Response Rate following the RDS Strategy – Net Draws Diagrams
A total of ten seeds were recruited in the Coast comprising of two women and eight men, while 8 seeds were recruited in Nairobi comprising of two women and six men. In the coast region, four seeds were distributed in Kilifi, Kisauni, three in Mombasa city/Ukunda and three in Malindi/Watamu/Lamu, while in Nairobi eight seeds were recruited and distributed equally between Nairobi East and West. Together, these seeds recruited a total of 646 PWIDs over a period of three weeks in the Coastal region and 7 weeks in Nairobi region. The Net Draws diagrams below (Figure 2) present the natural structures of client recruitment in the study using the RDS sampling technique, starting with the “seed” to the recruitment of other study participants in subsequent waves.
In general the non-response rate was less than 5% as most participants who were eligible, fulfilled all the requirements of the study and gave informed consented to participate in the study and were enrolled into the study.
Socio-demographic characteristics of study population
Of the 646 participants recruited in the study, 344 (53.5%) were drawn from Nairobi and 302 (46.7%) from the coast region. Considering the two regions, a total of 178 (27.5%) respondents were recruited in Eastlands and 166 (25.7%) in Western sections of Nairobi, while in the Coast region, 97 (15.0%) respondents were recruited from Malindi, 92 (14.2%) from Mombasa city, 83 (12.6%) from Kisauni and 30 (4.6%) from Kilifi area.
A majority (590, 91.3%) of the PWIDs were males while 56 (8.7%) were female. Of the female population, 33 (58.9%) were from the Coastal region and 23 (41.1%) from Nairobi region. The youngest PWID in this study was 18 years old and the oldest was 55 years old. Overall adjusted mean and median ages for the whole study population were 31.6 and 31 years, respectively, [IQR: 27-36]. Majority of respondents were aged between 25 and 29 years (29.4%), followed by 30 to 34 years (26.9%), 35-39 years (17.5%), 15 to 19 years (13.9%) and the least comprised 40 to 45 years (12.2%). For Coastal region the women PWID were younger compared to men, their mean age was 27.1 years and their median age was 26 years [IQR: 22-29]. The mean age among coastal men was 32.3 years while the median was 32 years [IQR: 28-37]. As was the case in the Coast region, women PWIDs in Nairobi region were younger compared to men. The mean and median ages for women were 28.2 and 28 years, respectively, [IQR: 24-32]. The mean and median age for men in Nairobi region was 31.8 and 31 years respectively [IQR: 27-36]. Drug use peaked earlier between 25 and 29 years in Nairobi compared to 30 and 34 years in the Coast region.
Over 70% of the respondents were educated to primary school level, 23% to secondary school level, 1.6% had postsecondary education, with 9 respondents being students from local universities, while 3% of the respondents never had any formal education. In relation to marital status, 50% of respondents were single and never married, 30% were either divorced or separated and 9% were married. Of those married, only 9% of the males were in monogamous relationships. With regard to religion, over 80% of PWID in Nairobi were of the Christian faith and 72% of PWID in the Coastal region were of the Islamic faith (Table 1).
Generally, over 60% of the respondents did not have any professional skills, 20% were semi-skilled, 7% were skilled artisans, 4% were professionals while about 2% were pupils/students. Figure 3 below shows skills level per study region.
Respondents’ household incomes in the past one month ranged from as low as KShs. 100 (US$1) to KShs., 50,000 (US$500). Twenty five percent (25%) of respondents earned up to KShs. 6,000 (US$60), 38% earned between KShs. 6,000 (US$60) and 15,000 (US$150), 33% earned between KShs. 15,000 and 40,000 (US$400) in the past month and only 4% of respondents earned over KShs. 40,000. The main source of income was temporary work (55%), while 15% were engaged in self-employment, 14% in criminal activities such as theft and robbery, 4% were in formal employment, 3% were sex workers, 3% were supported by spouses, relatives or friends and 6% had other sources of income (Table 2).
