Helgar Musyoki is a Public Health Specialist. She has more than 15 years of experience in implementing programmes to combat HIV and worked as programme coordinator of the National Programme on AIDS and Sexually Transmitted Diseases in Kenya. Among the many effective interventions she initiated were Harm Reduction ones. She is currently a Key Populations Advisor at the Global Fund, an international initiative to end the spread of AIDS, tuberculosis and malaria. In this interview with GPDPD, she explains the different aspects that should be considered when Harm Reduction is getting implemented and what we can learn from the Kenyan example.

GPDPD: Why is it important to embed Harm Reduction in national policies?


Helgar Musyoki: Most countries have relied on abstinence-based approaches, which sometimes have failed us. Instead, we should embrace what we have seen to be working, which is evidence-based Harm Reduction. Harm Reduction is usually an unpopular approach and needs a lot of advocacy and lobbying. It requires a government that commits to implementing the measures and generates data that conveys the positive effects of Harm Reduction.


Another important aspect is sustainability. Most Harm Reduction programmes rely heavily on donors. Many countries would welcome Harm Reduction measures but are unwilling to spend money on them. Therefore, it is critical to embed Harm Reduction approaches into national policies so that they can be included in the state budget, either at the national or the district level and that they are integrated into the public health system and primary healthcare. We need to make clear that Harm Reduction is everyone’s business. If we can do that, it will help to expand the programmes further. And finally, we need national policies that create an enabling environment in which partners, implementers and communities can trust the government to support them. Harm Reduction approaches deal with behaviours that are already criminalised in many countries. So, if the government is taking leadership, the communities, implementers, and donors see that Harm Reduction measures are taken seriously and are being embedded in policy. 


What is the Key Populations Programme, and how does it address drug use? 


The Key Population Programme focuses on high-risk groups that are disproportionately affected by HIV, which are gay men, sex workers, people who inject drugs, transgender and recently, WHO has also included the prison population. The entry point for many programmes is HIV. They are implemented to reduce the chances of transmitting HIV or other blood-borne diseases like hepatitis C and thus reach populations that traditionally are not part of the target group as many countries focus on the general population. 


In the case of Kenya, the government found in 2008 based on a study on the modes of transmission, that a third of HIV infections are attributable to key populations. That was a wake-up call for the government. It then developed a national programme to implement Harm Reduction measures through the key populations programme. 


Which steps did Kenya take to implement this policy?


The study in 2008 marked a paradigm shift towards focusing on the key populations and moving away from the traditional focus on the general population. What did Kenya do? Kenya has established new structures and strategies. Firstly, together with relevant stakeholders, the government has launched a national programme. This programme was designed to address key populations and implement various Harm Reduction measures targeting people who use drugs. This won the trust of the implementers and the communities who now began to use the services. They now know that the government is supportive and that they’re not going to be arrested. Secondly, Kenya established a technical working group. The working group brought together all stakeholders and functioned as a platform where donors, communities, implementers, and researchers could exchange ideas. This created a space for constructive advocacy. 


Civil society was then able to advocate for implementing Harm Reduction measures for people who use drugs. Civil society organisations are critical in any country wishing to expand its Harm Reduction programmes. 


Objective data is also essential. Kenya has implemented a system for generating data and evidence, which civil society organisations then use to support their programmes. Many governments will not believe in success until they see it. Therefore, it is necessary to show governments the data and that we have a problem and need to deal with it. 


What were the outcomes of this policy change?


The same data was eventually used to show the effects of the programmes. It became clear that there was a reduction in needle sharing in some areas where Harm Reduction approaches were adopted early on. Kenya has been able to prioritise key populations in the national strategy. Various counties integrated this at the local level and developed their own plans. This was very critical in terms of expanding and decentralising the programmes. 


Another important aspect is high-level political support through the involvement of governors, the Ministers of Health and Interior, senior government officials and parliamentarians. Some of these government officials visited countries such as the UK, Spain, China, and India, which have successfully implemented Harm Reduction and have been able to share best practices. Within Africa, Mauritius and Tanzania, in particular, have been very successful in this area, and some parliamentarians from Kenya visited those countries and saw that Harm Reduction is also possible in the African context. Another key aspect is the involvement of communities in the design of programmes and the development of policies. Many communities are actively involved. Lastly, Kenya has also successfully engaged the judiciary and the police. Currently, Kenya is institutionalising Harm Reduction by developing a curriculum jointly with the police to integrate Harm Reduction into the training of police officers. 


Which lessons learned could guide other countries in implementing Harm Reduction in their national policies?


Advocacy needs to be continuous. Every five years, there is an election, and new leaders are coming, which must be taken into account in the programmes to include entry meetings with the new governments. In the long term, we need to find a way to integrate Harm Reduction policies through legislative changes sustainably. Our priority is to provide Harm Reduction services to people, but in the long run, we need to take sustainable measures to ensure that there are no interruptions when a new government is elected. We need long-term strategies to ensure that Harm Reduction is part of primary health care.