{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,28]],"date-time":"2026-03-28T12:29:27Z","timestamp":1774700967984,"version":"3.50.1"},"reference-count":45,"publisher":"Public Library of Science (PLoS)","issue":"7","license":[{"start":{"date-parts":[[2024,7,2]],"date-time":"2024-07-02T00:00:00Z","timestamp":1719878400000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100000026","name":"National Institute on Drug Abuse","doi-asserted-by":"crossref","award":["R01DA043409-05"],"award-info":[{"award-number":["R01DA043409-05"]}],"id":[{"id":"10.13039\/100000026","id-type":"DOI","asserted-by":"crossref"}]},{"name":"NIH Diversity Supplement","award":["R01 DA043409-S1"],"award-info":[{"award-number":["R01 DA043409-S1"]}]},{"name":"University of Washington Global Opportunities Health Fellowship"}],"content-domain":{"domain":["www.plosglobalpublichealth.org"],"crossmark-restriction":false},"short-container-title":["PLOS Glob Public Health"],"abstract":"<jats:p>In Kenya, overdose remains a major public health concern with approximately 40% of persons who inject drugs (PWID) reporting personal overdoses. PWID living with HIV (PWID-LH) are particularly vulnerable to experiencing fatal and non-fatal overdoses because of the surrounding physical, social, economic, and political environments, which are not fully understood in Kenya. Through qualitative inquiry, this study characterizes Kenya\u2019s overdose risk environment. Participants were purposively recruited from a larger cohort study from September to December 2018 using the following inclusion criteria: HIV-positive, age \u226518 years, injected drugs in the last year, and completed cohort study visits. Semi-structured interviews explored experiences of personal and observed overdoses, including injection settings, sequence of events (e.g., pre-, during, and post-overdose), safety strategies, and treatment. Interviews were transcribed, translated (Swahili to English), reviewed, and analyzed thematically, applying a risk environment framework. Nearly all participants described personal and\/or observed overdose experiences (96%) and heroin was the most frequently reported substance (79%). Overdose precursors included increased consumption, polysubstance use, recent incarceration, and rushed injections. There were also indications of female-specific precursors, including violence and accessing prefilled syringes within occupational settings. Overdose safety strategies included avoiding injecting alone, injecting drugs incrementally, assessing drug quality, and avoiding polysubstance use. Basic first-aid techniques and naloxone use were common treatment strategies; however, naloxone awareness was low (25%). Barriers to treatment included social network abandonment, police discrimination, medical stigma, fatalism\/religiosity, medical and transportation costs, and limited access to treatment services. In Kenya, the overdose risk environment highlights the need for comprehensive overdose strategies that address the physical, social, economic, and political environments. Morbidity and mortality from overdose among PWID-LH could be reduced through overdose prevention initiatives that support harm reduction education, naloxone awareness, and access, destigmatization of PWID, and reforming punitive policies that criminalize PWID-LH.<\/jats:p>","DOI":"10.1371\/journal.pgph.0003435","type":"journal-article","created":{"date-parts":[[2024,7,2]],"date-time":"2024-07-02T18:40:48Z","timestamp":1719945648000},"page":"e0003435","update-policy":"https:\/\/doi.org\/10.1371\/journal.pgph.corrections_policy","source":"Crossref","is-referenced-by-count":2,"title":["\u201cWe only trust each other\u201d: A qualitative study exploring the overdose risk environment among persons who inject drugs living with HIV in Nairobi, Kenya"],"prefix":"10.1371","volume":"4","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-1013-7572","authenticated-orcid":true,"given":"Megan","family":"Maurano","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"David","family":"Bukusi","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9836-4616","authenticated-orcid":true,"given":"Sarah","family":"Masyuko","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Rose","family":"Bosire","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Esther","family":"Gitau","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Brandon L.","family":"Guthrie","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Aliza","family":"Monroe-Wise","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Helgar","family":"Musyoki","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Mercy