Outreach and Peer Education for Drug Users In Cairo’s Streets: The Freedom HIV/AIDS Program : Outreach and Peer Education for Drug Users In Cairo’s Streets: The Freedom HIV/AIDS Program Ehab El Kharrat PhD, MSc Psych,MBBCh


Ex-IDUs educating their Peers: Ex-IDUs educating their Peers 22 former drug users work full or part time in the streets of Cairo Reaching out for 1030 street addicts in two years 145 of those reached are now abstinent Reported Needle Sharing dropped from 29% on baseline to 5 % on 6-12 and 12-18months follow-up Unprotected sex dropped from 52% to 25%


How Did It Happen?: How Did It Happen? Challenges: 1.HIV/AIDS denial 2.Double stigmatization 3.Fear 4.12-Step resistance 5.The safe sex issue


How Did This Happen?: How Did This Happen? Assets: 1.History of doing outreach, but the goal was abstinence only. 2.Strong peer education/involvement, but only as part of the 12-Step and/or TC models 3.Professional and former addicts team 4.FHI bringing in the international expertise and credibility


Freedom Identity and History: Freedom Identity and History Freedom is a Not for Profit FBO Part of Kasr El Doubarah Presbyterian Church Largest Drug rehabilitation Program in the Arab Region 105 Beds in 4 rehab Centers and one Detox. Over 530 recovered addicts came out of the Freedom Doors A Minnesota Model Abstinence Based Rehab Program


Freedom Drugs and HIV/AIDS Program: The Program Context of Peer Education: Freedom Drugs and HIV/AIDS Program: The Program Context of Peer Education Drug Rehabilitation and Detoxification HIV/AIDS Prevention Outreach among IDUs Drugs and HIV Prevention Training Drug Workers Training A Reclamation Project Follow-up and family activities


Freedom Drug Rehabilitation CentreWady El Natroun: Freedom Drug Rehabilitation Centre Wady El Natroun


Outreach To IDUs:: Outreach To IDUs: Freedom has been reaching out for IDUs from its very beginning: Thousands have been reached since 1989: The strong training heritage helped The sense of a community within the community was an asset and a challenge IDU/Youth Peers:45% of workers and 55% of those reached are below the age of 30


Shoubra Outreach Center : Shoubra Outreach Center Peer Education Counseling Meals Psycho-social support Referrals to VCT and other services as required Medical Care Hygiene Services Distribution of IEC materials Distribution of clean clothes At the Shoubra Outreach Center, the following services are offered to IDUs:


Dealing with Special Challenges to Peer Education: Dealing with Special Challenges to Peer Education Professionals doubting the peer education method The program started in 1989 with non- residential drug rehabilitation activities. In 1991 it started its urban residential services in Cairo. In 1996 its farm center started functioning. All the way through we faced the same doubts


Dealing with Special Challenges to Peer Education: Dealing with Special Challenges to Peer Education Former Addicts not motivated to work on HIV/AIDS prevention The FHI and MOH training helped orienting and motivating The strong “Freedom” person-centered culture was called upon ( Your abstinence is important but you are more important) The maturation process


Dealing with Special Challenges to Peer Education: Dealing with Special Challenges to Peer Education HIV denial: Addiction we see, HIV not yet:5,000-30,000 PLWHA in Egypt Educating the educators: window of opportunity, Russia, Ukraine, Iran, Indonesia, Libya But let us start with the peers passion and interest: moving from your interest to the peers interest Breaking the denial takes time


Dealing with Special Challenges to Peer Education: Dealing with Special Challenges to Peer Education Avoiding the risk of relapse: Only use stable former addicts:1- 14 years of abstinence in the streets Training before the work and every 4-6 months more training Pre and post outreach meetings Weekly seminars Move in teams: never left alone with users Two days a week or one day a week of outreach Continuous support to educators


Dealing with Special Challenges to Peer Education: Dealing with Special Challenges to Peer Education Can 12-Steppers do outreach for HIV prevention? 12-Step groups were extremely suspicious about the work We called upon the 12th Step tradition of carrying the message We called upon the tradition of admitting powerlessness over hurrying the addict into abstinence


Dealing with Special Challenges to Peer Education: Dealing with Special Challenges to Peer Education Did Freedom compromise its strong abstinence history? Colleagues said after 14 years of pioneering abstinence work, Freedom compromised to a harm reduction model Again we need to keep them alive if we want to have anyone abstaining We matured into knowing that abstinence does not come immediately many times We had more people abstaining this way and never written off the abstinence goal


Dealing with Special Challenges to Peer Education: Dealing with Special Challenges to Peer Education Perceived Challenges from the culture Actual reality neighbors did not mind Not a single incident from the streets Landlord did not mind


Dealing with Special Challenges to Peer Education: Dealing with Special Challenges to Peer Education HIV/AIDS Stigma Authorities in dilemma An official stamped “letter” of “conducting research” not of doing outreach/peer education, no IDs delivered til now


Changing a Subculture: Changing a Subculture What did addicts in Cairo believe about HIV/AIDS high risk behavior? Buying clean syringes before buying the “stuff” is a jinx ! Hepatitis C is a problem but HIV is not


Dealing with Special Challenges to Peer Education: Dealing with Special Challenges to Peer Education What did recovering addicts believed about the non abstaining addict? Will never trust a non-addict Do not like themselves enough to protect themselves Need a relationship more than the information Education does not come except through a relationship Mostly these beliefs were proven true


Working with Stigma: Working with Stigma Government balance needed Female addicts-a double stigma True stories of educators with law enforcement


Challenges of Follow up: Challenges of Follow up Why would I give you my correct contacts? Following up a population on the run Changing residence, family issues and selling your phone line


Unsafe Sex how and when can it Change?: Unsafe Sex how and when can it Change? What are the sexual beliefs of street addicts? What are the sexual beliefs of recovering addicts? The meanings of sex: pleasure, conquest, shame versus expression of love, respect and commitment Using addicts are mostly not expected to change their life views to reach sexual abstinence or faithfulness without abstaining from drugs, but progress is possible


The condom issue: The condom issue The Condom Issue Focusing on not sharing needles more Effort to understand the issues


Change In Unprotected Sex Behaviour: Change In Unprotected Sex Behaviour


Change In Injection Behaviour: Change In Injection Behaviour


Peer education to addicts why does it work?: Peer education to addicts why does it work? Trust Empathy Knowing the tricks Knowing the language A shared stigma A shared hope Communicating self worth


Can a Peer educator be a researcher? : Can a Peer educator be a researcher? The challenge of documenting Passion and science Doing more than what is needed Trusting the institutions Age groups and social classes


Lessons Learned on Working with Marginalized Groups : Lessons Learned on Working with Marginalized Groups Start with their interest e.g. from addiction to HIV Find assets within the sub-culture e.g. carrying the message Find assets within the culture e.g. tolerance Plan for contingencies but expect possibilities e.g. neighbors not resenting They may better know the real problems e.g. the jinx belief