{"_asset":{"@search.score":6.4820824,"Name":"‘I can change my life’: perceptions and experiences of people who use drugs engaging in medically assisted therapy in Kiambu County, Kenya","AlternateTitleCommaDelimited":"","Id":"9067","AssetLocationUri":null,"Abstract":"

INTRODUCTION

The Médecins Sans Frontières (MSF) Kiambu People Who Use Drugs (PWUD) project, which started in September 2019, had enrolled 590 PWUD in its Medically Assisted Therapy (MAT) program by April 2022. This project provides a one-stop-shop model, offering a comprehensive range of medical and psychosocial services. This study aimed to explore how PWUD navigate from heroin use to MAT enrolment.

METHODS

The study involved individual, paired and group interviews conducted between August and October 2022. Purposive sampling was applied. Interviews were recorded, transcribed, coded with NVivo and analysed using reflexive thematic analysis. Methodological triangulation enhanced interpretation.

RESULTS

PWUD faced various challenges to engage in the MAT program. Replacing heroin with MAT, the ‘medicine,’ was insufficient to ensure meaningful recovery. Engaging in MAT required personal motivation to exit the hotspots that their lives revolve around. Main barriers were coping with changed lifestyles and behavioural patterns, and the need to develop new perspectives on dealing with ‘idleness.’

CONCLUSION

The study revealed the complex realities PWUD are confronted with when trying to engage in MAT. MAT programs need to address medical, psychosocial, employment and other structural factors while supporting people to restore their broken social conditions.

","PublicationOrPresentationDate":"2024-11-17T00:00:00Z","LastModifiedDate":"2025-01-24T17:03:25.731Z","IsDeleted":false,"DigitalObjectIdentifier":"10.1080/09687637.2024.2416043","ContentTypeName":"Research","ParentContentTypeName":"Journal Article","JournalName":"Drugs: Education, Prevention and Policy","ContentType":"Journal Article > Research","AvailabilityTypeId":1,"AvailabilityType":"Full Text","JournalIssue":null,"JournalVolume":"Online ahead of print","JournalPages":"1-10","JournalAbbreviation":null,"Conference":null,"ConferenceStartDate":null,"ConferenceEndDate":null,"content":"\nDrugs: Education, Prevention and Policy\n\nISSN: (Print) (Online) Journal homepage: www.tandfonline.com/journals/idep20\n\n‘I can change my life’: perceptions and experiences\nof people who use drugs engaging in medically\nassisted therapy in Kiambu County, Kenya\n\nDoris Burtscher, Winnie Riitho, Morris Kariuki, Angela Thiong’o, Tolbert\nAyuaya, Bernhard Kerschberger, Edi Atte, Jesse Verschuere, Livia Tampellini,\nUmberto Pellecchia, Lucy O’Connell, Tom Ellman, Barrett Levine, Janet\nNgethe & Annick Antierens\n\nTo cite this article: Doris Burtscher, Winnie Riitho, Morris Kariuki, Angela Thiong’o, Tolbert\nAyuaya, Bernhard Kerschberger, Edi Atte, Jesse Verschuere, Livia Tampellini, Umberto\nPellecchia, Lucy O’Connell, Tom Ellman, Barrett Levine, Janet Ngethe & Annick Antierens\n(17 Nov 2024): ‘I can change my life’: perceptions and experiences of people who use drugs\nengaging in medically assisted therapy in Kiambu County, Kenya, Drugs: Education, Prevention\nand Policy, DOI: 10.1080/09687637.2024.2416043\n\nTo link to this article: https://doi.org/10.1080/09687637.2024.2416043\n\n© 2024 The Author(s). Published by Informa\nUK Limited, trading as Taylor & Francis\nGroup\n\nPublished online: 17 Nov 2024.\n\nSubmit your article to this journal \n\nArticle views: 273\n\nView related articles \n\nView Crossmark data\n\nFull Terms & Conditions of access and use can be found at\nhttps://www.tandfonline.com/action/journalInformation?journalCode=idep20\n\nhttps://www.tandfonline.com/journals/idep20?src=pdf\nhttps://www.tandfonline.com/action/showCitFormats?doi=10.1080/09687637.2024.2416043\nhttps://doi.org/10.1080/09687637.2024.2416043\nhttps://www.tandfonline.com/action/authorSubmission?journalCode=idep20&show=instructions&src=pdf\nhttps://www.tandfonline.com/action/authorSubmission?journalCode=idep20&show=instructions&src=pdf\nhttps://www.tandfonline.com/doi/mlt/10.1080/09687637.2024.2416043?src=pdf\nhttps://www.tandfonline.com/doi/mlt/10.1080/09687637.2024.2416043?src=pdf\nhttp://crossmark.crossref.org/dialog/?doi=10.1080/09687637.2024.2416043&domain=pdf&date_stamp=17%20Nov%202024\nhttp://crossmark.crossref.org/dialog/?doi=10.1080/09687637.2024.2416043&domain=pdf&date_stamp=17%20Nov%202024\nhttps://www.tandfonline.com/action/journalInformation?journalCode=idep20\n\n\nDrugs: EDucation, PrEvEntion anD Policy\n\n‘I can change my life’: perceptions and experiences of people who use drugs \nengaging in medically assisted therapy in Kiambu County, Kenya\n\nDoris Burtschera, Winnie Riithob, Morris Kariukib, Angela Thiong’ob, Tolbert Ayuayab, Bernhard \nKerschbergera, Edi Atteb, Jesse Verschuerec, Livia Tampellinic, Umberto Pellecchiad, Lucy O’Connelle, Tom \nEllmane, Barrett Levinec, Janet Ngethef and Annick Antierensc\n\naMédecins sans Frontières (MsF), Wien, austria; bMsF, Kiambu, Kenya; cMsF, Brussels, Belgium; dMsF, operational research (luxor) unit, \nluxembourg city, luxembourg; eMsF, southern africa Medical unit (saMu), cape town, south africa; fMinistry of Health, Kiambu, Kenya\n\nABSTRACT\nIntroduction: The Médecins Sans Frontières (MSF) Kiambu People Who Use Drugs (PWUD) project, \nwhich started in September 2019, had enrolled 590 PWUD in its Medically Assisted Therapy (MAT) \nprogram by April 2022. This project provides a one-stop-shop model, offering a comprehensive \nrange of medical and psychosocial services. This study aimed to explore how PWUD navigate from \nheroin use to MAT enrolment.\nMethods: The study involved individual, paired and group interviews conducted between August \nand October 2022. Purposive sampling was applied. Interviews were recorded, transcribed, coded \nwith NVivo and analysed using reflexive thematic analysis. Methodological triangulation enhanced \ninterpretation.\nResults: PWUD faced various challenges to engage in the MAT program. Replacing heroin with MAT, \nthe ‘medicine,’ was insufficient to ensure meaningful recovery. Engaging in MAT required personal \nmotivation to exit the hotspots that their lives revolve around. Main barriers were coping with \nchanged lifestyles and behavioural patterns, and the need to develop new perspectives on dealing \nwith ‘idleness.’\nConclusion: The study revealed the complex realities PWUD are confronted with when trying to \nengage in MAT. MAT programs need to address medical, psychosocial, employment and other \nstructural factors while supporting people to restore their broken social conditions.\n\nIntroduction\n\nIncreasing availability of heroin, cocaine, and methamphet-\namine especially in urban areas has compounded the burden \nof drug use in Africa (Syvertsen et al., 2015). In addition, the \nincreased use of these drugs has resulted in devastating \nhealth effects, and social and economic dysfunction (NACADA, \n2021).