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Photo essay: Sex and drugs in an HIV-infected paradise

BY Jason Kane and Victoria Fleischer  July 17, 2014 at 5:09 PM EST
Tourists interact with local vendors on the beach in Malindi, Kenya. Photo by Mia Collis/PBS NewsHour

European tourists interact with local vendors on the beach in Malindi, Kenya. Photo by Mia Collis/PBS NewsHour

Malindi, Kenya: A vacation destination with something for everyone. Sitting on the crystal coast of east Africa, the resort town offers glass-bottomed boat cruises, authentic Italian pasta, sex-for-hire and dirt-cheap heroin.

When the sun’s hot and vacation packages from Europe to Kenya run cheap, Italian tourists pour into town. Both women and men come for “sex holidays,” seeking out local “beach boys” for a night or an entire weekend’s worth of activity.

But during the low season — the four months of the year when rain is more frequent and the hotels empty out — things turn darker here. When the crowds die down, it’s hard to ignore that this is a town struggling with drugs and disease.

Withdrawal

Buska Ismail waits for the clinical officer at the Watamu Drop-In Center. Photo by Mia Collis/PBS NewsHour

Buska Ismail waits for the clinical officer at the Watamu Drop-In Center. Photo by Mia Collis/PBS NewsHour

Like many “beach boys,” Buska Ismail works exclusively to get high. He’s learned Italian, French, German and English to grow a customer base for his personal safari tours. When times are good, the business gives him enough cash to shoot heroin five or six times per day.

When they aren’t — when tourism dollars dry up between mid-April and mid-July each year — so does his drug habit. The effect: Unintentional detoxification.

Buska Ismail fights the pain as a clinical officer applies antiseptic to a severe wound on his back. Photo by Mia Collis/PBS NewsHour

Buska Ismail fights the pain as a clinical officer applies antiseptic to a severe wound on his back. Photo by Mia Collis/PBS NewsHour

Sometimes, Buska can only afford to shoot once per day, triggering withdrawal symptoms like abdominal pain, nausea and dizziness. The combined effect caused him to fall hard on the pavement recently, ripping the top two layers of skin off most of his back.

Buska is 32 years old — about the same age as the booming hard drug business in Malindi. Back when it first started, dealers sold a form of heroin known as “brown sugar,” mostly to European tourists and businessmen. But they soon realized that hooking the locals would be much more profitable in the long-run.

Shooting for a High

Shee Omar shoots up while Ahmed Mohamed smokes a joint filled with heroin and marijuana in a back alley of Malindi. Photo by Mia Collis/PBS NewsHour

Shee Omar shoots up while Ahmed Mohamed smokes a joint filled with heroin and marijuana in a back alley of Malindi. Photo by Mia Collis/PBS NewsHour

For reasons that remain a mystery to most long-time drug users in Malindi, the “brown sugar” began disappearing from the market in the 1990s, replaced with a crystalline powder they call “white crest.”

The shift marked a turning point for the HIV epidemic in Malindi. Brown sugar was most easily consumed by placing it in a piece of foil, heating from underneath and inhaling the vapors — a technique called “chasing the dragon.” But “white crest” burned too quickly for that. So the addicts began rolling it with marijuana and smoking it as a “cocktail.” Or, for a faster, cheaper and longer-lasting fix, injecting it straight into their veins.

Shee Omar readies himself for injection as his friend, Ahmed Mohamed, prepares the dose of heroin. Photo by Mia Collis/PBS NewsHour

Shee Omar readies himself for injection as his friend, Ahmed Mohamed, prepares the dose of heroin. Photo by Mia Collis/PBS NewsHour

Shee Omar, 29, decided to make the switch from smoking to injection about six months ago, because “the quality of heroin in Malindi is very low,” he said. “You have to spend too much to smoke and get high. So this is better.”

In the back alley of a neighborhood called Sea Breeze — with the Islamic call to prayer echoing over the tin-roof houses — Omar sat on a heap of dried coral and listened to his friend, Ahmed Mohamed, explain the best way to shoot.