On average, most (41.3%) respondents reported living with relatives; comprising of either or both parents, grandparents, siblings, aunts and uncles, with the proportion being slightly higher in Nairobi (43.3%) compared to the Coastal region (39.5%). Up to 32.2% of the respondents in the Coast and 25.6% in Nairobi lived alone. Generally, 14.7% and 14.5% of the respondents lived with friends or with their spouses/partners in both regions. Only 0.5% of the respondents did not have a fixed address.
Sexual orientation of respondents
A large proportion of respondents in Nairobi region (91.4%) and Coast region (95.5%) considered themselves as straight or heterosexual, while 0.7% in the Coast and 1.6% in Nairobi were bisexual. A total of 3 respondents, 2 in the Coast and one in Nairobi were lesbians/homosexuals (Table 3).
Most preferred drugs and history of drug injection
The most preferred drug of injection among 98% of all the respondents was heroin, with 2% citing cocaine. Heroine and cocaine were also used through other non-injecting methods such as smoking or in combination with other drugs such as Cannabis or Rohypnol. Majority of the respondents reported using other substances like cigarettes, alcohol and cannabis before initiating injecting drug use.
Age at initiation
Majority of PWIDs in Coast province initiated injection practice in the 20-24 years age group unlike in Nairobi where those in 30-55 years age group were the majority (Figure 4). The mean and median age for commencement of initiation for women was 24.4 years and 20 years respectively [IQR: 20-26). Men initiate injecting at a much later mean and median age of 26.3 and 26 years respectively (IQR: 22-30). Over thirty percent (33%) of 30-55 years old, 26.9% of 25-29 years old, 29.2% of the 20-24 years old and 11% of the 11-19 years old had initiated drug injection in Nairobi. Whereas for Coast province, majority of injectors were mainly the 20-24 year old age groups at 34.1%, followed by 25-29 year olds at 30.8%, 30-55 year olds at 19.1% and 15.1% for the 30-55 year olds. About two thirds (64.9%) of users in Coast province initiated injecting drug use between ages 20-29 years which is a significant finding compared to 55% in Nairobi. However, the youngest age of initiating injection drug use was 11 years for men and 12 years for women and the oldest was 53 years for men and 49 years for women. Therefore initiation of injection drug use begins early and peaks mainly after formal school years (20-29 years).
Person who administered injection at initiation
All women respondents in the coast region reported getting their first injection administered by a man. However in Nairobi at least 4.3% of the women were injected by fellow women. Figure 5 shows the relationship to person who administered the injection during initiation. In Nairobi 87% compared to 78% in Coast were injected by a close friend, followed by those who self-injected at 6% in Nairobi and 9% in Coast. A primary sex partner injected 4.1% and 3.8% in Coast and Nairobi respectively. About 3% in Nairobi compared to 9.7% in Coast were injected by others who included dealer, a friend/acquaintance and a relative.
Place of first injection
Slightly over a third (37%) of all respondents injected for the very first time in an outdoor shooting gallery, indoor shooting gallery (19%), PWIDs residence (14%), a friend’s home (13%) or other public place (12%) in the two provinces (Figure 6).
Overall, 29.3% of the PWIDs reported sharing needles with about 28.3% of the respondents in Nairobi and 30.4% in the Coast region reported sharing needles. In Nairobi, 82% and 86.5% in Coast injected for the very first time in their current area of residence. Overall, 84.1% injected at their current area of residence (Table 4).
Reasons for sharing injecting equipment
The two most important reasons cited among male and female PWIDs for sharing injecting equipment were being careful on whom they shared the needles and syringes with and lack of their own needles/syringes. Women and men differed on the third reason as men thought it was safe to share since they were cleaning the needles and syringes while women cited pressure from other drug users as their reason for sharing the needles and syringes. Women cited being careful who they share with by 50% while men cited the reason by 100%. About 40% of women said that they did not have their own needles and syringes while 100% of men said the same (Figure7).