\n\nIn Kenya, an estimated 26,673 people use drugs (PWUD) in \n2021 (NASCOP, 2021a). Heroin has become the second most \nwidely used narcotic drug in Kenya, after cannabis (NACADA, \n2021). The increased availability of ‘white heroin’ powder \nresulted in a rise in heroin injection since the late-1990s sup-\nplanting the previously prevalent ‘brown heroin’ (Beckerleg \net al., 2005; NASCOP, 2013). Subsequently, the drug market \nalso shifted in the late-1990s when ‘brown sugar’ heroin was \nreplaced by ‘white crest’ heroin, which users in Kenya believed \nto be from Thailand (Beckerleg et al., 2005). Injecting drug \nuse carries a high risk of HIV infection and one study showed \nan HIV prevalence of 18.7% in this group compared to 4.6% \nin the general population in Kenya (NASCOP, 2014a, 2014b). \n\nIn response to the growing burden of HIV among people who \ninject drugs in 2010/2011, the Ministry of Health endorsed a \ncomprehensive harm reduction approach for PWUD in the \nnational HIV strategy in 2013 (Mital et al., 2016; NASCOP, \n2013). It included harm reduction interventions for opioid \ndependence (NACC & NASCOP, 2012), primarily consisting of \nHIV testing and treatment, needle/syringe exchange programs, \nand Medically Assisted Treatment (MAT) with methadone \n(Ayon et al., 2019; NASCOP, 2013; Wambugu, 2020; WHO, \n2009). Drug use is criminalized, and carrying of drug injection \nparaphernalia is considered illegal, thus adding to stigma and \nexclusion for PWUD as well as increasing difficulties in access-\ning necessary services. The first MAT program in Kenya was \nstarted in December 2014 in Nairobi and less than 1% of peo-\nple who inject heroin accessed this therapy (Wambugu, 2020). \nBy 2021, there were nine other MAT clinics in the country \noffering services to PWUD. MAT is a component of a compre-\nhensive approach of harm reduction to address illicit drug use \nand is endorsed as a best practice by the World Health \nOrganization (WHO) (Ministry of Health, 2017). MAT aims to \nreduce harms associated with illegal use of opioids including \n\n© 2024 the author(s). Published by informa uK limited, trading as taylor & Francis group\nCONTACT Doris Burtscher doris.burtscher@gmail.com, doris.burtscher@vienna.msf.org Médecins sans Frontières (MsF), Wien, austria\n\nhttps://doi.org/10.1080/09687637.2024.2416043\n\nthis is an open access article distributed under the terms of the creative commons attribution-noncommercial-noDerivatives license (http://creativecommons.org/licenses/by-nc-nd/4.0/), \nwhich permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any \nway. the terms on which this article has been published allow the posting of the accepted Manuscript in a repository by the author(s) or with their consent.\n\nARTICLE HISTORY\nReceived 16 April 2024\nRevised 27 September 2024\nAccepted 8 October 2024\n\nKEYWORDS\nDrug use; medically assisted \ntherapy; heroin; opiate \ndependency; drug transition; \nharm reduction\n\nmailto:doris.burtscher@gmail.com\nmailto:doris.burtscher@vienna.msf.org\nhttps://doi.org/10.1080/09687637.2024.2416043\nhttp://creativecommons.org/licenses/by-nc-nd/4.0/\nhttp://crossmark.crossref.org/dialog/?doi=10.1080/09687637.2024.2416043&domain=pdf&date_stamp=2024-11-14\nhttp://www.tandfonline.com\n\n\n2 D. BURTSCHER ET AL.\n\nheroin by providing a legal controlled supply of substitute \nopioids such as methadone and buprenorphine. Methadone \nand buprenorphine, although opioids themselves, have similar \neffects with significantly reduced harms. They ease withdraw-\nals and cravings, thereby possibly reducing HIV transmission \nand other negative outcomes linked with illicit drug practices \n(Hannah Fraser et al., 2021; H. Fraser et al., 2021; Ludwig-Barron \net al., 2021; Ministry of Health, 2017; Rhodes et al., 2015). \nDespite an expansion of MAT care, little is known about the \nperceptions, experiences, and behaviours of PWUDs towards \nMAT. Over the years, engagement with harm reduction ser-\nvices has often been challenging for PWUD as it requires \nthem to register at MAT clinics and attend daily for medica-\ntion, potentially increasing their exposure to stigma, discrimi-\nnation, and criminalization. Consequently, MAT programs have \nreported suboptimal retention rates (NASCOP, 2013). In 2019, \nMSF began supporting harm reduction and MAT for PWUD in \nKiambu County, a wealthier area compared to others in Kenya, \nwhich ranks among the top five counties with the highest \nnumbers of PWUD due to its relative affluence and its prox-\nimity to Nairobi. The aim of this qualitative study was to \nincrease understanding of the challenges PWUD face in \nenrolling and maintaining in MAT care in Kiambu County, \ntherefore informing the future strategy for improved program-\nmatic reach and retention, and increased appropriateness of \nMAT services from the users’ perspectives.\n\nMethods\n\nContext\n\nThe Médecins Sans Frontières (MSF) Kiambu project is an \nintegrated medical care project for PWUD in Kiambu County. \nIt started in 2019 at the Karuri Level 4 hospital and by end of \nSeptember 2023, 909 PWUD had been enrolled in the pro-\ngram. By that time, the retention which is calculated monthly \nwas 72.3%. The project offers a one-stop-shop model of care \nwhere PWUD eligible for the MAT program have access to a \ncomprehensive package of medical, psychological and social \ncare. It includes opioid substitution therapy (OST) for PWUD, \ngeneral outpatient care, sexual and reproductive health ser-\nvices, mental health and psychosocial services, nutritional \nsupport and management of malnutrition, pharmacy and lab-\noratory services. The overall approach of MSF’s intervention \nincluded peer education/work for PWUD and community \nengagement. The MAT clinic is operated in collaboration with \nthe National AIDS and STIs Control Program (NASCOP), \nKiambu County Government, Kenya Prison Services and \nLVCT-Health.1 To further increase access to services for PWUD, \nMSF opened two decentralised sites in Ruiru and Thika \nPrisons in May 2022 and July 2023 respectively. These decen-\ntralized sites operate independently from the MAT clinic, \nreducing travel barriers and improving access to care for \nPWUD, making it easier to receive the necessary services \nwithin their community. Both sites offer the same integrated \nmodel of care for PWUD in addition to the other essential \nservices accessible by both PWUD and the general popula-\ntion. This integrated and decentralized approach is viewed as \na more accessible and sustainable model of care as compared \n\nto a standalone centralised MAT clinic. However, the study by \nGuise et al. supports an approach that encourages continued \nintegration of services whilst allowing for differentiation of \nthese models to adapt to client preferences. Co-location of \nintegrated services must prioritize clinic organization that pre-\nvents HIV status disclosure (A. Guise et al., 2019).