50 percent of the prison population on remand and this over 50 percent which translates around 26 27 000 people 70 percent of them are you know on drug related charges so that's Kenya and the drug use sorry to society drug use is a criminal issue and not a health condition that is something that is very common everywhere you go unfortunately we've not been able to change the mindset of our people to start viewing drug issue as a health condition of course political pressure religious communities these two are at the forefront of trying to you know ensure that it remains a criminal issue that needs to be addressed by punishment and things like that so what exactly do we do in as far as legal aid is concerned one generally Haki Africa we provide legal assistance to the public who can walk into our office with their matters and get a lawyer to advise them on matters of the law we are three lawyers within the office and at any given point in time at least one lawyer is in the office so members can actually just walk in with whatever type of case that they have and then seek legal assistance which of course we will advise and then direct them on the steps they need to take we also visit justice institutions including police stations courts prisons and postals to conduct legal aid clinics so we don't just wait for clients to come to our offices but we also organize from time to time with lawyers on pro bono services to visit prisons to visit courts police cells where major atrocities occur in Kenya people would prefer and it's a common saying that you'd rather have your day with a thug than with a police officer you know if you're caught up in a dark alley and you're told to choose whom would you rather see in that alley a police officer or a thug 99% of the people would say I'd rather take my chances with a thug than the police officer yeah so police stations are major areas of violations which we also visit we also link individuals in conflict with the law with criminal justice system with their families and justice actors so for example someone is arrested their family they don't know and maybe all they need to pay is a small amount of bail for them to be released sometimes we have people who would stay in who would stay in jail for months simply because they cannot communicate to their families we don't have the mandatory one call yeah I think we see that in the movies in the US I think so we don't have that so if you don't have a way of communicating you could actually stay in prison for many months so we also do that we link people to their to their families and basically what we're trying to do is to narrow the gap between justice actors government and communities in general by amongst others providing legal education I think it's very very important wherever you go when you're in court we say ignorance is no excuse because you don't know the law you can go to court and tell the magistrate that I didn't know that that was a crime that's not an excuse so what we are doing basically is to go out there to empower the people to understand the law so that they can be you know key players in the in the advancement of their rights um that is again public education and we we very much try to use women leaders in our community forums because we feel women have a very good understanding of the issues on the ground um specifically for for drug users we carry out legal education within communities in particular within drug joints yeah where we know we'll find most of these drug users we go there purposely to talk to them to understand so that they can understand the law in as far as you know drug use is concerned when they are arrested what can they do because in Kenya it's like I said earlier it's very very strict you can even be jailed for being in an environment not for for using drugs or for being in possession of drugs but being in an area that is generally perceived to be a drug then that is a criminal offense in Kenya so if you're found in an area where usually people use drugs then that can be a criminal offense and you can be charged in court for being in that place and you can actually be sent to to jail so these are some of the issues that we try to bring awareness on so that they can understand so specific emphasis on drug users in conflict with the law because one we have realized and after participating in a number of forums that punishment of drug users is counter productive these people are arrested they are taken to prison and in prison it's even worse we know that drug use in prisons is rampant it's not that they in prison then they they will stay away from the communities they will not have drugs but drugs are actually present in prisons we know many drug users who are actually introduced to drugs while they were in prison yeah so punishment of drug users is actually counter productive why do we do this again to guarantee the right to health which is a constitutional right yeah so we try to ensure and that's the basis of human rights you know every person as long as you fit to be called a human being you are entitled to certain enjoyments it doesn't matter whether you are rich you're poor you're black you're fat you're white if you're a human being then there are certain entitlements that are owed to you and that is what we are saying that the right to health care is a constitutional right each and every person irrespective of their problem whether they're drug users or not they are entitled to the right to health care and that is why we are doing this dealing with this as as I mean legal aid for drug users also reduces congestion of prisons like we said over 70 percent of those in remand are on drug related cases so if we can be able to release most of these people then we will decongest our prisons not just the prisons but also police cells and also the courts we have so many backlog of