Mauritius: the island of addiction
As a 2009 study published in the Lancet noted, «in almost all sub-Saharan African countries, including those most affected by HIV, drug treatment is unavailable, needle exchange programs are non-existent, and legal services are too expensive». Since then, the situation, albeit very slowly, has begun to change for the better.
Located east of Madagascar, the tiny island nation of Mauritius, with a population of only 1.29 million, was the first country in Tropical Africa to introduce a substitution treatment program.
Cannabis and opium have been available in Mauritius since the nineteenth century, but for a long time their use remained within the boundaries of traditional culture and did not cause serious concern to anyone. The «drug boom» began on the island in the late 1970s due to the proliferation of heroin and Mauritius' proximity to important sea and air routes between Africa, Europe and Asia.
According to the 2009 UN World Drug Report, at the time, this tiny country had the second highest prevalence of opioid addiction in the world (after Afghanistan), with nearly 2% of Mauritians using opiates. 97.3% of injecting drug users were infected with hepatitis C and 47.4% with HIV.
A few years earlier, however, the Mauritian government had launched a harm reduction program under pressure from an angry public. Since January 2006, methadone substitution treatment has been available in Mauritius, and since November 2007, used syringes have been exchanged for new ones.
The result has been staggering: new HIV infections by injection have almost tripled (from 92% in 2005 to 31% in 2014) and crime rates have more than halved (2,650 violations of the law in 2007 versus 1,085 in 2012). Mauritius was also proud to be one of the few countries in the world where methadone treatment is available to prisoners in prisons.
Injecting drug use and crime rates increased in 2015-2016, when the new government decided to replace methadone treatment with buprenorphine and naltrexone and move the dispensing of pills from clinics to police stations. Not wanting to face the police, drug addicts began to refuse treatment en masse. In 2017, the country's new Minister of Health, Anwar Hasnu, announced to the relief of his fellow citizens that Mauritius was returning to a methadone program.
Today, Mauritius has 42 substitution therapy clinics, more than all other countries in Tropical Africa combined.
A few years earlier, however, the Mauritian government had launched a harm reduction program under pressure from an angry public. Since January 2006, methadone substitution treatment has been available in Mauritius, and since November 2007, used syringes have been exchanged for new ones.
The result has been staggering: new HIV infections by injection have almost tripled (from 92% in 2005 to 31% in 2014) and crime rates have more than halved (2,650 violations of the law in 2007 versus 1,085 in 2012). Mauritius was also proud to be one of the few countries in the world where methadone treatment is available to prisoners in prisons.
Injecting drug use and crime rates increased in 2015-2016, when the new government decided to replace methadone treatment with buprenorphine and naltrexone and move the dispensing of pills from clinics to police stations. Not wanting to face the police, drug addicts began to refuse treatment en masse. In 2017, the country's new Minister of Health, Anwar Hasnu, announced to the relief of his fellow citizens that Mauritius was returning to a methadone program.
Today, Mauritius has 42 substitution therapy clinics, more than all other countries in Tropical Africa combined.
Tanzania: a barrier to the HIV epidemic
In 2011, Mauritius was joined by Tanzania, an East African country where the opioid and HIV epidemic was also a disaster. By that time, there were about 50,000 injecting drug users (mostly heroin) in the country. Between 42% and 50% of them were infected with HIV, and among women the rate was as high as 71%.
Drug trafficking from Afghanistan entered Tanzania through the port city of Dar es Salaam, where a dose of diluted heroin could be bought on the street for less than the cost of breakfast, and gradually spread throughout the country.
A supportive care center, where patients received daily methadone, HIV and TB tests, and psychological and social support, opened at the Muhimbili National Hospital, the largest medical facility in Dar es Salaam and Tanzania.
According to a study published in 2014, 629 people dependent on opioid drugs sought help at the clinic during that time. One year later, the majority of them (57%, or 358 people) were still in the program: a rate comparable to the success of substitution therapy in Europe, Asia and North America. The highest risks of dropping out of treatment and returning to drug use were found among people who had experienced sexual violence and those who had received a small dose of methadone.
The study authors note that in a region with a generalized HIV epidemic, methadone treatment is critical to controlling the spread of the infection. «An effective HIV prevention program for drug users is to keep them on treatment for as long as necessary to minimize the risk of relapse to injecting heroin», the researchers say.
In 2018, according to Dr. Pilli Sahid Muthoki of Muhimbili National Hospital, about 3,000 patients were receiving substitution therapy in the city. At the same time, an estimated 25,000 residents of Dar es Salaam remained injecting drug users.
Dr. Mutoki was proud to report that Tanzania's methadone program has been one of the most successful on the continent and now doctors from other countries such as Kenya, Mozambique and Zambia are coming to learn and learn from this experience.