\n\nThe MAT clinic collaborates with the Civil Society \nOrganisation LVCT for referral of patients. LVCT is mandated by \nthe National AIDS/STD Control Programme (NASCOP) to con-\nduct outreach services to the dens and hotspots where PWUD \nfrequent, provide clean needles and syringes, and identify and \nrefer MAT-eligible PWUD to the MAT clinic. Before referral, eli-\ngible PWUD undergo a preparation session at LVCT detailing \nthe process and expectations of the MAT program. They are \nthen escorted by a peer worker or outreach worker to the \nclinic. Eligibility for enrolment is PWUD with Opioid depen-\ndency including heroin and other prescription opioids, and \ntheir willingness to access MAT care. At the MAT clinic, they \ninitiate Opioid substitution therapy (OST) based on their drug \nuse history. Those with a long drug use history and injecting \nand/or smoking usually start with methadone which is more \neffective for individuals with severe opioid dependence due to \nits full agonist properties, which can help manage cravings \nand withdrawal symptoms more robustly. The dose can also \nbe adjusted more easily to meet individual needs because it \nhas a longer half-life. Those with a shorter drug use history, \nusually smokers, are initiated on buprenorphine, which is \neffective at reducing cravings and withdrawal symptoms with \na lower risk of overdose and easier to wean off. The dose is \ninitiated low and titrated upwards gradually until the patient \nis no longer experiencing withdrawals or cravings. Methadone \nis taken daily and buprenorphine every 48 to 72 hours. The \nlonger a patient remains adherent on treatment, the lower the \nchances of relapse as supported by several studies (Buresh \net al., 2021; Kreek et al., 2010; Mattick et al., 2014). This adher-\nence is crucial for effective long-term management, and ther-\napy can be lifelong. Social reintegration is also considered key \nto recovery and returning to a productive and fulfilling life as \ndefined by Substance Abuse and Mental Health Services \nAdministration (SAMHSA) in their guiding principles of recov-\nery (U.S. Department of Health and Human Services XXXX). \nRecovery is understood in a holistic sense, encompassing ces-\nsation of heroin use, engagement in MAT, and improvements \nin health and social well-being. Therefore, mental health and \npsychosocial follow-up support is also provided during ther-\napy. Once the patient is stable and wishes to stop OST, the \ndose is titrated downwards gradually until they are at a dose \nwhere they are no longer experiencing withdrawals or crav-\nings and can finally stop the OST. Before the wean off process \nis commenced, the MAT team assesses if the patient is stable \nclinically, not concomitantly using heroin together with OST \nand is already socially reintegrated, as these factors are para-\nmount in ensuring that the patient is ready to be weaned off \nOST. After cessation, patients are followed up monthly, then \nevery six months. During this period, patients can still access \npsychosocial care in the MAT clinic or even other medical ser-\nvices when needed and they are also encouraged to join the \ngroup therapies in the MAT clinic to aid in their recovery jour-\nney and prevent relapse. As part of the support to empower \n\n\n\nDRUGS: EDUCATION, PREVENTION AND POLICy 3\n\nthe PWUD in recovery and those weaned off, MSF supported \nthe creation of a patient led Community based organisation \n(CBO) with a view of providing a harm reduction package of \ncare at community level once autonomous.\n\nStudy design\n\nA qualitative research design was used to gain multiple per-\nspectives (active PWUD, MAT patients, PWUD peer worker, \nMinistry of Health (MoH), MSF and LVCT staff ) on the com-\nplex factors of the daily lives of active heroin users (Pope & \nMays, 2006) between August and October 2022. The methods \nused for data collection were face-to-face in-depth interviews \n(IDIs), informal observations, paired interviews, and focus \ngroup discussions (FGDs). A methodological triangulation of \nfindings was undertaken to enhance the interpretation of \ndata, in-depth individual interviews were combined with \nfocus group discussions, informal observations, and a litera-\nture review (Patton, 2002). The choice of methodology \nencouraged rich text and reflective narratives from the main \nparticipants to answer the research question.\n\nSelection and recruitment of study participants\n\nPurposive sampling was applied for the interviews with PWUD \nlinked to hotpots where they buy or smoke heroin, individu-\nals enrolled in the MAT program, PWUD peer workers from \nLVCT and MSF, and healthcare workers. This sampling \napproach allowed us to select individuals who were most \nlikely to provide valuable and relevant information for the \nstudy. The sample size was not determined in advance as we \nfollowed the information saturation principle (Green & \nThorogood, 2018). In total, 61 interviews were completed \ncomprising 39 IDIs, seven paired interviews and 15 FGDs. \nTwelve interviews were performed with PWUD linked to \nhotspots, 13 with active MAT patients, eight with MAT patients \nwho have disengaged, two with persons who had weaned-off \nwith the MAT program, and two with buprenorphine patients; \ntwelve other patients using buprenorphine were asked in a \nsmall survey about their experience and perception of \nbuprenorphine. Nine interviews were done with healthcare \nstaff (MSF/MoH/LVCT) and 15 with PWUD peer workers. In \ntotal, 232 people participated in 61 interviews.\n\nObservations were part of every encounter with PWUDs, \npeer workers, MAT patients during the interviews, or in the \nopen space at either the Karuri clinic or Ruiru Decentralized \nFixed Dispensing and Ruaka Drop-In Centre. An informal \nobservation approach was applied meaning that the observer \nwas ‘passive, a participant observer.’ These observations were \nconducted in a non-structured manner, focusing on capturing \nspontaneous and naturally occurring behaviours and interac-\ntions without a formalized observational framework.\n\nPWUD were approached and selected with the help of \nLVCT-and MSF PWUD peers, who were trusted by them. The \nvarious groups of PWUDs were interviewed in separate FGDs \nthat were formed according to their belonging to a specific \nhotspot. Mappings of hotspots and the number of PWUD in \nthe sub-counties had been performed by LVCT prior to this \n\nstudy at project level, thus facilitating the selection and fre-\nquency of sites visited. MAT patients were approached at the \nclinic with the help of peers and asked about their availability \nfor an interview and their preference for being interviewed \nalone or in pairs. Some came for their methadone dose with \na partner or friend. Healthcare workers were selected directly \nat the clinic by personally asking if they had the time and \ninterest to participate in an interview. Additionally, some \nhealthcare providers volunteered their interest and availability.\n\nAny person or group that was interviewed was informed \nand asked beforehand for consent to participate in the inter-\nview and had the choice of location for the interview.\n\nThe primary investigator supported by a local study assis-\ntant and a PWUD peer worker of the chosen area, hot-spot or \nden2 approached potential participants, introduced them-\nselves, explained in detail the purpose and the aim of the \nstudy and asked potential study participants about their will-\ningness to participate in an IDI and/or FGD.