The story behind Uganda’s first opioid substitution treatment clinic

It has been a long road to get here. Many people have been waiting for years, some for decades, to receive methadone. It was a dream many did not dare believe would come true.

That first day our drop-in centres were overwhelmed as large numbers came to enrol. Initially, we were seeing around 80 people arrive each day in the hope of getting methadone. Currently we can only enrol four people a day but we are hoping this will change with time.

The difference the OST programme will make to people’s lives is hard to put into words. Now people will be able to manage their drug use in a way that enables them to get on with the business of living.

A symbolic step

The opening of Uganda’s first OST clinic is a symbolic step for harm reduction in this country. Although the biggest investment in the clinic comes from PEPFAR via the US Center for Disease Control (CDC) in Uganda, the clinic has been integrated into a mainstream public health facility, and has full government backing. Previously, all harm reduction interventions, including needle and syringe programmes (NSP), had been granted pilot status only.

In 2019, the Ministry of Health released guidelines on harm reduction and standard operating procedures for OST programming, both of which indicate strong government support for the clinic – and hopefully future clinics elsewhere.

 The OST clinic will operate in a way that genuinely meets the needs of people who use drugs. This has been achieved by ensuring people who use drugs have driven the advocacy that has gotte us to this stage as well as the design of the clinic itself.

For example, initially it was stated that people should be referred by public health facilities, but many people who use drugs avoid such facilities due to the stigma and discrimination they can encounter there and for fear of arrest. So we advocated for this to change – and we were successful. Now UHRN’s drop-in centres make all referrals. Our psychosocial support officers prepare people to enrol in the OST programme and offer support once they are enrolled. This process makes the likelihood that people stay on the programme much higher. It also ensures they can access other important services and products, such as counselling and sterile injecting equipment, to stay healthy.

Gaining influence

It is PEPFAR, through CDC Uganda, the Infectious Disease Institute and the Partnership to Inspire, Transform and Connect the HIV (PITCH) response that have supported us to make the OST clinic a reality in a relatively short time.

With PITCH’s support we have empowered our grassroots members as advocates, increasing understanding among them about what harm reduction is and how it can benefit their lives. PITCH has also invested in strengthening our network by building the capacity of community-led organisations to form effective partnerships, both within Uganda and across country borders. One such partnership led to interreligious groups visiting UHRN’s centres and engaging with people who use drugs.

Through our Harm Reduction Works campaign, which we began in 2016, and global campaigns such as Support. Don’t Punish, network members have built an understanding among policy-makers, the police and the media about the lived realities of people who use drugs and why harm reduction is more beneficial for individuals and for society than punitive approaches. We have also joined key advocacy spaces, including national arenas such as the Ministry of Health technical working groups and district-level AIDS and health committees. Community members have led all these efforts.

Cross-country learning

 A turning point came when we took officials from the Ministry of Health, the police, the Uganda AIDS Commission, members of parliament and community advocates to other countries to learn about harm reduction.

Earlier on, with support from the Global Fund, we had visited Kenya and Tanzania where most delegates took an observational role. In 2018, when we visited China and Portugal, I saw group members asking more informed questions. This was one of the moments I realised our advocacy was working; these key stakeholders had developed a genuine interest in, and knowledge of, harm reduction. And they were interested in learning more.

These two visits felt significant. People seemed energised and ready to adopt some of these ideas and practices in Uganda. Many of these people have become champions of harm reduction, and their contribution is invaluable for driving progress.

Getting results

In 2019, a major step forward came when the Ministry of Health formed a national taskforce on the issue, consisting of harm reduction advocates, technical teams from the Ministry of Health and the Uganda AIDS Council, the World Health Organization, UNAIDS and others.

Without this taskforce we would not have secured the harm reduction guidelines or OST standard operating procedures mentioned above, which were so crucial for seeing the OST clinic open successfully. The taskforce has also ensured people who use drugs have been officially recognised as a key population group in Uganda’s National HIV and AIDS Strategic Plan. The importance of this is only just being felt but will be essential in reaching future goals.

Looking forward

 Most harm reduction interventions in Uganda largely remain supported by external funders, which means their sustainability cannot be guaranteed. I would love to see the government take full ownership of such important, community-led interventions and expand them further.

OST programmes are only available in Kampala’s main city centre at present, yet UHRN operates in 40 districts. One of our dreams is to see OST programmes scaled up so that the people we support in other cities and districts can have access to this life-changing intervention, and live the full and healthy lives to which we are all entitled.

The Partnership to Inspire, Transform and Connect the HIV response (PITCH) is a joint partnership between Aidsfonds, Frontline AIDS and the Dutch Ministry of Foreign Affairs.