In 2018, according to Dr. Pilli Sahid Muthoki of Muhimbili National Hospital, about 3,000 patients were receiving substitution therapy in the city. At the same time, an estimated 25,000 residents of Dar es Salaam remained injecting drug users.
Dr. Mutoki was proud to report that Tanzania's methadone program has been one of the most successful on the continent and now doctors from other countries such as Kenya, Mozambique and Zambia are coming to learn and learn from this experience.
Yusuf Ahmed Mzitto, 33, nicknamed Kessi, told the World Health Organization that medical methadone helped turn his life around after three years of heroin addiction and several unsuccessful attempts to end his drug use: «What drug users fear most is the withdrawal syndrome. Nothing can compare to it, not even the fear of HIV or death. I tried to cope alone, even locking myself in a room. But nothing worked until I started taking methadone».
Cassie explained that most drug addicts are afraid to start methadone treatment because of the stigma associated with it in the community. Many people think that methadone is just another drug and that it will do nothing but replace one addiction with another, and drug dealers spread all sorts of scary stories about methadone therapy to avoid losing clients.
Fortunately, Cassie has managed to overcome this stigma, and now he is systematically reducing his methadone dosage so that he can reduce it to zero in the foreseeable future and live without opioid dependence. The man visits the clinic every day: not only for his dose, but also to socialize with other patients, to see his counselor and to provide professional assistance to the institution as an IT specialist.
Over time, methadone treatment programs have sprung up at Kinondoni District Hospital (a district in Dar es Salaam with a particularly high number of drug addicts), in Zanzibar and in the city of Mwanza. «I urge Tanzanians who meet young people with drug addiction to bring them to a registered clinic to receive treatment» Tanzanian Prime Minister Kassim Majaliwa said at the opening ceremony of the Mwanza hospital and promised that the government would create jobs for patients after rehabilitation.
Senegal: therapy in the shade of mango trees
In December 2014, the first state-funded substitution treatment center in West Africa opened in Dakar, the capital of Senegal. Back in 2011, a study by the UN Office on Drugs and Crime showed that at least 1,300 people in Dakar were injecting drug users. 9.4% of them were infected with HIV and 38.9% with hepatitis C.
One-third of those surveyed admitted that they had last injected outside the home (meaning that they lacked a safe and sterile environment for drug use), and more than 10% reported sharing syringes.
Since then, the problem of drug dependence has become more pressing for Senegal every year. The country, which is washed by the Atlantic Ocean on its west coast and is 95 percent Muslim, has in the past decade become an important transit point for drug trafficking to Europe from Latin America.
As Pierre Lapak, UNODC representative for Central and West Africa, explains, smugglers often pay their intermediaries with goods instead of money and thus gradually create a drug market in a country where none historically existed.
In December 2014, the first state-funded substitution treatment center in West Africa opened in Dakar, the capital of Senegal. Back in 2011, a study by the UN Office on Drugs and Crime showed that at least 1,300 people in Dakar were injecting drug users. 9.4% of them were infected with HIV and 38.9% with hepatitis C.
One-third of those surveyed admitted that they had last injected outside the home (meaning that they lacked a safe and sterile environment for drug use), and more than 10% reported sharing syringes.
Since then, the problem of drug dependence has become more pressing for Senegal every year. The country, which is washed by the Atlantic Ocean on its west coast and is 95 percent Muslim, has in the past decade become an important transit point for drug trafficking to Europe from Latin America.
As Pierre Lapak, UNODC representative for Central and West Africa, explains, smugglers often pay their intermediaries with goods instead of money and thus gradually create a drug market in a country where none historically existed.
Based in the disadvantaged Fanné district of Dakar, the Center for the Integrated Management of Addictions of Dakar (CEPIAD) offers needle exchange, harm reduction counseling and antiretroviral therapy.
In its first seven months of operation, the organization served about 250 people, three quarters of whom were heroin users. The Center's popularity among Senegalese drug users was hampered by its inconvenient location: many needed to spend hours on the road to get to CEPIAD, so it was easier for them to inject themselves than to seek help.
Anyway, upon arriving at Fann in 2018, CNN reporters found a line of drug users at CEPIAD. While some were receiving cups of methadone dissolved in blue liquid from a nurse, others were escaping the sweltering heat with a game of checkers in the shade of mango trees. Over the past two years, harm reduction specialists have distributed more than 18,000 sterile syringes and 17,000 condoms to drug addicts.
Thanks to methadone treatment, 58-year-old Mustapha Mbodj, a heroin user for more than 30 years, was able to kick his devastating addiction and start his own drug user support group called Santé Espoir Vie. Every day, Mbodj and his colleagues travel to the slums of Dakar to talk to addicts, convince them to contact CEPIAD and become part of the methadone program.
