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