Inside the grounds of Fann hospital in Senegal, men and women form a substantial queue. They are here for the Center for the Integrated Management of Addictions – the first drop-in clinic in West Africa running a free opioid substitution service – writes Nosmot Gbadamosi for CNN.
Those people without seats loiter in hallways, and others able to bear the sweltering heat outside play checkers under a canopy of overgrown mango trees. A nurse calls them one by one, dispensing a small cup of blue liquid.
It's a daily routine for methadone treatment and psychological counseling at the center and one that many journey hours to receive.
Known locally as CEPIAD [Centre de prise en charge intégrée des addictions de Dakar], the drop-in clinic’s aim is to reduce the spread of HIV and AIDS among addicts.
"You get here, have your methadone and you are not thinking about taking drugs. You are thinking about moving your life forwards," says Senegalese native Moustapha Mbodj, a former heroin addict for more than 30 years.
The service available to addicts is rare in this part of the world.
CEPIAD's program is the only one of its kind in Senegal, and West Africa, offering clean needles and opioid substitutes. A 2017 report showed that out of 37 nations in Africa reporting drug use data to the United Nations, just eight offer this type of therapy to addicts.
"Most users are coming here because it's the only center really," says Mbodj, who is 58. He began snorting heroin after traveling to Paris in his early twenties to study for a degree in technology.
By the age of 27 he was jailed for dealing cocaine and deported home after serving a three-year sentence.
"My family put a lot of hopes on me. When I started using they were extremely disappointed. There was a lot of deception," he recalls. On returning home to Dakar he would steal things at home to sell and buy heroin.
A local market for opiates
Over 10% of injecting users in the country are living with HIV, the United Nations Office on Drugs and Crime (UNODC) estimates, compared with less than one percent of the general population.
The country has seen a spike in opiates trafficked on their way to Europe creating an uncommon local market over the last decade according to the UNODC.
"Often what the traffickers are doing is they are paying their support staff not only in cash but in drugs," Pierre Lapaque, UNODC representative for West and Central Africa, told CNN.
"It's a very smart approach because you are creating a market in a region where there was absolutely no market ten years ago and it was just a transit area."
A voluntary survey carried out by the French National Agency for Research against AIDS unearthed more than 1,300 injecting addicts in Dakar in 2011. Previously there were no official statistics on how many people in the country were injecting drugs. A 2010 study of six states in Nigeria provided the only data for West Africa as a region.
'Harm reduction' through free needles
Senegal's government reacted with a "harm reduction" program when the survey was released. Back then 18,614 free needles and 17,564 condoms were handed out to addicts over a two-year period.
By December 2014, the government opened CEPIAD, offering methadone, condoms and clean needles with money from its AIDS prevention budget and training from UNODC and various international partners, including from the US and France.
"When I came in 2015," says Mbodj, "it allowed me to slow my life down a little bit and have time for myself to think about things."
Later that year and with money from the country's National AIDS Council, CLNS,Mbodj was able to launch a community group for addicts, Santé Espoir Vie (SEV), which translates as "health, hope, life."
The nonprofit operates independently of CEPIAD but a few members, including Mbodj, are paid mediators recruiting new patients for the clinic.
These mediators network the city's high drug-use areas every day to connect with addicts. There are 12 mediators that go out in teams of two.
"When we go into these drug hotspots people are very comfortable with us because we used to be users. We know how to approach them," says Mbodj.
‘I wasn't looking for help'
"If they miss a treatment we go to their homes. This is the social component of our jobs. We have to sit down and talk to them and re-convince them. It's a lot of back and forth," said Mbodj.
Many of the patients believe the treatment and therapy offered at the center has saved them. They assume without it they'd still be using, in prison perhaps, or worse.
"For me at least it saved my life," says one woman, 33, who didn't want to be identified because she fears for her safety.
She would burn through 100,000 West African CFA francs ($175) worth of cocaine a day, funded through prostitution.
A musician friend introduced her to crack cocaine at a club when she was 20. At first he bought the drugs.
"Then he lost his job so he said 'I have some friends on the street who could help you out' and that's when I became a sex worker," she recounts.
By the age of 22 she was selling herself on the streets. In 2013, she was jailed for 15 days for begging in public.
"I wasn't looking for help. All I was thinking about was just getting money and smoking."
She was at risk because of the unprotected sex and the violence that came with a drug-fueled lifestyle.
"At night sometimes thugs would follow us and steal our money, they would threaten us with knives and call us druggies," she says.
In 2015, she became very ill. When her sister took her to the hospital she was referred to CEPIAD for treatment and was diagnosed as HIV positive. Initially when she started treatment with counseling and drug substitution she relapsed and would still use cocaine.
"I made an agreement with the doctor that if I get married I am going to completely stop," she says. "I've been married one year and eight months. I met someone here at the center. He is on methadone treatment but he's sober."
Quitting without a substitute drug, users say, is incredibly difficult.
Mauama, who prefers we don't use her last name because of the stigma her family would face, knows this first-hand.
She sought exile from heroin and cocaine addiction in Touba, a holy city in the Muslim nation some 200 kilometers from Dakar.
"I went there because they have no dealers, no drugs, it's completely conservative," she says. "I took [opioid painkiller] Tramadol as a substitute to stop cravings but I'd last two months and go back to Dakar, get the drugs and go back up."
Her routine of abstinence and relapse lasted seven years. Then she met outreach workers from CEPIAD who offered her an alternative.
"I have been coming every day for two-and-a-half years."
Comprehensive treatment
At CEPIAD, psychologists and doctors provide counseling, HIV services, skills workshops and help with reintegrating into family networks.
Peer support workers who are themselves former drug users also offer help along the journey to a drug-free life.
"All of those things are a good part of a comprehensive approach to treatment," says Robin Clark, a professor in the Departments of Family Medicine and Community Health and Quantitative Health Sciences at the University of Massachusetts. He focuses on substance abuse and primary care.
It is crucial for such clinics to move beyond medication, he says of the use of methadone.
"There are a lot of psychosocial support just around daily living that really good effective centers try to offer to help people re-enter normal life after they have been unemployed, many people have been in prison," says Clark.
Apart from Senegal, Tanzania, Kenya and Mauritius are among the only eight countries in Africa offering 'harm reduction' approaches due to lack of funding and preference for faith-based and traditional healers.
"There are still challenges," admits Mbayang Fall Bousso, CEPIAD's health coordinator, who calls herself the organization's temple guardian.
"It's still only in Dakar and inside a hospital so not many people know it exists."
Those making the daily commute face logistical challenges and she wants the clinic to run nationally.
"This way we can be able to reach out to those who are still not able or willing to come," says Bousso. "To reduce the prevalence of HIV, hepatitis B, TB and of course to reduce the amount of users."
Since CEPIAD opened, more than 700 addicts have sought reprieve here. Now, outreach teams are targeting M'bour, about 80 kilometers south of Dakar.
"It's a beach town. It's a very touristy town too with a lot of cocaine and heroin. Consequently a lot of users," says Mbodj. "Every day I meet people that I think can be helped."
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