\n\nPWUD inclusion into the study followed their own will, \navailability, and informed decision to participate within a \ngiven period for enrolment. We assured potential participants \nto respect confidentiality, and that non-participation was not \nto impact their future access, care and treatment provision, or \nwork in the case of healthcare staff. Interviews with PWUD \nwere conducted directly in the hotspots when deemed appro-\npriate by the PWUD themselves; other interviews were con-\nducted in a rented location near the hotspot. Conversations \nwith MAT patients took place at the clinic during their visits \nfor MAT, as did the interviews with healthcare workers. PWUD \npeer workers were interviewed either near the hotspot where \nthey were assigned to work or at the clinic, depending on \ntheir preferences. The study team encountered slight difficulty \nin engaging active PWUD because many potential participants \nwere unsure of the benefits of participation in the study and \nwere hesitant to engage with the peer workers. Many, active \nPWUD look for money in the morning through touting at the \nbus stations or collecting scrap metals; staying an hour or \nmore for an interview was a loss of time and income for them. \nHowever, the peer workers did manage to explain and encour-\nage their peer PWUD to participate in IDIs and FGDs. As a \nresult, we were able to talk to a total of 232 individuals. On \ntwo occasions, PWUD participants who were not on MAT \nexpressed withdrawal symptoms, both verbally and physically, \nand requested to complete the interview as soon as possible. \nIn other instances, some participants requested compensation \nin the form of heroin for the time they spent in the interview. \nTo address this issue, the study team explained that providing \nheroin as compensation would be ethically inappropriate and \ncontrary to the principles of harm reduction, which aim to \nminimize the negative impacts of drug use. The team offered \nnon-drug incentives such as bread and milk, aligning with our \ncommitment to support the health and well-being of PWUD \nwithout contributing to potential harm.\n\nData management and analysis\n\nAll data obtained through interviews were anonymised and \nstored on password-protected computers, without the inclu-\nsion of personal identifiers such as names, address, phone \n\n\n\n4 D. BURTSCHER ET AL.\n\nnumber or any other variable that can lead to identification \nof the participant (Richards & Schwartz, 2002).\n\nThe analysis and interpretation of data was drawn on social \nand structural factors as the key determinants for the challenges \nin enrolling and maintaining participants in a MAT program. The \nrole of social networks (peers, friends, family), stigma, peer influ-\nence, and community support (or non-support) affecting partic-\nipants’ readiness and ability to enrol and stay in the program \nwere considered for social factors. For structural factors the avail-\nability of MAT, geographical accessibility (distance to reach the \nclinic for MAT and availability of transportation), and healthcare \ninfrastructure on participant engagement were included.\n\nData analysis was conducted by the primary investigator \nusing NVivo©11 qualitative data analysis software. All interview \ntranscripts were imported into NVivo after translation and tran-\nscription, where they were then coded. A coding framework \nwas developed based on themes emerging during the inter-\nviews, as well as themes pre-identified by the study team. \nEmergent categories and themes were identified based on \nmeticulous and systematic reading and coding of the tran-\nscripts. Codes and sub-codes were refined during the analysis. \nData coding and analysis began whilst data collection was \nongoing, to allow for the refining of questions and the in-depth \nexploration of certain themes if required. Codes and themes \nwere discussed with the study assistant for accuracy and quality \nassurance. The analysis involved a reflexive thematic analysis by \nBraun and Clarke (Braun & Clarke, 2019). The transcripts were \nscreened for relevant information, organised, coded, catego-\nrised, and interpreted. A category (label) was attached to the \nstatements to structure the data. The content was analysed in \ntwo ways, one was free of interpretation, while the other was \nfocused on interpreting what was meant by it (Hancock, 2002).\n\nContinuous reflection on data was part of the creative pro-\ncess of analysis and necessary for contextualising and linking of \nfindings with theory. To adhere to principles of good practice \nthe research process was clearly described in the study report \n(Burtscher, 2022). Credibility and richness of the qualitative \nresearch context are ensured by presenting a ‘thick’ description \n(Geertz, 1973) and by also presenting deviant cases if they occur.\n\nA methodological triangulation was applied. The content \nand emerging themes of the individual IDIs were combined \nwith FGDs, observations, and a literature review (Brikci, 2007). \nVarious data types (IDIs, FGDs, and observations) that were \nused for triangulation were harmonized by coherent transla-\ntion, transcription, and coding, and therefore integrated into \na cohesive analysis.\n\nEthical approval\n\nThe study protocol was approved by the MSF Ethics Review Board \n(ID 2251) and the Kenya Medical Research Institute’s (KEMRI’s) \nScientific and Ethics Review Unit (SERU) in Nairobi (ID SERU 4490).\n\nResults\n\nStudy participants\n\nThe study population included diverse groups of respondents \n(Table 1) characterized by gender, years of drug use, method \n\nof drug intake, hot spots of drug use and location3, and type \nof enrolment to the MAT program. The individuals approached \ncomprised PWUD not yet enrolled into MAT, MAT patients, \nPWUD peer workers of LVCT and MSF, and healthcare profes-\nsionals (MoH, MSF and LVCT).\n\nFour main themes evolved when exploring perceptions \nand experiences of the journey from the den and the ‘old life’ \nwith heroin use to the ‘new life’ in MAT. These themes were \n(1) leaving the ‘old life’; (2) engaging in MAT; (3) life on MAT \nand (4) maintaining the ‘new life’ in MAT.\n\nLeaving the ‘old life’: ‘sick of being sick’\nInterview participants, both PWUDs and MAT patients, \ndescribed that quitting heroin is a daunting task. They \nspoke of growing tired of the lifestyle they had been living \nand expressed a desire to break free from their addiction, \nsaying ‘we are sick of being sick.’ Many had disappointed \ntheir families, and if they were married, their relationships \nhad broken down. Moreover, PWUD reported that they \nneglected their children, as most of their money went \ntowards buying drugs. Reflecting on those experiences, \nPWUD often expressed regret about starting to use heroin, \nrecognizing the losses they suffered as a result. Most \nPWUD and MAT patients wished they could start over and \nrebuild their lives.\n\nTable 1. characteristics of study participants.\n\ntotal (n = 232) %\n\nsex\n Men 201 87%\n Women 31 13%\nage groups, years\n 18–24 56 24%\n 25–34 97 42%\n 35–44 49 21%\n ≥45 11 5%\n n/a 19 8%\nBackground\n active heroin users 103 44%\n Mat methadone 46 20%\n Mat buprenorphine 14 7%\n Mat/disengaged 22 9%\n Mat weaned off 4 2%\n PWuD peer workers of MsF and lvct 29 12%\n Healthcare workers 13 6%\nDuration of using heroin, years\n 0–3 56 24%\n 4–6 49 21%\n 7–9 40 17%\n 10–15 36 16%\n 16–20 11 5%\n n/a and na (because weaned off) 40 17%\nMode of heroin use\n smoking 141 61%\n smoking and injecting 42 18%\n injecting 8 3%\n sniffing 3 1%\n injecting and sniffing 4 2%\n n/a or na 34 15%\nHighest education\n no school 2 1%\n Primary school 68 29%\n secondary school 120 52%\n university/college 27 12%\n n/a 16 6%\n\nn/a, no answer; na, not applicable.