Ahmed Mohamed, right, known as 'the doctor' in this neighborhood, teaches Shee Omar how to shoot heroin safely. Photo by Mia Collis/PBS NewsHour

Ahmed Mohamed, right, known as ‘the doctor’ in this neighborhood, teaches Shee Omar how to shoot heroin safely. Photo by Mia Collis/PBS NewsHour

Ahmed describes himself as a “fisher, carpenter and thief” — he’ll do just about anything for the next fix. But he’s developed a set of habits that have earned him the nickname, “doctor.” For one thing, he’s among the best people in town to help find difficult veins, so he’ll often lend a hand to people like Omar who are still learning to inject. But while he’s helping them get high, Ahmed will also talk with them about the health risks.

Sharing used needles — and the blood that comes with it — is one of the fastest ways to spread HIV. The Kenyan government estimates that along the coast, people who inject drugs account for 17 percent of new infections. And while the HIV prevalence rate in the general population stands at 5.6 percent, roughly a quarter of injection drug users are infected with the virus.

Public health officials warn that ignoring such startling figures will come at a price. After shooting up, many of these drug users return home for unprotected sex with their spouses — or they sell sex for drug money. The higher HIV rates then spill into the general population.

Ahmed knows the cycle all too well. He’s been injecting since he was 14, uses a condom only when he’s sober enough remember it, and recently tested positive for HIV. But one thing he does without fail these days is use clean needles for every new injection.

“I make myself a role model,” he said. “I don’t want anybody else to get in this trap. If my brothers and sisters are going to inject,” he said, “I want to teach them how to do it safely.”

Harm Reduction

The recently opened Watamu Drop-In Center helps addicts in Watamu and Malindi with basic health care, as well as services to make their drug habits safer. Photo by Mia Collis/PBS NewsHour

The recently opened Watamu Drop-In Center helps addicts in Watamu and Malindi with basic health care, as well as services to make their drug habits safer. Photo by Mia Collis/PBS NewsHour

At the Watamu Drop-In Center, one female addict, a regular, cuts straight to the point: “Welcome to Junky House — the big house for drug addicts,” she says. The Kenya Red Cross started funding the Watamu drop-in center in 2012 to reduce HIV rates among one of the country’s “most-at-risk” groups.

Before it opened, most of the 1,065 people who come here had nowhere to go for even basic medical care. “Because wherever they go, they will be turned away and labeled as thieves,” said Salim Mwakidzuga, the staff clinical officer. “If they are not turned away, they will never be given the first priority to be attended to. And these people are very impatient.”

Here, addicts receive fast and friendly treatment for just about any illness, as well as counseling for their addiction and evidence-based education on how to make their drug use safer.

Lessons Learned

Hajji Fadhil Mohammed, right, listens to Ludovick Tengia, describe the steps of safe injection. Photo by Mia Collis/PBS NewsHour

Hajji Fadhil Mohammed, right, listens to Ludovick Tengia, describe the steps of safe injection. Photo by Mia Collis/PBS NewsHour

Addictions counselor Ludovick “Lion” Tengia makes a point of sitting down with all of the users who come into the center for treatment. Though he rarely shares his own history with clients, Tengia speaks to them from a place of experience.

He spent more than a decade shooting and smoking heroin. His family watched as his circle of friends dwindled — many to drug overdoses, some to HIV. They were convinced he would follow them to the grave.

“I remember my mom telling me, ‘I have your coffin ready, you just tell me when it is. I can’t even grieve. I’ve grieved already.’ And that was so painful for me. So I just decided that me and the needles, that’s it,” he said.

In 2003, he made his way to a rehabilitation center in Malindi. But when administrators there met him at the gate, they discovered he was carrying some leftover drugs and they refused to let him in.

So Tengia waited outside the facility long enough to convince them that he was serious — that they should change their minds. Three days later, they finally did.

As a former addict himself, Ludovick Tengia, the addictions counselor at Watamu Drop-In Center, tries to mitigate some of the harm the drug users cause themselves. Photo by Mia Collis/PBS NewsHour

As a former addict himself, Ludovick Tengia, the addictions counselor at Watamu Drop-In Center, tries to mitigate some of the harm the drug users cause themselves. Photo by Mia Collis/PBS NewsHour

That’s why, as a counselor, Tengia has resolved to meet patients where they are. He knows they won’t listen unless they’ve made up their minds to change.

“If you are trying to quit, I’ll work with you on that. If you want to switch from injection to smoking, I’ll work with you on that. If you come to me and say, ‘I think I need to start injecting,’ I’ll tell you the facts about injecting, the risks which you are exposing yourself to. And then I’ll tell you how to do it safely.”