cases in our country over 10,000 cases you can actually go through a hearing for 10 years I think there was an example yesterday by the former president Sampaio who said that someone was arrested and then after he had already moved on is when the sentence was given out so this is the same in our country so again by addressing these issues as a health issue we are able to decongest some of these cases saves money for both state and non-state actors of course improves family ties you know if someone can be assisted to get over the drug use we just saw the picture in Tanzania the someone who was rehabilitated and was able to take care of their families these are some of the reasons why we do what we do okay I have two minutes I don't know if it's two minutes or 21 because there's a why illegal aid is crucial in dealing with drug use one it safeguards the right of individuals to health care I think I've explained that each and every person irrespective of who you are you have the right to health care and human rights are inherent they are inborn no one can take them away from you so by doing this we are guaranteeing the right to health care of each and every person two improve social ties and livelihoods for communities when we are able to get these people from the drug dens to actual you know meaningful employment then we are not only contributing to their own well-being but to the well-being of the community and the nation and three we are actually helping the criminal justice system to be able to address some of the difficulties they're experiencing through this the key steps in legal aid provision amongst drug users screening very important whenever we get someone we have to ask him who he is what problems he's been through what kind of charges are they facing and then we trust we try to find out where their family is where the lawyer is sometimes some of these people come from affluent families you know but they are afraid of talking to their families because they feel if they do so then they will be you know an outcast so we try to talk to their families we trust them and link them with their relevant authorities very very important to introduce them to treatment now as Haki Africa we do not at any point in time claim to be experienced in treatment we don't do that basically what we do is to try and create a conducive environment for healthcare for drug users so when we encounter some of these individuals who need treatment then we get in touch with the NGOs and medical practitioners who are experienced in treatment so even though we're providing legal aid it can be an entry point to actual treatment because we are in partnership with a number of these institutions of course introduction to treatment and legal assistance and linking with key justice stakeholders and last but not least secure release and follow up to reduce recidivism so it's not just about ensuring that person is free but also ensuring that they don't go back or they don't repeat or they don't fall into the same trap they were in so maintaining maintaining contacts very quickly the challenges and successes stigmatization is a major challenge in Kenya still we have a huge problem most members of the public do not want to hear anything to do with drug abuse or drug users they view them very negatively they view them as outcast so this is a huge problem that we are really trying to educate members of the public on that these are our brothers and sisters and because the problem is so huge we cannot run away from it so stigmatization is a major challenge disabling laws like I said earlier just being found in an area you could be arrested holding syringes and things like that just as is the case in Tanzania if you're found with a syringe you could actually be taken to court and charged with that police police are a major, major challenge you know they've basically refused to work with the with the you know drug users and wherever they find them they mistreat them you know torture them and we have had so many cases of people dying in police cells after undergoing torture of all sorts of kind so the police remain a major challenge to overcome in Kenya successes very quickly judiciary we're very happy that the judiciary is slowly but surely seeing things our way we've been able for example to communicate with them that you know we need to treat this issue differently as a health issue and on several occasions we've been able to win some of these cases that was one of them one of the drug users who was charged with being in an environment actually not a drug user but a healthcare provider who was actually visiting some of his clients and he got arrested for being in that environment and we were able to go to court and successfully won that case um the prisons another success the prisons have already adopted an open door policy and they're allowing us access to visit some of these prisoners and talk to them and address some of the issues that they're experienced with so prisons have been a key ally in Kenya in terms of dealing with drug users a health health issue very quickly harm reduction works I know there are many doubting Thomas's out there about harm reduction whether it really works or whether it makes issues you know worth but for us we have seen it and trust me we've seen people's lives changing just from harm reduction those two are recovering drug users and they have gone they they underwent they're still actually undergoing harm reduction and they're now back with their families and are very productive members of the community it's not all gloom and sad of course if there are any issues we can arrange to meet that's back home in Mombasa and we can always have a cup of tea and chat some more by the sea thank you very much Thank you very much Dr. Hussain Khalid and then Dr. Idrisa Ba West African Commission on drugs from Senegal