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Moonlight Methadone for Muslims on Medically Assisted Therapy
Curbing Drug Relapse in Malindi, Kenya
S Abdallah1, A.Omar2, F Ibrahim2, M Kirimo3, A Mongi3, S Hubeiss3, D Kule3, D Mohamed4, M Shossi4,
M Sirengo5 , H Musyoki5, E Mwamburi6, H Manji1 , S Bertrand1
1.United Nations Office on Drugs and Crime, ROEA 4. The Omari Project
2. Kilifi County, Department of Health, Klifii Kenya 5. National AIDS and STI Control Programme (NASCOP)
3. Malindi Sub-County Hospital, Malindi Kenya 6. USAID, Kenya
Background
Heroin trafficking along Kenya’s coast documented since 1980s, with increasing use over time among the local population
While 2009 Census estimates 11.1% of all Kenyans are Muslims, proportion is much higher along Kenya’s coastal region.
2011 UNODC Study revealed that in Kenya 55% PWID Christian and 42% Muslim, however at Coast 72% PWID Muslim.
To address high HIV prevalence (18.3%) among PWID, Kenya Government introduced Medically Assisted Therapy since 2014, as part of comprehensive HIV combination prevention package
Malindi Hospital initiated MAT since February 2015
By May 145 clients accessing methadone daily at daytime at MAT Clinic via DOT (directly observed therapy)
SEQUENCE OF EVENTS
Fasting is the fourth pillar of Islam. It is mandated on all
healthy Muslims from puberty.
"O you who believe! Fasting is prescribed for
you as it was prescribed for those before you,
that you may become God-fearing."
(The Quran, 2:183)
PRESENTED AT THE 21ST
INTERNATIONAL AIDS CONFERENCE - DURBAN, SOUTH AFRICA
Indicator Value
Total Clients Enrolled Feb-May 2015 (n) 145
% Female 20% (23/145)
Median Age (years) 35 (IQR 29—41)
% Muslim 72% (102/145)
Median Duration on MAT (months) 2.5 (IQR 2.25—3)
Median Methadone Dose (mg) 90 mg (70—119)
Urine Drug Screen Results—% Clean 47.3% (21/44)
PRIOR RAMADHAN EXPERIENCES OF MUSLIM CLIENTS
I never fasted before
when I was using
heroin! I only fasted first 2-3 days
then stopped because of
arosto
During Ramadhan I reduced
my drug use; only smoked 1-2
times so that I could fast
I weaned myself off
drugs 2-3 weeks before
Ramadhan then fasted
drug-free.
For all my years of drug
use, I only fasted when I
was in prison.
I don’t believe drug
users can fast!
METHOD
WIDE CONSULTATION BEFORE RAMADHAN 2015
Malindi and Mathari MAT Clients:
Ramadhan is coming. We want to fast. Please adjust our metha-done dosing during Ramadhan. Give us take away doses so we can take it after/ before fasting. Administer our dose either at 5am or 7pm at the MAT pharmacy Allow main pharmacy to dispense methadone after 6pm. Or leave our doses with MAT Clinic security guard.
If above options not possible, help us to taper off methadone over the next 4-6 weeks.
Muslim Staff and Imams:
Islam exempts from fasting if sick, traveling, pregnant or elderly Muslim MAT clients should forfeit this Ramadhan and plan to
wean off methadone before next Ramadhan of 2016 so hey fast drug-free (no heroin, no methadone)
International MAT Consultant Physicians:
You must instill a structured lifestyle for MAT clients. Detox only recommended for MAT clients who are incarcerated
and lack continued methadone access.
National AIDS & STI Control Programme (NASCOP)
No provision for Ramadhan in National SOP for MAT MAT program should respond to client needs where possible.
Mathari and Malindi MAT Clinic Staff:
Dosing time for Ramadhan beyond MAT clinic operating hours. Methadone a controlled drug cannot be left with security guard. No option for take away doses in National SOP for MAT
Mathari MAT Clinic Staff:
At Mathari, Muslim MAT clients are very few (<10) Evening dispensing also not feasible due to location of clinic
Civil Society Organisations (CSOs):
Decentralize methadone dispensing to a public health facility near locations of MAT clients, then allow staff on night shift to dispense pre-packed doses
Permit CSOs to dispense take away doses for Muslim clients at Drop-in-Centres
CONCLUSION
1. MAT adherence among clients influenced by myriad of factors
2. Strong desire for spirituality among MAT clients after years of negligence
3. Ramadhan serves as important means for reconnecting with creator
4. Moonlight dispensing for 44 Muslim MAT clients affirmed Malindi MAT
Team’s client centered approach
5. Positive behavior change noted post-Ramadhan (reduced illicit drug use)
6. 27.3% (12/44) recognized as model clients after 12 months on MAT
7. Strategies to enhance healing of body, mind and soul for MAT clients:
Incorporate spiritual beliefs and practices within MAT assessment and
treatment planning tools
Monitor effect of spiritual practices on MAT adherence and outcomes
Pilot other therapeutic and dispensing options as per evolving client
needs (buprenorphine, detox, community dispensing, take away doses,
extended hours, etc.)
RESULTS
25th – 28th Day 8 - 11
June 2015 of Ramadhan
29th Day 12
June 2015 of Ramadhan
April 2 Months
2015 Before Ramadhan
May 6 Weeks
2015 Before Ramadhan
Early June 4 Weeks
2015 Before Ramadhan
2 Weeks
Before Ramadhan
1 Week
Before Ramadan
June Day 1
18th 2015 of Ramadhan
June Day 2
19th 2015 of Ramadhan
June Day 3
20th 2015 of Ramadhan
24th Day 7
June 2015 of Ramadhan
3 clients express strong desire to fast
10 clients ask MAT Clinic staff for
evening Methadone in Ramadhan
Opinion sought from
Muslim staff and Imams
Further opinion from
International Consultant Physicians,
National HIV Program Coordinator
Mathari dismisses request
Malindi MAT Clinic: No decision
28 Muslim Clients skipped daytime
methadone dose
8 Clients reluctantly return for
Methadone dose at daytime
10 more clients in severe withdrawal
return for Methadone dose at daytime
Crisis meeting: County Health Director,
MAT clinic, Omari Project and UNODC.
Evening dispensing for Ramadhan
approved!
10 Muslim Clients who defaulted
return for daytime re-induction.
Methadone dispensed after sunset to
28 fasting clients + 16 other Muslims
also registered for fasting
30th June to Day 12-30
July 17th 2015 of Ramadhan
May 4 Weeks
2016 Before Ramadhan
7th Day 1
June 2016 Ramadhan 2016
18th Eid ul Fitr
July 2015
April 2 Months
2016 Pre-Ramadhan 2016
Smooth moonlight dispensing by 1
pharmacist with 2 ORW & 2 guards
Pilot Moonlight methadone halted
44 Muslim clients thank clinic & CSO staff & resume daytime doses.
Review of SOPs for MAT
National SOP recommends flexible
dispensing for ‘Special Days,’
which include Ramadhan
CSOs in Malindi and Mombasa
lobby for moonlight dispensing for
180 Muslim MAT clients
Muslim Clients get evening dose:
105 at Mombasa MAT Clinic, 74 Clients at Malindi MAT Clinic
However, outcomes are variable…
Poster No: WEPDD0103
Malindi MAT Client Profile, May 2015
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