Supporting people who use drugs in Uganda - Gift's story
By Medina Gift, referral counsellor at the Uganda Harm Reduction Network, and a participant in the Alliance's Photovoice project in Uganda.
HIV is a complex issue. Before I started working in harm reduction, I had no idea about people who use drugs. I only knew the stereotypes. But my work has shown me that instead of looking at HIV as an issue in isolation, we need to get to the roots of it, as support needs to come from every angle.
The Uganda Harm Reduction Network (UHRN), a coalition of community based organisations and peer groups formed by people who used to use drugs, now exists in many districts. In Kampala, where I work, there are 14 staff members. We have familiarised ourselves with most of the drug ‘hotspot’ dens in the city and have been able to establish trust in the people we find there. We do this by building relationships with representatives at each hot spot who will then introduce us to other people. After an outreach operation, we often find we have more than 100 cases to manage.
Together with The AIDS Support Organisation (TASO) and the Most At Risk Population Initiative (MARPI) in Mulago hospital, we mobilise organisations to provide services and health care for people who use drugs, such as counselling, HIV testing and treatment, and treatment for sexually transmitted infections (STIs).
My role is to help people who use drugs access these services. I write formal letters, linking people to whatever they need to deal with the situations they face, be it medical assistance, legal assistance or rehabilitation services.
We have developed a good relationship with a contact at the police’s Anti-Narcotic Department. He now acts a champion for our cause. When people who use drugs are detained, he will call URHN, asking us to come and pick them up.
Those that want to, we will accompany to Botanica, the national referral hospital for mental health, where they can access ‘rehabilitation’ services for addiction management. With the involvement of our staff, or where possible a family member or guardian, we support people to enrol and stay in the programme, visiting them twice a month to ensure they are getting the care they need.
Many of the drug users we work with worry that others will think they are ‘mad’ if they go to Botanica. They have seen the hardship that others go through when they leave and return to their communities. They carry that stigma.
We need to consider what people experience when they come out of rehab. We need to think what next? Too often people go back to the dens because they don’t have an alternative. Support needs to be put in place, whether it’s counselling to help people reconcile with their families if they want to, or training to help them learn skills so they can have a sustainable income and build a new life.
The instability of the population we serve is a big challenge. Many of our clients are homeless or highly mobile and you often find that what you intend to deliver is not what you are able to provide.
Some people withdraw from treatment. You find that when you go for a follow-up visit, they will have gone. Many don’t have a mobile number and you lose them. You linked them to care but they are now out of reach.
But there are big successes too. One of my best experiences at URHN was when a young man came to the secretariat with his bag and asked for support, saying he wanted to stop using drugs. At that point, even his parents had given up on him.
We were so happy to see that he had come to us by himself, without any pressure. When we took him to Botanica, he stopped using drugs within two months. During his stay at the hospital, he took other clients under his wing, giving them the courage to stay in treatment and get the support they needed.
The human approach
In Uganda, there is a perception that people who work in harm reduction are promoting drug use. We try to explain we are working to reduce the harms associated with drug use.
Some people don’t want to see that drug use exists. Others think people who use drugs deserve the bad things that can happen to them. But they forget that the person you are abandoning is a human being with their own story to tell and will also affect other people’s lives.
Many of our clients face violence. After an attack, they can be in a serious condition and we will take them to hospital worrying they might die. But the health providers we meet there often have the opinion that violence is a normal thing for drug users to experience and they don’t need or deserve emergency care. They will have to wait to be seen, sometimes all day until late at night. The attitude of the healthcare workers is very negative, many just don’t care about people who use drugs.
Women who use drugs
In Uganda, cultural norms say women are supposed to be obedient and humble. A woman who uses drugs is looked upon by many as a spoilt woman and they are often thrown out of their communities. This makes them extremely vulnerable, and they face discrimination on many levels. They will face harassment at the hands of men who use drugs and men in the general population. Men who perpetrate these actions know these women have no one to report abuses to.
Often, the only way for women to get the drugs they need is to engage in sex work and shoulder all the risks that come with it. It is different for men who use drugs; it is easier for them to find some other sources of income. Young women, in particular, are in a corner as they have no one to guide them.
Many have a desire to be a parent but because of their situation they are taken away from their children and they end up giving up. Many also need information about family planning but they don’t know where to find it. Those that do know often get negative responses when they try to access services. This means they will not go back, yet they still have the same issues affecting them: violence, lack of information on sexual and reproductive health and rights, and the stigma associated with drug use.
The snowball effect
Often women who use drugs feel unable to express themselves, to negotiate with others on issues such as condom use and to make informed decisions. We need to empower these women so they can speak out about their issues rather than sitting down, feeling voiceless and swallowing everything that comes.
UHRN encourages women who use drugs to take part in community dialogues, and we work to ensure they are given more opportunities. When they are engaged, you find that these women are extremely resourceful.
Recently we helped a group of seven women who were facing violence from their clients who did not want to pay. UHRN followed up on each case until the perpetrators were arrested. We encouraged every woman we helped to tell others, and five more came and reported violence to us.
These peer-to-peer referrals are like a snowball and UHRN’s activities keep expanding, helping more people who use drugs as we grow.