Apiyo","family":"Owuor","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Betsy","family":"Sambai","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"William","family":"Sinkele","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1181-5507","authenticated-orcid":true,"given":"Hanley","family":"Kingston","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8575-3439","authenticated-orcid":true,"given":"Carey","family":"Farquhar","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Loice","family":"Mbogo","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Natasha T.","family":"Ludwig-Barron","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"340","published-online":{"date-parts":[[2024,7,2]]},"reference":[{"key":"pgph.0003435.ref001","unstructured":"United Nations Office on Drugs and Crime. World Drug Report 2023: Special Points of Interest [Internet]. Vienna, Austria; 2023 [cited 2023 Sep 12]. https:\/\/www.unodc.org\/res\/WDR-2023\/Special_Points_WDR2023_web_DP.pdf"},{"issue":"1","key":"pgph.0003435.ref002","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1186\/1477-7517-2-12","article-title":"The rise of injecting drug use in east Africa: a case study from Kenya","volume":"2","author":"S Beckerleg","year":"2005","journal-title":"Harm Reduct J"},{"issue":"4","key":"pgph.0003435.ref003","doi-asserted-by":"crossref","first-page":"428","DOI":"10.1007\/s40429-018-0232-9","article-title":"The Opioid Epidemic in Africa And Its Impact","volume":"5","author":"AE Kurth","year":"2018","journal-title":"Curr Addict Rep"},{"issue":"S3","key":"pgph.0003435.ref004","doi-asserted-by":"crossref","DOI":"10.1002\/jia2.25729","article-title":"A decade and beyond: learnings from HIV programming with underserved and marginalized key populations in Kenya","volume":"24","author":"H Musyoki","year":"2021","journal-title":"J Int AIDS Soc"},{"issue":"4","key":"pgph.0003435.ref005","doi-asserted-by":"crossref","first-page":"403","DOI":"10.1097\/QAD.0b013e32834f19b6","article-title":"HIV infection and risk of overdose: a systematic review and meta-analysis","volume":"26","author":"TC Green","year":"2012","journal-title":"Aids"},{"key":"pgph.0003435.ref006","unstructured":"Publications on drug prevention and treatment [Internet]. [cited 2023 Sep 13]. https:\/\/www.unodc.org\/unodc\/en\/drug-prevention-and-treatment\/publications.html"},{"key":"pgph.0003435.ref007","unstructured":"Ministry of Health Republic of Kenya, Mental Health & Substance Abuse Management Unit. The National Protocol for Treatment of Substance Use Disorders in Kenya. Nairobi, Kenya; 2017."},{"key":"pgph.0003435.ref008","unstructured":"United Nations Office on Drugs and Crime. World Drug Report 2021 [Internet]. 2021 [cited 2023 Sep 7]. https:\/\/www.unodc.org\/unodc\/en\/data-and-analysis\/wdr2021.html"},{"key":"pgph.0003435.ref009","unstructured":"The Global State of Harm Reduction 2020-Harm Reduction International [Internet]. [cited 2023 Sep 12]. https:\/\/hri.global\/flagship-research\/the-global-state-of-harm-reduction\/the-global-state-of-harm-reduction-2020\/"},{"issue":"7","key":"pgph.0003435.ref010","first-page":"867","volume":"10","author":"T Rhodes","year":"2015","journal-title":"Navigating the poverty of heroin addiction treatment and recovery opportunity in Kenya: Access work, self-care and rationed expectations"},{"issue":"2","key":"pgph.0003435.ref011","first-page":"95","article-title":"Implementing needle and syringe programmes in Kenya: Changes, opportunities and challenges in HIV prevention","volume":"14","author":"J Ndimbii","year":"2016","journal-title":"Afr J Drug Alcohol Stud"},{"issue":"2","key":"pgph.0003435.ref012","doi-asserted-by":"crossref","first-page":"85","DOI":"10.1016\/S0955-3959(02)00007-5","article-title":"The \u2018risk environment\u2019: a framework for understanding and reducing drug-related harm","volume":"13","author":"T Rhodes","year":"2002","journal-title":"Int J Drug Policy"},{"key":"pgph.0003435.ref013","doi-asserted-by":"crossref","first-page":"86","DOI":"10.1016\/j.drugpo.2019.03.012","article-title":"Stigma and drug use settings as correlates of self-reported, non-fatal overdose among people who use drugs in Baltimore, Maryland","volume":"68","author":"CA Latkin","year":"2019","journal-title":"Int J Drug Policy"},{"issue":"3","key":"pgph.0003435.ref014","doi-asserted-by":"crossref","first-page":"217","DOI":"10.1016\/j.drugpo.2008.08.008","article-title":"Geographic approaches to quantifying the risk environment: a focus on syringe exchange program site access and drug-related law enforcement activities","volume":"20","author":"HL Cooper","year":"2009","journal-title":"Int J Drug Policy"},{"issue":"3","key":"pgph.0003435.ref015","doi-asserted-by":"crossref","first-page":"503","DOI":"10.1016\/j.drugpo.2014.03.004","article-title":"Integrating place into research on drug use, drug users\u2019 health, and drug policy","volume":"25","author":"HLF Cooper","year":"2014","journal-title":"Int J Drug Policy"},{"key":"pgph.0003435.ref016","doi-asserted-by":"crossref","first-page":"188","DOI":"10.1016\/j.drugalcdep.2018.06.009","article-title":"Frequent experience of discrimination among people who inject drugs: Links with health and wellbeing","volume":"190","author":"C Couto e Cruz","year":"2018","journal-title":"Drug Alcohol Depend"},{"key":"pgph.0003435.ref017","unstructured":"UNAIDS. UNAIDS Data 2020 [Internet]. 