\n\n\n\nDRUGS: EDUCATION, PREVENTION AND POLICy 5\n\n‘When the landlord threw my things out and locked me out of my \nhouse, I went and sold all my possessions and now I got deep into \ndrug use. That’s when now I started sleeping outside, I stopped my \njob because my motorbike had been claimed by the loan collectors \nand I saw like my life was now coming to an end. I could no longer \nlook after my family and there was nothing else I was doing, except \nlooking for money to buy the drugs. I even got dirty and smelly \nbecause I wasn’t bathing and lived like a chokoraa [streetboy]. \nThere came a friend of mine who had started MAT before me, and \nhe told me that I had to stop the heroin and change and that I \ncould do so if I joined MAT.’ male MAT patient, 26y\n\nAnother trigger to stop heroin was when active PWUD \nmet a friend with whom they had used heroin together or a \npeer worker, who was now ‘clean’ and had a better life. Such \nan encounter encouraged them to also try to stop using her-\noin. However, stopping heroin and starting MAT was worrying \nas replacing heroin with methadone or buprenorphine did \nnot seem easy and it was not merely a medical and physical \nquestion. Respondents emphasized that it had to be tackled \nin a holistic way by including psycho-social, economic, finan-\ncial and personal characteristics, to be able to create a sup-\nportive environment. Others referred to the ‘old life’ in the \nden and said that leaving an ‘old love’ is difficult despite the \n‘toxic’ relationship. Many PWUD feared the ‘unknown’ and said \nthat ‘staying with the known’ felt more comfortable. Starting \nMAT meant leaving the den, which had become their ‘home’ \ntheir friends and family. They had to engage in a new lifestyle \nand end ties with their social network, thus refraining from \naccustomed conduct and behaviours.\n\n‘They [PWUD] try to figure out where they can go and stay, they \ntry to figure out the friends that they have. They see if they go \nand stay with the friends who they weren’t communicating so \nmuch with when they were back in the den, there won’t be any \nconstructive conversations. As a result, they think of going back to \nthe friends they used to smoke with in search of comfort, of \nwhich it doesn’t work.’ male PWUD peer worker, 28y\n\nRespondents also emphasized that quitting heroin needs \nmotivation and readiness. Many MAT patients insisted that \n‘the mind has to be ready,’ and it is the person who is the \none who has to be ‘determined’ to be able to stop using her-\noin and start MAT.\n\n‘What I can say is that the decision to stop comes from inside \nsomeone’s heart. If you haven’t decided to completely change, \nyou will still find yourself going back to the drugs, but if you have \ndecided to stop using heroin, you can continue with life.’ male \nPWUD peer worker, 40y\n\nAs described earlier, many active PWUD are motivated by \nthe example and inspiration of other people like partners, \nfriends or a relative who were PWUD; they encounter them \nand see the changes they were able to bring to their lives \nwith MAT.\n\n‘I want to live a good life basically because that cannot happen \nwith heroin. I wouldn’t want my family and me to live a life filled \nwith problems that can be avoided. In a few years to come, I \nwould like us to have achieved something better than what we \nhave now. I have also witnessed the change in people that come \nto MAT and I know that we can change too. So, that motivates me \na lot.’ male MAT patient, 25y\n\nOthers have experienced traumatic events and hardship \nand want to change their lives for better.\n\n‘yes, that’s the point [when two PWUD were beaten to death]. \nBecause now I had to introspect myself and try to figure out what \nI can do after what had happened. At the same time this is when \nthe peer worker came through and gave me the idea about the \nMAT clinic and I found it exciting.’ male PWUD peer worker, 28y\n\nOne healthcare worker, experienced in working with \nPWUD, insisted that most women who start MAT are more \ndetermined than men and it would be easier for them to \nmaintain in MAT. Two female MAT patients explain their moti-\nvation to start MAT:\n\n‘My youngest child has been a great source of encouragement \nand has really pushed me to finally quit heroin since she has \nalways been telling me that I should leave that thing that I have \nalways been smoking [heroin].’ female PWUD peer worker, 32y\n\n‘Why I would like to go for MAT is so that I can change and trans-\nform my life. you might even find that I have another unplanned \npregnancy and that is not okay. So, I would like to join MAT and \nleave the stuff.’ FGD active PWUD, female participant\n\nEngaging in MAT: ‘fear of experiencing withdrawal \nsymptoms’\nFor many PWUD, the preparation phase to engage in MAT \nwas challenging regarding their readiness, determination and \nthe time spent at the clinic. The fear of experiencing with-\ndrawal symptoms was prevalent and prevented people from \nstarting the process: from the first methadone or buprenor-\nphine dose, over the monitoring period for withdrawal symp-\ntoms until they were adjusted to the right dose.\n\n‘Through all that process, the travelling and waiting to be pro-\ncessed, the PWUD will have had intense arosto [withdrawal], but if \nthe clinic was nearby then the PWUD will reason out and see that \nsince the clinic is not that far away and they will not spend much \ntime, they can hold off the arosto until they get processed and \nfinally receive the methadone. you see even when we are having \nclasses here at the LVCT, the PWUD are always asking, ‘are we \nspending much time here?.’ The distance and time spent is the \nproblem, the PWUD sees it as a real burden.’ male PWUD peer \nworker, 27y\n\n‘My greatest problem with leaving heroin was the withdrawals \nbecause I knew they would last for days, not hours. If the with-\ndrawals only lasted for hours, that could have been a different \ncase. But I could not sleep, even when I was in the rehab facility \nI didn’t sleep, I only closed my eyes for five minutes and then I \nwas up.’ male PWUD peer worker, 40y\n\nRespondents expressed quite differing views and opinions \nregarding MAT. Perceptions ranged from viewing methadone \nas a drug like heroin, some MAT patients said it would be \nstronger than heroin whereas some compared it to heroin \nbecause they would still experience withdrawal symptoms \nwhen they did not take it.\n\n‘They think that methadone is a drug. Do you know why people \nsay that methadone is a drug? It’s because when someone used \nto take heroin takes methadone, they “feel” a high that lasts lon-\nger than that of heroin.’ male PWUD, 38y\n\n\n\n6 D. BURTSCHER ET AL.\n\nOthers said that one would even get a greater addiction \nwith methadone. A remarkable perception by active PWUD \nwas that methadone had to be taken alone by the person \nwhile heroin can be shared with others. Two particularly \ninteresting perceptions arose during the interviews. Firstly, \nMAT patients referred to methadone as ‘budget’ or ‘to be \nhigh on another money,’ alluding to the fact that they \nreceived methadone for free. Secondly, some referred to MAT \nas ‘the heroin from the government.’ This perception came \nfrom their observation that the methadone was delivered to \nthe clinic with armed guards.\n\nLife on MAT: ‘it’s a lack of hope’\nThis topic relates to the challenges MAT patients face when \nthey talk about their experiences with retention and main-\ntaining in the MAT program. It is largely influenced by com-\nmunity perception and acceptance, family reintegration, \noccupational opportunities and income generating activities. \nIn a FGD with active PWUD those challenges were discussed:\n\n‘I would wish for you to consider our lives after MAT. I know for \nnow you are considering our lives in MAT but consider also how \nwe can be reintegrated back into the world. I know the sensitiza-\ntion process is tough, but we need also the community at large \nto know that we exist and how to help us.’ FGD PWUD\n\nIt highlights the question of leaving the accustomed social \nenvironment and is closely related to the notion of belong-\ning. Those who have successfully transitioned from a life as \nan active PWUD to being a stable MAT patient with family \nreintegration and support have a different perspective. \nHowever, here mainly the voices of those who continue to \nstruggle with their lives are presented.\n\n‘Sometimes you start MAT, but you don’t have anywhere to go \nafterwards, so you end up going to hang around your friends and \nwhen they are smoking marijuana, you find yourself smoking too \nas you keep each other company. It’s because you are not busy or \ncommitted to something, you find yourself idling with your friends \nsince everyone else seems like they hate you.’ FGD MAT patients\n\n‘Like most of them say, it’s a lack of hope, even after MAT because, \nit is not automatic that you will get a job, you know. So, I think \nthat is what bothers most of them. How will we be able to make \na living which is not criminal, you know, which is not antisocial? \nThat is, I think, a big question, almost everybody who is in MAT \nand not yet working, wonders what will happen next. They wish, \nthey hope for something better.’ female MAT patient, 62y\n\nA healthcare worker emphasized the importance of leav-\ning one’s old environment and starting a ‘new healthy life’ \nwith different behavioural patterns.\n\n‘We are telling them [PWUD] that we want them to stop heroin \nand start MAT. Fine, they then start MAT, then what? They are still \ngoing back to those dens, what makes you think they won’t \nrelapse? Even for the homeless people, so I think the only gap we \nhave is that lack of an exit plan, a proper exit plan.’ female health-\ncare worker, 37y\n\nThis healthcare worker further expanded on the theme \nand insisted that the emotional life of the patients should be \nequally addressed like the heroin addiction is treated with \n\nmethadone or buprenorphine. One MAT patient said, ‘they \nneed to be taken by their hand.’ Another healthcare worker \nreferred to the importance of emotional and social support \nsaying that addiction was not a ‘one man show.’\n\n‘It has to be a multi-faceted approach where clients are involved, \nthe clinic and family members too are involved as well as the \ncommunity.’ female healthcare worker, 51y\n\nMaintaining, the ‘new life’ on MAT: ‘your friends are still \nthe same’\nThe main challenges people face to maintain in their MAT, \ninclude distance to the MAT clinic and daily transport fees. \nSecond, lack of occupation and joblessness, and third, home-\nlessness. The MAT program was criticized for focusing only on \nmedication and not on providing opportunities to find jobs \nand access shelter for the homeless. On a positive note, MAT \npatients and MAT defaulters reported a change in their \nbehavioural patterns, as they no longer want to engage in \npetty crimes.\n\n‘When you go to MAT, you go to change, and in the process of \nchanging you become idle because of the areas you were used to \ngoing to, you now avoid them because the only thing that made \nyou steal is the arosto [withdrawal]. And now because you don’t \nhave arosto you cannot risk yourself anymore, so you try and find \ngenuine work.’ FGD active PWUD and MAT defaulters\n\nOther positive outcomes that encouraged MAT patients to \ncontinue with the treatment were related to getting support \nfrom Matatu [minibus] drivers who gave them free lifts to go \nto the MAT clinic. PWUD peer workers recounted that they \nreceive support for transport expenses from a family member \nand other MAT patients said they moved closer to the clinic \nto be able to go for their daily dose and others again stated \nthat they come by foot every day as transport fare is not \naffordable. Support in general from family members or other \n‘treatment supporters’ was paramount to maintain in MAT, as \nacknowledged by one PWUD peer worker:\n\n‘It is easy to retain someone who has support from the family on \nmedication than someone who didn’t have support. Because \ngiven that maybe, one was homeless and we enrolled them for \nmethadone, they’ll still come back and stay at the den and it’s \neasy for them to relapse.’ male PWUD peer worker, 41y\n\nThe other major challenge for MAT patients was maintain-\ning a job, earning money or finding purpose through an \noccupation. Interview participants often talked about ‘idle-\nness,’ which was closely linked to ‘joblessness.’ ‘Idleness’ was \nfrequently cited as a reason for returning to the den, recon-\nnecting with old friends, engaging in cross-addiction, and \nsubsequently disengaging from MAT. In a focus group discus-\nsion with active PWUD they expressed their worries:\n\n‘These people who want to help us should give us not only the \nmethadone but also the capital for a job so I can feed my family. \nDon’t give me drug but there is no job. you only give me the \ndrug, drug, drug. I don’t need to take that. I went back to the den \nto take heroin so that I am also able to steal to feed myself and \nmy family.’ FGD active PWUD\n\n\n\nDRUGS: EDUCATION, PREVENTION AND POLICy 7\n\n‘Those on MAT are our friends, and since they don’t have \nany other friends out there, they will come to the den to look \nfor some company. As they hung around while we are smok-\ning [heroin], they will obviously get tempted to take a few \npuffs. So, as days go by, they might find that they have \nrelapsed and abandoned the MAT and have come back to \nusing heroin, all because of the company they are keeping.’ \nFGD, PWUD.\n\nOne healthcare worker recounted what one of her clients \ntold her about how his life on heroin was better than going \nfor MAT:\n\n‘There are some things that PWUD miss. First, they miss the com-\npany. It’s company they have lived with for five, ten years. The \nmoment they stop using the drugs they feel like they are all \nalone. The other thing he [the client] was saying about the basic \nneeds, he said that when you are in those dens, even if you don’t \nmanage to steal something, your friend will get something, and \nhe/she will share. He was saying the friends those who use drugs \nare very generous compared to the other population.’ female \nhealthcare worker, 39y\n\nWhile some of the MAT patients managed to engage in \ninformal income activities it was rarely enough to make a \ndecent living:\n\n‘Once we have taken our Methadone dose, we pick up our sacks \nand go look for scrap metal which we then sell to the recyclers and \ndealers. We earn enough to get us through the day but not enough \nto rent a house and other requirement.’ male MAT patient, 27y\n\nThis case example from the healthcare worker matches \nwhat a disengaged MAT patient was referring to when he \nsaid that he is better off when using heroin.