Injection drug user Hajji Fadhil Mohammed listens carefully to addictions counselor Ludovick Tengia at the Watamu Drop-In Center. Photo by Mia Collis/PBS NewsHour

Injection drug user Hajji Fadhil Mohammed listens carefully to addictions counselor Ludovick Tengia at the Watamu Drop-In Center. Photo by Mia Collis/PBS NewsHour

In a recent counseling session, Tengia asked Hajji Fadhil Mohammed to take him through “the steps of a typical injecting session.” Whenever Mohammed forgot one, Tengia interjected, explaining why it’s necessary to have a clean surface area and sufficient light.

But the No. 1 rule Tengia drills into his patients: Use a clean needle with each injection. Don’t share. No excuses.

Evidence-Based and Forbidden

Clinical officer Sailm Mwakidzuga inspects a needle and syringe kit at the Watamu Drop-In Center. Photo by Mia Collis.

Clinical officer Sailm Mwakidzuga inspects a needle and syringe kit at the Watamu Drop-In Center. Photo by Mia Collis.

Before they leave, drug users like Mohammed pick up free needles and syringes directly from the Watamu Drop-In Center. The packets come by the boxful from the Kenya Red Cross, which fully endorses the idea of “harm reduction.”

The theory goes that drug users will find a way to shoot regardless, so they should at least do it safely and without spreading HIV in the process — either to each other or to their sexual partners.

Lenora Lippmann, program development officer for the Kenya Red Cross - Coast Region, delivers the syringe kits given to injecting drug users at the Watamu Drop In Center. Photo by Mia Collis/PBS NewsHour

Lenora Lippmann, program development officer for the Kenya Red Cross – Coast Region, delivers the syringe kits given to injecting drug users at the Watamu Drop In Center. Photo by Mia Collis/PBS NewsHour

The world’s largest public health groups support the concept of “harm reduction” — from the World Health Organization to the Global Fund to Fight AIDS, Tuberculosis and Malaria, which has funneled nearly $600 million toward “harm reduction” programming and other services for people who inject drugs in the past 11 years.

But many conservatives cringe at the idea of handing drug users a tool for getting high. The U.S. government bans the use of federal dollars on needle and syringe programs — including any flowing through the massive President’s Emergency Plan for AIDS Relief, or PEPFAR. President George W. Bush, who created PEPFAR in 2003, said he didn’t believe in “so-called harm reduction strategies to combat drug use,” and that needle exchange programs signal “nothing but abdication, that these dangers are here to stay. Children deserve a clear, unmixed message that there are right choices in life and wrong choices in life, that we are responsible for our actions, and that using drugs will destroy your life.” Rather, he supported a mix of prevention, education, treatment and law enforcement activities to help drug users recover from addiction and to discourage others from trying in the first place. President Obama signed a bill ending the ‘Needle Exchange Ban’ in 2009, but a group of conservatives in Congress reinstated it as part of a spending bill passed two years later.

Similarly, when the government of Kenya launched a series of pilot needle and syringe programs along its coast in 2012, Muslim clerics demanded they end immediately. “The Quran strongly forbids such harm,” said Sheikh Yusuf Omar on behalf of the clerics at a community meeting in the coastal city of Mombasa. “This program seeks to use harm to stop another harm. This goes against the Islamic teachings. It is forbidden.”

Scattered Needles

Mohamed Ali Issa, a recovering heroin addict, says Needle and Syringe Programs don't work. Photo by Mia Collis/PBS NewsHour

Mohamed Ali Issa, a recovering heroin addict, says Needle and Syringe Programs don’t work. Photo by Mia Collis/PBS NewsHour

Among the Malindi area’s most outspoken critics is Mohamed Ali Issa, a once-powerful international businessman who lost everything — his Swiss wife, his children, his job — when he got hooked on heroin. “It was like a poison to me,” he said. “It took everything I had.”

So nine years ago, Issa checked himself into a rehabilitation program, where he quit cold-turkey. He’s been working to repair his relationships and shattered career ever since, and he now calls himself a model for the recovery approach.

“It’s much better to give them treatment or to bring them to a rehabilitation center rather than handing them needles for free. Because if they do that, they will just use more. More and more,” he said.