2020. https:\/\/www.unaids.org\/sites\/default\/files\/media_asset\/2020_aids-data-book_en.pdf"},{"issue":"4","key":"pgph.0003435.ref018","doi-asserted-by":"crossref","first-page":"e041083","DOI":"10.1136\/bmjopen-2020-041083","article-title":"Peer-mediated HIV assisted partner services to identify and link to care HIV-positive and HCV-positive people who inject drugs: a cohort study protocol","volume":"11","author":"A Monroe-Wise","year":"2021","journal-title":"BMJ Open"},{"issue":"1","key":"pgph.0003435.ref019","doi-asserted-by":"crossref","DOI":"10.1186\/s12889-021-11373-9","article-title":"Rapid situational assessment of people who inject drugs (PWID) in Nairobi and coastal regions of Kenya: a respondent driven sampling survey","volume":"21","author":"FO Oguya","year":"2021","journal-title":"BMC Public Health"},{"issue":"4","key":"pgph.0003435.ref020","doi-asserted-by":"crossref","first-page":"420","DOI":"10.1097\/QAI.0000000000000769","article-title":"HIV prevalence, estimated incidence, and risk behaviors among people who inject drugs in Kenya","volume":"70","author":"AE Kurth","year":"2015","journal-title":"J Acquir Immune Defic Syndr 1999"},{"issue":"9","key":"pgph.0003435.ref021","first-page":"1408","article-title":"Are We There Yet? 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London, UK; 2021 Jun [cited 2023 Sep 6]. https:\/\/www.hri.global\/files\/2021\/06\/14\/HRI_Briefing_Prisons_June2021_Final1.pdf"},{"issue":"1","key":"pgph.0003435.ref024","doi-asserted-by":"crossref","first-page":"125","DOI":"10.1111\/j.0887-378X.2004.00304.x","article-title":"Addressing the \u201cRisk Environment\u201d for Injection Drug Users: The Mysterious Case of the Missing Cop","volume":"82","author":"S Burris","year":"2004","journal-title":"Milbank Q"},{"key":"pgph.0003435.ref025","doi-asserted-by":"crossref","first-page":"108419","DOI":"10.1016\/j.drugalcdep.2020.108419","article-title":"Correlates of Non-fatal, Opioid Overdose among Women Who Use Opioids in Dar es Salaam, Tanzania","volume":"218","author":"HT Saleem","year":"2021","journal-title":"Drug Alcohol Depend"},{"key":"pgph.0003435.ref026","doi-asserted-by":"crossref","first-page":"103287","DOI":"10.1016\/j.drugpo.2021.103287","article-title":"High occurrence of witnessing an opioid overdose in a sample of women who use heroin in Tanzania: Implications for overdose prevention","volume":"96","author":"HT Saleem","year":"2021","journal-title":"Int J Drug Policy"},{"key":"pgph.0003435.ref027","first-page":"107","article-title":"Editorial for \u201cUS Heroin in Transition: Supply Changes, Fentanyl Adulteration and Consequences\u201d IJDP Special Section","volume":"46","author":"D. Ciccarone","year":"2017","journal-title":"Int J Drug Policy"},{"key":"pgph.0003435.ref028","doi-asserted-by":"crossref","first-page":"109380","DOI":"10.1016\/j.drugalcdep.2022.109380","article-title":"Xylazine spreads across the US: A growing component of the increasingly synthetic and polysubstance overdose crisis","volume":"233","author":"J Friedman","year":"2022","journal-title":"Drug Alcohol Depend"},{"key":"pgph.0003435.ref029","article-title":"National Vital Statistics Reports Volume 68, Number 3 March 21, 2019 Drug Overdose Deaths Involving Fentanyl, 2011\u20132016","volume":"68","author":"MR Spencer","year":"2018","journal-title":"Natl Vital Stat Rep"},{"key":"pgph.0003435.ref030","first-page":"1","author":"B Armoon","year":"2021","journal-title":"Drug type and risk behaviors associated with non-fatal overdose among people who use drugs: a systematic review and meta-analysis"},{"issue":"2","key":"pgph.0003435.ref031","doi-asserted-by":"crossref","first-page":"261","DOI":"10.1093\/jurban\/jtg029","article-title":"Fatal heroin-related overdose in San Francisco, 1997\u20132000: a case for targeted intervention","volume":"80","author":"PJ Davidson","year":"2003","journal-title":"J Urban Health"},{"key":"pgph.0003435.ref032","doi-asserted-by":"crossref","first-page":"103077","DOI":"10.1016\/j.drugpo.2020.103077","article-title":"Restrictive opioid prescribing policies and evolving risk environments: A qualitative study of the perspectives of patients who experienced an accidental opioid overdose","volume":"92","author":"SR Mueller","year":"2021","journal-title":"Int J Drug Policy"},{"key":"pgph.0003435.ref033","unstructured":"National Harm Reduction Coalition. Opioid Overdose Basics: Responding to Opioid Overdose [Internet]. National Harm Reduction Coalition. 