\n\n‘I’d better use heroin because when I wake up at 3 AM and get \nmoney, I can smoke, feel good, and continue with my work during \nthe day. But now going to Karuri [MAT clinic] and coming back, \nthat’s a lot of time wasted. If methadone was maybe nearer, \nI would opt to continue taking it.’ male MAT defaulter, 52y\n\nDiscussion\n\nThis study reflects on challenges PWUD are confronted with \nwhen engaging in MAT in Kiambu county. Although extensive \nresearch has addressed various topics related to PWUD in \nKenya’s coastal region and Nairobi (Ayon et al., 2018, 2019; \nBazzi et al., 2019; Beckerleg et al., 2005; Andy Guise et al., \n2015; Mburu et al., 2018, 2019a; Mwangi et al., 2019; Syvertsen \net al., 2015, 2019) harm reduction initiatives are widely unex-\nplored for this area. We examined the social and structural \nfactors as key determinants for the challenge in enrolling and \nmaintaining participants in a MAT program. As reported in \nother studies, a combination of factors (e.g. continued social \nexclusion, stigmatisation, financial hardship, lack of job oppor-\ntunities) contributed to low adoption or difficulties to stay in \nMAT (Anoma, 2018; Hassan et al., 2019; Kageha Igonya et al., \n2021; Mburu et al., 2019b; Rhodes et al., 2015; Ruiseñor- \nEscudero et al., 2015). Our findings further reflected on how \nthe social environment could support an individual in the \njourney to and staying in MAT, exploring how best a person \n\ncan be accompanied during the process of involvement and \nenrolment in MAT and consequently staying in MAT (Ndimbii \net al., 2021).\n\nFindings in context\n\nStudy findings suggest that navigating the transition from \nheroin use and the ‘old life’ to being in a MAT program and \nengaging in a ‘new life’ was accompanied by numerous diffi-\nculties. Leaving the ‘old life’ in the hotspots and dens meant \nleaving families, friends, homes, and belonging hence all the \nsocial relationships and foundations linked to their life in the \nden. A person had to separate from individuals they could \nrely on, share, exchange and live common experiences. \nLeaving this life, even full of hardship, meant approaching the \nunknown and facing an uncertain future. PWUD might have \nexpectations and hopes for the future that may be unrealistic \ndue to social exclusion, marginalisation and stigmatisation \naccompanied by feelings of fear and stress. At the same time, \nthere were various motivating factors that encouraged PWUD \nto participate in a MAT programme. PWUD were tired of the \nlife they live, confronted with constant ill-health conditions \n(related to heroin use and withdrawal symptoms), broken \nsocial relations, and the constant struggle for money genera-\ntion and petty crimes going along with it. Encountering, ‘see-\ning’ and talking with others who managed to stop using \nheroin and engaging in MAT was a motivation for many \nPWUD to leave their past lives on heroin use. Reflections on \ntheir social and personal hardship, they went through, and an \nincreasing level of tiredness of ‘being sick’ helped them to \nmake up their mind and consider an engagement in medi-\ncally assisted therapy.\n\nHowever, even if one’s mind was ready, engaging in MAT \nwas accompanied by misconceptions and anxieties regarding \nthe medication and the MAT program as also documented in \nthe literature (Childs et al., 2021; Hobden & Cunningham, \n2006; Laswai, 2017). The fear of experiencing withdrawal \nsymptoms resulting from medication adjustment in the initial \nphases of therapy was a prevailing topic emerging and as \ndescribed in other studies (Earnshaw et al., 2013; Kageha \nIgonya et al., 2021; Laswai, 2017; Masese et al., 2022). Peer-led \nactivities form one part of the project, but the need for a \n‘health navigator’ system with a one-to-one buddy for each \nnewly enrolled MAT patient emerged as the most pressing \nneed for PWUD support at the beginning and throughout the \nMAT implementation and adjustment phase.\n\nOur findings are consistent with other studies reporting on \nthe importance of social support systems for MAT patients \n(Earnshaw et al., 2013; Ezard, 2001; Laswai, 2017; Ratliff et al., \n2013). Social support and acceptance by family, friends and \nthe community as a whole are central for a positive life on \nMAT. Our study results showed that life on MAT was coming \nwith a lack of hope for the future as many MAT patients \nstruggled finding new friends, being reintegrated into their \nfamilies and missed this feeling of belonging when living in \nthe hotspots with their peers. The new life on MAT did not \nmirror the positive life that was expected, turning many \npatients to relapse and going back to their ‘old’ friends from \n\n\n\n8 D. BURTSCHER ET AL.\n\nthe hotspots, restarting with heroin use and other sub-\nstance abuse.\n\nBarriers to maintaining in MAT were structural challenges \nincluding the economic hardship related to the distance and \ntransportation costs to the MAT clinic. Going along with these \nfinancial burdens were the questions of homelessness, job-\nlessness and idleness. Financial support for transport, occupa-\ntional and income generating opportunities were important \nfeatures for MAT patients to support them in staying in the \nprogram.\n\nThe MAT program was criticized for focusing mainly on \nmedication and not on providing opportunities to find jobs \nand access shelter for the homeless. Therefore, the MAT pro-\ngrams should be part of a comprehensive multi-sectoral harm \nreduction approach including social and economic support \ninterventions for people who navigate their lives from drug \nuse to being a MAT patient (Laswai, 2017). In addition to psy-\nchosocial support at the clinic, the MAT programme should \nalso consider a more holistic support package including \nfinancial support for transport, and occupational activities \nthat are coupled with income generation to tackle idleness \nand the feeling of worthless (Ratliff et al., 2013). It appears \nessential to engage individuals right from the initiation of the \nMAT process and to raise awareness among families, partners, \nand communities about the nature of MAT, its general func-\ntioning, its effects on the body, and the impact on the \npatient’s mindset. Engage health navigators for individuals \nnew on MAT, who ideally is a former PWUD. Homeless MAT \npatients could be referred to partner organisations that can \nsupport them in finding temporary shelters until they can be \nreunited with their families, partners or find a place to stay \nthemselves (NASCOP, 2021b; Ratliff et al., 2013).\n\nLimitations and strengths\n\nThe main limitation was that the PWUD included in the study \nmight not be representative of all PWUD in Kiambu county, \nas we did not include PWUD not linked to hotspots, and the \nlow number of women who use drugs in the cohort raises \nconcerns that they may have been underrepresented. We \naddressed this by carefully going more in-depth in individual \ninterviews with female PWUD who knew about behavioural \npatterns of this target group. There remains a need for greater \nefforts to understand challenges and barriers of female PWUD. \nIn addition, the translator and the peer workers assisting in \nidentification of study participants were MSF staff which \npotentially created response bias. Therefore, we carefully \nexplained the primary investigator’s role, highlighting the \nprinciples of neutrality and strict assurance of anonymity and \nconfidentiality. The sensitivity of the topic related to the stig-\nmatisation of PWUD when approaching hotspots represented \nanother limitation that was addressed by preparing PWUD \nbeforehand for the FGD and providing the option to be inter-\nviewed in another place.\n\nThe main strength of this study is that it has helped us to \nunderstand PWUD and MAT patients from their perspective \nwith all their struggles they have to endure. These in-depth \ninsights enabled us to analyse the underlying causes and \n\ndraw a number of programmatic recommendations to inform \nfuture planning.