Used needles are collected  from the ground by The Omari Project’s outreach workers at a heroin den in Malindi. Photo by Mia Collis/PBS NewsHour

Used needles are collected from the ground by the Omari Project’s outreach workers at a heroin den in Malindi. Photo by Mia Collis/PBS NewsHour

Issa says the drug addicts don’t remember to return their used needles to the drop-in centers for proper disposal — they simply throw them on the ground, where children can play with them. Recently, one of his friends stepped on one while walking through town and was rushed to the hospital for tests and treatment.

He says that if volunteers and clinic staff are picking up the discarded needles — as they promised they would — they’re not doing it fast enough.

“Before this, we didn’t have many drug users who were using an injection,” he said. “But now, after this center started giving these things for free, many young boys are now trying it.”

Gateway

Shosi Mohamed,  the Omari Project drug rehabilitation and outreach program coordinator, was among leaders responsible for bringing the needle and syringe programs to the coast. Photo by Mia Collis/PBS NewsHour

Shosi Mohamed, the Omari Project drug rehabilitation and outreach program coordinator, was among leaders responsible for bringing the needle and syringe programs to the coast. Photo by Mia Collis/PBS NewsHour

Shosi Mohamed, program coordinator for the nonprofit “Omari Project” in Malindi, says that’s blatantly not true — that there’s no proof beyond anecdotal stories that the new needle and syringe programs are causing new harm. In fact, a recent study by the Omari Project and the London School of Hygiene and Tropical Medicine “proves that the NSP program has not contributed to an increase of drug use in Malindi or the coast, in general,” he said. Elsewhere in the world — in cities from Amsterdam to New York — long-term studies show that implementation of needle and syringe programming has led to dramatically lower HIV rates without any uptick in drug use.

It’s why the Omari Project — a group named after the first injection drug user in Malindi to die after using a contaminated needle — now sends dozens of volunteers directly into the back alleys and drug dens of this city daily to hand-deliver the syringe packets. Rather than encouraging drug use, Mohamed said it can often be the first step to helping them connect with Omari Project’s other programming, including life-saving treatment and counseling services.

The Omari Project Drop-In Center in Malindi takes its name from the first injection drug user in Malindi to die after sharing a contaminated needle. Photo by Mia Collis/PBS NewsHour

The Omari Project Drop In-Center in Malindi takes its name from the first injection drug user in Malindi to die of AIDS after sharing a contaminated needle. Photo by Mia Collis/PBS NewsHour

“Handing them that needle is sometimes the only way we can engage them and talk seriously about their drug use,” Shosi Mohamed said. “Do they really want to keep on using drugs? Do they really need to keep on injecting? Are they injecting properly? Because we can give you new needles and syringes, but who’s going to give you new veins? It makes people think more about their best options. And the best options for most people is not sharing needles, or stopping injection altogether.”

Recovery

Hassan Abdul receives medical care for an infected hand at the Omari Project Drop-In Center in Malindi. Photo by Mia Collis/PBS NewsHour

Hassan Abdul receives medical care for an infected hand at the Omari Project Drop-In Center in Malindi. Photo by Mia Collis/PBS NewsHour

Hasan Abdul's hand became severely inflamed after he missed a vein and shot heroin directly into the tissue. Photos by Mia Collis/PBS NewsHour

Hasan Abdul’s hand became severely inflamed after he missed a vein and shot heroin directly into the tissue. Photos by Mia Collis/PBS NewsHour

Take, for example, Hassan Abdul, who knows about the Omari Project through its needle and syringe services. When he missed a vein the other day and shot heroin directly into the tissue of his hand, he knew to come here for emergency treatment. Later, he’ll receive follow-up counseling to help him change his lifestyle, if he wishes to do so — or learn how to inject more safely in the future.

Roughly 40 percent of injection drug users in Malindi have developed wounds from poor injection practices. One of them is Mbarak Salim. Photo by Mia Collis/PBS NewsHour

Roughly 40 percent of injection drug users in Malindi have developed wounds from poor injection practices. One of them is Mbarak Salim. Photo by Mia Collis/PBS NewsHour

Before the Omari Project launched the needle and syringe program in 2012, 32-year-old Mbarak Salim used the same dirty needles so often they became dull. A bloody wound opened at his regular injection site, eventually spreading and becoming infected.