Types of reagents used for cleaning injecting equipment
Majority used water (92.7% Nairobi, 87.5% Coast and 90.3% overall). The numbers of those who responded were higher than those who shared needles/syringes because they employed more than one method depending on circumstances. Overall, only about 1% used bleach which is the recommended method of cleaning needles/syringes in harm reduction strategies (Figure 8). The respondents cited the procedure and steps employed in the use of bleach which they consider to be unfriendly as the reason for not using it.
Sources of first drug of injection
Overall, 80.4% of the PWIDs bought their own drug, 12.7% got it as a gift, 5.1% gave someone money to buy them the drugs during initiation into injecting drug use. In Nairobi, 80% of respondents bought their own drug, 14% got it as a gift, 4.4% sent someone to buy the drug and only about 1 % were dealers or peddlers. None of the PWIDs got drugs as a result of trading for sex. In the Coast region as is Nairobi, majority (81%) bought their own drug, 11.4% received the drug as gifts, 6% sent someone with money to buy the drug, and 0.3% got the drug from a dealer.
Reasons for initiating injecting drug use
The reasons for initiating injecting drug use varied between the two studied regions. In Nairobi, majority (96.3%) thought injecting would give a better high, and this was mentioned by more than 95% of both gender. Curiosity was mentioned by 78% and 66% of women and men respectively, and drug quality was mentioned by 62% women and 70% men while 100% of women and 69% of men were worried about health consequences. More than 75% said they started injecting because friends and companions were injecting and 67% said that the type or quality of drug available was inadequate for non-injection, 19% injecting because they were worried about the health consequences of other methods of use such as snorting, 64.5% injected out of curiosity, 28.3% due to depression and 18.1% because everyone was doing it (Figure 93).
In the Coast region, 99.1% thought injecting would give a better high, 86.6% friends/companions were injecting and wanted to try, 84.9% due to pressure from friends/companions and 15 % worried about consequences of snorting, 84.6% curiosity, 44.8% due to depression and 25% because everyone else was doing it. The proportion that initiated injection drug use because of curiosity and depression were much higher in Coast than in Nairobi. At initiation, majority thought that they would inject once or twice and then stop, but they continued to inject more regularly as they got addicted to the drugs. Majority have been active injectors in the last six months with a few having injection free months.
HIV status versus age at initiation of drug injection
PWIDs in Nairobi exhibited the highest HIV prevalence (24.4% unadjusted) compared to the Coastal region (18.5% - unadjusted). Majority of those who initiated injecting drug use at 11-19 years had the highest prevalence of HIV in Nairobi [44.7% unadjusted), followed by 20-24 years at 29.4%, 25-29 years at 21.1%. In Coast the highest unadjusted HIV prevalence was seen in those who initiated PWID at 20-24 years (23.2%) which was half the prevalence seen among 11-19 years old initiators in Nairobi. This was followed by 30-55 years at 21.4% (Figure 10
HIV testing among PWIDs
A very high percentage of PWIDs in the study had ever had an HIV pre-test counseling. Nairobi recorded 84% versus 77% in Coast with an average of 80% in the overall study. About 84% in Nairobi and 80% in Coast had tested for HIV prior to the study and a high proportion of 93% and 86% in Nairobi and Coast regions respectively had ever received the results of an HIV test, whereas 85% and 78 % had received negative HIV test results. A very small proportion of the study population of 11.5% and 15.6% had received an HIV positive test results from Nairobi and Coast with 13.4% for the overall study population. Of the 27 PWIDs that were aware of having AIDS, not all were on ARV treatment.
Future plans and desires of PWIDs
Up to 92% in the Coast region and 95% in Nairobi expected to change their drug consumption in the next 12 months to lesser levels or if possible to quit the habit altogether. Respondents who expected to get employment in the same period of time were 82% from Coast and 90% from Nairobi. Another desire was to have children in which 76% and 73% of the respondents in the Coast and Nairobi regions, respectively, expressed their desire to have children in 12 months’ time. With regard to change in the source of income, slightly more respondents in Nairobi (91%) compared to 82% in the coast region had an expectation of changing their source of income in terms of improving their health, 94% of respondents in Nairobi and 92% of the respondents in the Coast region expected to have a better health in the next 12 months.