\n\nConclusion\n\nThe study shows the complex realities faced by people who \nuse drugs when engaging in MAT care. Their lives as active \nPWUD revolve around addiction and withdrawal symptoms \nand the daily struggle to find money for the next dose. PWUD \nare criminalised and subjected to stigma and discrimination. \nTransitioning from heroin to methadone or buprenorphine \ncan be a positive and difficult experience at the same time. \nIndividuals often struggle with balancing the transition from \na life of heroin use to methadone treatment, both from a \nmedical and a psycho-social standpoint. Our findings show \nthat effective programming for PWUD should go beyond dis-\npensing medication but must take a comprehensive and \nholistic approach to also address psychosocial and structural \nchallenges including economic integration, homelessness, \nand destigmatization of drug addiction and MAT. As part of a \npatient-centred comprehensive harm reduction approach, \nMAT can have a meaningful impact on the lives of PWUD and \ntheir families.\n\nNotes\n\n 1. Formerly Liverpool Voluntary Counselling & Testing Health now \ncalled LVCT-Health.\n\n 2. 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Role of boyfriends and inti-\nmate sexual partners in the initiation and maintenance of injecting \ndrug use among women in coastal Kenya. Addictive Behaviors, 93, \n20–28. https://doi.org/10.1016/j.addbeh.2019.01.013\n\nMinistry of Health. (2017). The national protocol for treatment of substance \nuse disorders in Kenya, 2017.\n\nMital, S., Miles, G., McLellan-Lemal, E., Muthui, M., & Needle, R. (2016). \nHeroin shortage in Coastal Kenya: A rapid assessment and qualitative \nanalysis of heroin users’ experiences. International Journal on Drug \nPolicy, 30, 91–98. https://doi.org/10.1016/j.drugpo.2015.08.010\n\nMwangi, C., Karanja, S., Gachohi, J., Wanjihia, V., & Ngang’a, Z. (2019). \nDepression, injecting drug use, and risky sexual behavior syndemic \namong women who inject drugs in Kenya: A cross-sectional survey. \nHarm Reduction Journal, 16(1), 35. https://doi.org/10.1186/s12954-019- \n0307-5\n\nNACADA. (2021). 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BURTSCHER ET AL.\n\nNdimbii, J., Guise, A., Igonya, E. K., Owiti, F., Strathdee, S., & Rhodes, T. \n(2021). Qualitative analysis of community support to methadone ac-\ncess in Kenya. Substance Use & Misuse, 56(9), 1312–1319. https://doi. \norg/10.1080/10826084.2021.1922450\n\nPatton, Q. M. (2002). Qualitative research & evaluation methods (3rd ed.). \nSage Publications Thousand Oaks.\n\nPope, C., & Mays, N. (2006). Qualitative research in health care. Blackwell \nPublishing.\n\nRatliff, E. A., McCurdy, S. A., Mbwambo, J. K. K., Lambdin, B. H., Voets, A., \nPont, S., Maruyama, H., & Kilonzo, G. P. (2013). An overview of HIV \nprevention interventions for people who inject drugs in Tanzania. \nAdvances in Preventive Medicine, 2013, 183187–183186. https://doi.org/ \n10.1155/2013/183187\n\nRhodes, T., Guise, A., Ndimbii, J., Strathdee, S., Ngugi, E., Platt, L., Kurth, \nA., Cleland, C., & Vickerman, P. (2015). Is the promise of methadone \nKenya’s solution to managing HIV and addiction? A mixed-method \nmathematical modelling and qualitative study. BMJ Open, 5(3), \ne007198. https://doi.org/10.1136/bmjopen-2014-007198\n\nRichards, H. M., & Schwartz, L. J. (2002). Ethics of qualitative research: Are \nthere special issues for health services research? Family Practice, 19(2), \n135–139. https://doi.org/10.1093/fampra/19.2.135\n\nRuiseñor-Escudero, H., Vu, A., Wirtz, A. L., Familiar-Lopez, I., Berry, M., \nMfochive, I., Engineer, C., Farhad, A., Tschakarjan, S., Wisse, E., Paikan, \n\nF. M., & Burnham, G. (2015). Cross-sectional assessments of partici-\npants’ characteristics and loss to follow-up in the first opioid substitu-\ntion therapy pilot program in Kabul, Afghanistan. Harm Reduction \nJournal, 12(1), 28. https://doi.org/10.1186/s12954-015-0062-1\n\nSyvertsen, J. L., Agot, K., Ohaga, S., & Bazzi, A. R. (2019). you can’t do this \njob when you are sober: Heroin use among female sex workers and \nthe need for comprehensive drug treatment programming in Kenya. \nDrug and Alcohol Dependence, 194, 495–499. https://doi.org/10.1016/j.\ndrugalcdep.2018.10.019\n\nSyvertsen, J. L., Agot, K., Ohaga, S., Strathdee, S. A., Camlin, C. S., Omanga, \nE., Odonde, P., Rota, G., Akoth, K., Peng, J., & Wagner, K. D. (2015). \nEvidence of injection drug use in Kisumu, Kenya: Implications for HIV \nprevention. Drug and Alcohol Dependence, 151, 262–266. https://doi.\norg/10.1016/j.drugalcdep.2015.02.037\n\nU.S. Department of Health and Human Services. SAMHSA’s working defi-\nnition of recovery, 2012.\n\nWambugu, G. M. (2020). Uptake of medically assisted therapy among peo-\nple who inject heroin in Mathare low income settlements, Nairobi County, \nKenya [Master Thesis]. Jomo Kenyatta University of Agriculture and \nTechnology.\n\nWHO. (2009). Technical guide for countries to set targets for universal access \nto HIV prevention, treatment and care for injecting drug users. WHO, \nUNODC and UNAIDS.\n\nhttps://doi.org/10.1080/10826084.2021.1922450\nhttps://doi.org/10.1080/10826084.2021.1922450\nhttps://doi.org/10.1155/2013/183187\nhttps://doi.org/10.1155/2013/183187\nhttps://doi.org/10.1136/bmjopen-2014-007198\nhttps://doi.org/10.1093/fampra/19.2.135\nhttps://doi.org/10.1186/s12954-015-0062-1\nhttps://doi.org/10.1016/j.drugalcdep.2018.10.019\nhttps://doi.org/10.1016/j.drugalcdep.2018.10.019\nhttps://doi.org/10.1016/j.drugalcdep.2015.02.037\nhttps://doi.org/10.1016/j.drugalcdep.2015.02.037\n\n\tI can change my life: perceptions and experiences of people who use drugs engaging in medically assisted therapy in Kiambu County, Kenya\n\tABSTRACT\n\tIntroduction\n\tMethods\n\tContext\n\tStudy design\n\tSelection and recruitment of study participants\n\tData management and analysis\n\tEthical approval\n\n\tResults\n\tStudy participants\n\tLeaving the old life: sick of being sick\n\tEngaging in MAT: fear of experiencing withdrawal symptoms\n\tLife on MAT: its a lack of hope\n\tMaintaining, the new life on MAT: your friends are still the same\n\n\n\tDiscussion\n\tFindings in context\n\tLimitations and strengths\n\n\tConclusion\n\tNotes\n\tDisclosure statement\n\tFunding\n\tData availability statement\n\tReferences\n\n\n","UrlSlug":null,"collections":[],"countries":[{"Name":"Kenya","Id":115}],"asset_languages":[{"AlternateTitle":null,"language":[{"Id":1,"Name":"English"}],"contentTranslation":[],"contentLocation":[]}],"creators":[{"Name":"Ellman T","Id":17158,"ac":[{"Order":11}]},{"Name":"Antierens A","Id":17906,"ac":[{"Order":14}]},{"Name":"Tampellini L","Id":18156,"ac":[{"Order":8}]},{"Name":"Pellecchia U","Id":18370,"ac":[{"Order":9}]},{"Name":"Verschuere J","Id":19910,"ac":[{"Order":7}]},{"Name":"Kerschberger B","Id":19962,"ac":[{"Order":5}]},{"Name":"Burtscher D","Id":21122,"ac":[{"Order":0}]},{"Name":"O’Connell L","Id":23653,"ac":[{"Order":10}]},{"Name":"Ayuaya T","Id":31093,"ac":[{"Order":4}]},{"Name":"Atte E","Id":31095,"ac":[{"Order":6}]},{"Name":"Riitho W","Id":32850,"ac":[{"Order":1}]},{"Name":"Kariuki M","Id":32851,"ac":[{"Order":2}]},{"Name":"Ngethe J","Id":32854,"ac":[{"Order":13}]},{"Name":"Thiong’o A","Id":35871,"ac":[{"Order":3}]},{"Name":"Levine B","Id":35872,"ac":[{"Order":12}]}],"keywords":[{"Name":"mental health","Id":57},{"Name":"substance use disorders","Id":114}]}}

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‘I can change my life’: perceptions and experiences of people who use drugs engaging in medically assisted therapy in Kiambu County, Kenya