He uses clean needles now, which reduces the risk that the abscess will grow. And while doctors at the local hospital once told him that his leg would probably need to be amputated, consistent treatment at the Omari Project means he’s now headed for recovery instead.

Mbarak Salim receives counseling from Monica Wanja at the Omari Project Drop-In Center in Malindi. Photo by Mia Collis

Mbarak Salim receives counseling from Monica Wanja at the Omari Project Drop-In Center in Malindi. Photo by Mia Collis

Omari Project paralegal Monica Wanja also meets with clients like Salim when they stop in for treatment. She tells them about their civil rights and advises that they can find legal support at the center should they get into trouble.

Now sober for seven years, Wanja wants them to understand that full recovery is possible.

She tells them that she was once so overcome by addiction that she resorted to injecting in her breasts and genitals because the veins everywhere else were too damaged. When she gave birth to a daughter, she breastfed with one-hand and injected with the other. She rummaged through hospital trash cans for used needles. She had sex with Italian tourists at night for drug money. And eventually, she contracted HIV.

Monica Wanja, a recovering addict and a paralegal at the Omari Project, wipes away tears while describing her former life of drug abuse. Photo by Mia Collis/PBS NewsHour

Monica Wanja, a recovering addict and a paralegal at the Omari Project, wipes away tears while describing her former life of drug abuse. Photo by Mia Collis/PBS NewsHour

Like most of Malindi’s addicts, Wanja remembers vaguely talking about wanting to quit. She even checked herself into the Omari Project’s rehabilitation center nine times without ever taking it very seriously.

But before Wanja’s tenth stint at the facility, her grandmother — her only real source of support — sat her down to announce she was dying and had some tough words to leave behind: “This is your last chance. When I am gone, you will have no one. It is you now that has to make the decision.’”

Seven years have passed and temptation visits her daily, but Wanja says she hasn’t touched heroin since.

Relapse and Rehabilitation

The Omari Project Drug Rehabilitation Center sits several miles outside of the town of Malindi, far removed from many of the temptations the recovering addicts face in normal life. Photo by Mia Collis/PBS NewsHour

The Omari Project Drug Rehabilitation Center sits several miles outside of the town of Malindi, far removed from many of the temptations the recovering addicts face in normal life. Photo by Mia Collis/PBS NewsHour

The gate is always open at the Omari Project Drug Rehabilitation Center, several miles outside of town. Those who check themselves in can leave at any time.

But most find this a peaceful spot to heal — or at least try. They cook meals together and garden between counseling sessions and meditation. They care for baby goats and chickens. Mostly, they sit and think about where they’ve been and where they want to go.

Fatima Lali Athman was once employed by the Omari Project as an outreach worker. She is now, once again, a patient. Photo by Mia Collis/PBS NewsHour

Fatima Lali Athman was once employed by the Omari Project as an outreach worker. She is now, once again, a patient. Photo by Mia Collis/PBS NewsHour

Fatima Lali Athman knows this piece of land well. She checked in here for treatment in 2010, sobered up and became such a success story for the Omari Project that the rehabilitation center hired her as staff.

But her husband — a recovering drug user himself — started into heroin again shortly after Fatima returned home. She tried to resist the urge but said the easy access and constant temptation became too much. When she started smoking again, she quickly lost control.

Athman checked herself back in as a patient several months ago — a deep embarrassment for her and testament to the fragility of the recovery process. But it’s what needed to happen, she says.

“I didn’t look after my children. I didn’t do anything for myself. I stopped caring about everything. I knew it wasn’t healthy for anyone,” she said. “So I’m taking this chance again and hoping for the best.”

Traditional Swahili dhows sail in the Indian Ocean off the coast of Malindi. Photo by Mia Collis/PBS NewsHour

Traditional Swahili dhows sail in the Indian Ocean off the coast of Malindi. Photo by Mia Collis/PBS NewsHour

Even the most desperate drug users in Malindi haven’t lost that feeling of hope — that a brighter future is somehow possible for themselves and their city.

Drug use continues to thrive here. But disease rates seem to have leveled off, health officials say. And that in itself, most agree, is a reason to keep hoping for more.

This photo essay was produced with the support of the International Center for Journalists.