In its first seven months of operation, the organization served about 250 people, three quarters of whom were heroin users. The Center's popularity among Senegalese drug users was hampered by its inconvenient location: many needed to spend hours on the road to get to CEPIAD, so it was easier for them to inject themselves than to seek help.
Anyway, upon arriving at Fann in 2018, CNN reporters found a line of drug users at CEPIAD. While some were receiving cups of methadone dissolved in blue liquid from a nurse, others were escaping the sweltering heat with a game of checkers in the shade of mango trees. Over the past two years, harm reduction specialists have distributed more than 18,000 sterile syringes and 17,000 condoms to drug addicts.
Thanks to methadone treatment, 58-year-old Mustapha Mbodj, a heroin user for more than 30 years, was able to kick his devastating addiction and start his own drug user support group called Santé Espoir Vie. Every day, Mbodj and his colleagues travel to the slums of Dakar to talk to addicts, convince them to contact CEPIAD and become part of the methadone program.
«When we come to these hot spots, people are very comfortable with us because we were drug users ourselves. We know how to find an approach to them. If they skip treatment, we go to their homes. We have to sit down, talk to them and convince them to come back» — Mbodj told reporters.
Social rehabilitation is as important as taking medication. Psychologists, art therapists, and professional retraining specialists help people who have long lost their jobs and spent years in prison to regain social skills and return to normal life.
At the same time, Mbayang Fall Bousseau, CEPIAD's health program coordinator, admitted that the organization's work is still far from ideal: even in Dakar, not all drug addicts are aware of its existence, and the challenge is to reach the national level.
In 2020, the UN Office on Drugs and Crime gave CEPIAD money to continue its work during the pandemic. It was used to buy personal protective equipment, and when quarantine and curfew were declared in Dakar, some of the Center's patients were treated at home.
Social rehabilitation is as important as taking medication. Psychologists, art therapists, and professional retraining specialists help people who have long lost their jobs and spent years in prison to regain social skills and return to normal life.
At the same time, Mbayang Fall Bousseau, CEPIAD's health program coordinator, admitted that the organization's work is still far from ideal: even in Dakar, not all drug addicts are aware of its existence, and the challenge is to reach the national level.
In 2020, the UN Office on Drugs and Crime gave CEPIAD money to continue its work during the pandemic. It was used to buy personal protective equipment, and when quarantine and curfew were declared in Dakar, some of the Center's patients were treated at home.
In addition to the Tropical African countries mentioned above, substitution therapy is now practiced in South Africa, Kenya, Burkina Faso, Côte d'Ivoire and the Seychelles. Unfortunately, most African countries are not in a hurry to follow suit, and without substitution therapy programs, it is hardly possible to talk about defeating the HIV epidemic sweeping the continent.
According to the Global Harm Reduction Report 2020, between 560,000 and 2.7 million Africans in sub-Saharan Africa inject drugs (this significant variation in numbers is due to a lack of adequate statistics).
About 30% of them are HIV-positive, and only about half (51%) of these people are receiving the necessary treatment. Finally, there is still no country in Tropical Africa where naloxone is available «hand-to-mouth» and safe drug consumption rooms exist.
According to the Global Harm Reduction Report 2020, between 560,000 and 2.7 million Africans in sub-Saharan Africa inject drugs (this significant variation in numbers is due to a lack of adequate statistics).
About 30% of them are HIV-positive, and only about half (51%) of these people are receiving the necessary treatment. Finally, there is still no country in Tropical Africa where naloxone is available «hand-to-mouth» and safe drug consumption rooms exist.
The ideologue of the methadone program, Robert Newman, MD, said that methadone:
- Is completely safe when dosages are properly administered;
- Dramatically reduces illegal heroin use;
- Can be produced on a large scale at low cost;
- Is attractive to users of illegal opiates who take it despite the fact that daily doses of methadone do not create any euphoria;
- Can be used for several years or even decades without any side effects.
The effectiveness of the methadone program in combating the HIV epidemic, reducing crime, and improving the quality of life of drug addicts and their loved ones has long been statistically proven, but the reasons for its rejection are irrational.
Many authorities still believe that the problem of drug use will be solved not by a harm reduction campaign, but by an uncompromising war to the point of total destruction. However, as we have discussed above, even those countries to which hardliners like to refer have learned to adopt more flexible policies towards drug addicts.
Many authorities still believe that the problem of drug use will be solved not by a harm reduction campaign, but by an uncompromising war to the point of total destruction. However, as we have discussed above, even those countries to which hardliners like to refer have learned to adopt more flexible policies towards drug addicts.