2020 [cited 2023 Sep 7]. https:\/\/harmreduction.org\/issues\/overdose-prevention\/overview\/overdose-basics\/responding-to-opioid-overdose\/"},{"key":"pgph.0003435.ref034","unstructured":"Harm Reduction International. The Global State of Harm Reduction 2020 [Internet]. London, United Kingdom; 2020 [cited 2023 Sep 6]. Report No.: 7th Edition. https:\/\/hri.global\/wp-content\/uploads\/2022\/10\/Global_State_HRI_2020_BOOK_FA_Web-1.pdf"},{"key":"pgph.0003435.ref035","doi-asserted-by":"crossref","first-page":"4639","DOI":"10.2147\/RMHP.S244720","article-title":"Assessing Drug Consumption Rooms and Longer Term (5 Year) Impacts on Community and Clients","volume":"14","author":"V Tran","year":"2021","journal-title":"Risk Manag Healthc Policy"},{"key":"pgph.0003435.ref036","doi-asserted-by":"crossref","first-page":"103294","DOI":"10.1016\/j.drugpo.2021.103294","article-title":"Good Samaritan Laws and Overdose Mortality in the United States in the Fentanyl Era","volume":"97","author":"L Hamilton","year":"2021","journal-title":"Int J Drug Policy"},{"issue":"11","key":"pgph.0003435.ref037","doi-asserted-by":"crossref","first-page":"e1002969","DOI":"10.1371\/journal.pmed.1002969","article-title":"Stigma as a fundamental hindrance to the United States opioid overdose crisis response","volume":"16","author":"AC Tsai","year":"2019","journal-title":"PLOS Med"},{"key":"pgph.0003435.ref038","doi-asserted-by":"crossref","first-page":"108338","DOI":"10.1016\/j.drugalcdep.2020.108338","article-title":"Health communication campaigns to drive demand for evidence-based practices and reduce stigma in the HEALing communities study","volume":"217","author":"RC Lefebvre","year":"2020","journal-title":"Drug Alcohol Depend"},{"issue":"8","key":"pgph.0003435.ref039","doi-asserted-by":"crossref","first-page":"1051","DOI":"10.3111\/13696998.2013.811080","article-title":"Cost-effectiveness of distributing naloxone to heroin users for lay overdose reversal in Russian cities","volume":"16","author":"PO Coffin","year":"2013","journal-title":"J Med Econ"},{"issue":"7","key":"pgph.0003435.ref040","doi-asserted-by":"crossref","first-page":"1177","DOI":"10.1111\/add.13326","article-title":"Are take-home naloxone programmes effective? 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Kenya Essential Drugs List. 2003;"},{"issue":"1","key":"pgph.0003435.ref042","doi-asserted-by":"crossref","first-page":"117","DOI":"10.1186\/s12954-022-00700-x","article-title":"A systematic review of the distribution of take-home naloxone in low- and middle-income countries and barriers to the implementation of take-home naloxone programs","volume":"19","author":"HS Sajwani","year":"2022","journal-title":"Harm Reduct J"},{"issue":"6","key":"pgph.0003435.ref043","first-page":"434","article-title":"COVID-19 restrictions and increased risk of overdose for street-based people with opioid dependence in South Africa","volume":"110","author":"MJ Stowe","year":"2020","journal-title":"South Afr Med J Suid-Afr Tydskr Vir Geneeskd"},{"issue":"1","key":"pgph.0003435.ref044","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1186\/s12954-021-00561-w","article-title":"Personal experience and awareness of opioid overdose occurrence among peers and willingness to administer naloxone in South Africa: findings from a three-city pilot survey of homeless people who use drugs","volume":"19","author":"M Wilson","year":"2022","journal-title":"Harm Reduct J"},{"key":"pgph.0003435.ref045","author":"T Townsend","journal-title":"Cost-effectiveness analysis of alternative naloxone distribution strategies: First responder and lay distribution in the United States"}],"container-title":["PLOS Global Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pgph.0003435","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2024,7,2]],"date-time":"2024-07-02T18:41:24Z","timestamp":1719945684000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pgph.0003435"}},"subtitle":[],"editor":[{"given":"Padmasayee","family":"Papineni","sequence":"first","affiliation":[],"role":[{"role":"editor","vocabulary":"crossref"}]}],"short-title":[],"issued":{"date-parts":[[2024,7,2]]},"references-count":45,"journal-issue":{"issue":"7","published-online":{"date-parts":[[2024,7,2]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pgph.0003435","relation":{},"ISSN":["2767-3375"],"issn-type":[{"value":"2767-3375","type":"electronic"}],"subject":[],"published":{"date-parts":[[2024,7,2]]}}}