Even though numerous strong global proofs support harm reduction strategies, the coverage, adoption, and implementation for people who inject drugs (PWID) is poor, and Nigeria is not an exception to this. PWID constitute a considerable quota of at-risk drug users in Nigeria, and 20% of vulnerable drug users are injecting drugs (NBS, 2018). It has been reported that the most common drugs injected were pharmaceutical opioids, followed by cocaine and heroin. In Nigeria, the level of risky injecting practices and sexual behaviors among high-risk drug users is worrisome. Particularly, women who injected drugs are more prone to engage in high-risk sexual behaviors compared to their male counterparts, which further catalyzes their risk of acquiring and transmitting HIV among other infections. This problem is doubly compounded by the criminalization of drug use and not the adoption of evidence-based harm reduction in the country. Although extensive evidence and mathematical models revealed that a combination of opioid substitution therapies (OST), needle and syringe programs (NSP), and antiretroviral treatment (ART) among PWID can reduce new HIV by more than 50% (Degenhardt et al., 2010), the adoption of harm reduction globally is still abysmally low.
Injecting drug use is known to be associated with much serious drug-related distress, including, but not limited to, transmission of HIV and viral hepatitis, overdoses, and injection site infection among others. Among the high-risk drug users in Nigeria, 21% had injected drugs both in the past 12 months and currently, and nearly 17% of the PWID were women (NBS, 2018). The interconnection between injecting drugs and HIV is deep-seated. The Global State of Harm Reduction 2018 establishes that in Nigeria, the HIV prevalence among PWID is 3.4%; hepatitis C prevalence is 5.8%, while hepatitis B prevalence in the country is 6.7% among this key population. Unsafe injection practices, such as sharing contaminated needles, are a major risk factor for transmission of blood-borne infections such as hepatitis B, C, and HIV. Access to interventions such as NSP and OST is known to be effective in reducing harm and improving morbidity and mortality among this at-risk group. Having knowledge about injecting practices and behaviors of PWID is an important first step to effectively target such interventions. Even though, the recently released Drug Use Report 2018 (NBS, 2018) revealed a lot of information about the state of injection drug use in the country. It is important to note that there is a data dearth on the total number of death due to overdose in the country. This is a public health issue and it is of necessity to be treated as such in the country. It is therefore pertinent for the country's stakeholders to start seeing drug use from a public health perspective rather than criminalizing people who use drugs and investing in waging war on drugs.
Harm reduction coupled with good education on drugs is actually a necessity in the country. Nigeria, with a population of over 180 million, has been identified by the United Nations as a high-priority country for HIV prevention among PWIDs. The worldwide attestation in support of HIV prevention for PWID is entrancing. From the Drug Use Report 2018, about 50% of the PWID reported that they had used a needle or syringe after someone else had used it or another person had injected with their used needle or syringe – practices among PWID that increase the risk of HIV and hepatitis C transmission (NBS, 2018). Non-performance of the government to implement harm reduction programs against HIV, hepatitis C, and avoidable death among PWID has been a major factor extenuating against the progress of the nation’s public health sector. This calls for systemic interventions to address scathing communal, legislative, governmental, and environmental facilitators of HIV risk among PWID.
Harm reduction interventions include symbiotic biomedical, behavioral, and organizational interventions, which are not only evidence-based but rights-based as well as community-involved. It is therefore important for the Nigerian government to endorse and develop a package of HIV prevention intervention for PWIDs, including to varying extent, medically aided treatment for treating opiate use and addiction, access to ART, NSP, sexual behavior change communication, and community outreach. The majority of PWID in Nigeria do not know what naloxone is for and how/when to use it. This is seen to be less important because of the data dearth on the number of death due to opioid overdose. If a baseline countrywide study is done, it will be convincing to see the number of people that die due to opioid overdose which is preventable. The important part to note is that many stakeholders are fearful of adopting harm reduction because of the fear of it increasing drug use among its population. It has been confirmed by numerous studies that harm reduction does not increase drug use. At this point, adopting harm reduction and reforming drug policy in the country is a matter of urgency. The need to engage and equip the stakeholders with the right knowledge base is pertinent.
The Global State of Harm Reduction 2018 has shown that Nigeria is politically resistant to implementing NSP and OST, despite all the overwhelming evidence. Not only politically resisting harm reduction, poor funding of the health sector, as it is convincing that the country has little or no budgetary allocation to setting up and sustaining rehabilitation centers in the country. Citing an example, the country place ban on codeine, but do not make provision to rehabilitate people that are already addicted. It is therefore pertinent for the country to start establishing rights-based, adequate, effective, and affordable rehabilitation and drug treatment centers in the country. As affirmed by the World Health Organization (WHO), the United Nations Office on Drugs and Crime (UNODC), Harm Reduction International (HRI), International AIDS Society (IAS), Students for Sensible Drug Policy (SSDP), and other reputable partners at the heart of science, an all-inclusive package of harm reduction interventions has been demonstrated scientifically to support the prevention and spread of HIV and the reduction of other harms and distresses among PWID. In spite of this, there continues to be dissonance between levels of HIV and viral hepatitis among PWID and the availability of harm reduction services.
A lesson should be learned by other countries in Africa on how Mauritius successfully achieved high coverage of harm reduction services among PWID. It would not be surprising if Mauritius would be the number one country in Africa to achieve zero new HIV infections among PWID. It is time for Nigeria to adopt harm reduction intervention among PWID and invest in setting up affordable and quality rehabilitation and drug treatment centers; this should be more than just policy recommendation and clear-cut support in the national reference book, but successful and actual implementation is much-needed. Harm reduction works.
References
Degenhardt, L., Mathers, B., Vickerman, P., Rhodes, T., Latkin, C., & Hickman, M. (2010). Prevention of HIV Infection for People Who Inject Drugs: Why Individual, Structural and Combination Approaches Are Needed. Lancet, 376, 285–301.
MacArthur, G., Minozzi, S., Martin, N., Vickerman, P., Deren, S., Bruneau, J., et al. (2012). Opiate Substitution Treatment and HIV Transmission in People Who Inject Drugs: Systematic Review and Meta-Analysis. British Medical Journal, 345, e5945.
National Bureau Statistics (NBS). (2018). Drug Use in Nigeria.