The Integrated Addiction Care Centre of Kodjoviakopé (CEPIAK) in Lomé, Togo, served as the setting for our study.

CEPIAK is a pilot centre set up by the Abidjan-Lagos CORRIDOR Organisation (OCAL) in collaboration with the Togolese state since 2018. But it was only operational in June 2019. It is the 2nd centre of its kind in West Africa after the Integrated Addiction Care Centre of Dakar (CEPIAD). The CEPIAK raises awareness among drug users, through their mode of consumption, about the risks of transmission of diseases such as HIV, tuberculosis and Hepatitis B and C. These drug users are registered, monitored and selected for care. Some heroin users, especially injectors, are taken into care and put on methadone if necessary.

CORRIDOR is an inter-state organisation of five countries born under the initiative of the Heads of State of the countries concerned (Ivory Coast, Ghana, Togo, Benin and Nigeria). This CORRIDOR drains a migratory flow of 110 million people per year. Seeing the importance of this migratory corridor for the West African sub-region, the Heads of State have taken steps to protect this population in terms of health by setting up CORRIDOR. This sub-regional institution has set up a Border Committee for the Fight against AIDS on the eight borders crossed by the Organisation. The objectives of CORRIDOR are, among others, to facilitate the crossing of borders by people and goods and to fight against HIV/AIDS and sexually transmitted diseases at the borders. The priority targets are migrants, drivers and trainees of heavy machinery or trailers and semi-trailers, young girls and women, key populations such as sex workers, men having sex with men and injecting drug users. As the latter has an HIV prevalence rate above the national average, a risk reduction strategy for them was to set up a methadone centre, hence the creation of this pilot project, the CEPIAK. The aim of this pilot project is to offer comprehensive outpatient care to people addicted to psychoactive substances while respecting their human rights.

During the study period, 200 heroin users had been put on methadone and constituted our sample of 300 addicts registered at CEPIAK. Of these, 89.0% were Togolese and 11.0% were foreigners (Ghana, Benin, Nigeria, Niger, Ivory Coast and Cameroon). Their average age was 43.4 ± 9.6 years with extremes ranging from 16 to 66 years. The age group from 45 to 54 years represented 41.5% of heroin users put on methadone (HUM). Males accounted for 90.5% of HUM, i.e. a sex ratio of 9.5. Primary education accounted for 39.0% of cases. Single people accounted for 44.0% of cases. They were artisans in 31.5% of cases. They had no medical coverage in 97.0% of cases. These HUM were heterosexual in 99.5% of cases. Table 1 summarises all socio-demographic aspects.

The HUM had their father deceased in 70.5% of cases and their mother deceased in 55.0% of cases. Before their death, the parents were living together in 68.0% of cases. The average number of siblings was 7.76 ± 4.98. In the HUM family, 16.5% of siblings, 7.5% of fathers and 2.0% of mothers were drug users. Hypertension accounted for 4.5% of the HUM family. Table 2 summarises the family situation of the HUM.

One hundred and nineteen HUM (59.5%) had a history of incarceration and of these, 71.4% were incarcerated for drug use and possession. During the study period, 198 people (99.0%) had no ongoing judicial problems; one person (0.5%) was under judicial supervision and another person (0.5%) was on provisional release. Table 3 summarises all legal aspects.

One hundred and fifty-one HUM (75.5%) stayed abroad at least once. Ghana was the country of stay in 60.9% of cases. One hundred and five HUM (52.5%) started using drugs abroad. Cannabis, tobacco and cocaine were the other drugs associated with heroin use in 79.5%, 74.5% and 59.5% of cases respectively. In order to obtain drugs directly or to find the financial means to buy the drugs, 5.0% of the HUM had opted for sex work. In terms of the age at which drug use began, the 20 - 30 age group accounted for almost half of the patients for all drugs (heroin 51.0%, cannabis 47.2%, tobacco 47.0%, cocaine 52.1% and alcohol 46.7%). Table 4 and Table 5 give a summary of the addictive behaviours.

A history of overdose accounted for 18.0% of the HUM in our sample. Twenty-nine HUM (14.5%) had a history of addiction treatment and 19.5% had attempted suicide. Tuberculosis had been detected in 5.5% of the HUM in our sample. HIV accounted for 3.0% of our HUM. Table 6 summarises all medical aspects.

In our study, males predominated among HUM at 90.5% of cases, i.e. a sex ratio of 9.5. This over-representation of men among drug addicts has already been found in the sub-Saharan literature [7] [8] [9]. For example, at CEPIAD in Dakar, men were in the vast majority (93.65%) in the study by Cissé Diallo et al. [7]. This male predominance found in this south of the African Sahara context could be explained by the intense activity of men, especially in the informal sector, in order to earn more money [4]. It must also be said that in this south of the African Sahara environment, men’s misguidance is more tolerated than that of women, who must, according to the culture, remain a model for the family. Through their role as educating mothers, women convey values of good morals. This can make women embarrassed to recognise their addiction and ask for help.

The average age of the HUM in our study was 43.4 ± 9.6 years, with a predominance of the 45 to 54 age group (41.5%). Taking into account the age of the start of drug use, which for almost half of the HUM was between 20 and 30 years, we can say that the drug users started in adolescence or young adulthood and experienced between 10 and 20 years of drug use before seeking help for withdrawal. The young age of onset of drug use has already been reported by several authors [10] [11] [12].

As the level of education was low in our study (8.5% not attending school, primary school 39.0%, secondary school 36.0%), we can say that these HUM had

not understood the awareness messages. It is only when faced with the complications of their addictions that they would have sought care. We can also say that since their addictions started very early in adolescence, they would have prevented them from developing at school.

In our study, single people accounted for 44.0% of cases. This is a low proportion compared to the result of M’bongo’o et al. [10] in Cameroon. In their study, singles represented 96% of their sample. It must be said that their study population was made up of pupils and students in two thirds of cases. The celibacy of our HUM could be explained by the fact that drug use can lead to marginalisation, which turns the individual away from marriage and/or encourages the separation of couples.

Trafficking, possession and use of illicit drugs are not yet decriminalised in Togo, which explains the history of incarceration among 59.5% of the HUM in our sample. In 71.4% of cases, they said they had been imprisoned for drug use and possession. We also say that addictive behaviour leads to repressive acts such as theft, rape, physical aggression and even homicide.

In our study, cannabis, tobacco and cocaine were the other drugs associated with heroin use in 79.5%, 74.5% and 59.5% of cases respectively, making our study population poly addicts. The use of several drugs at the same time had already been found in some Togolese studies [4] [8]. In Abidjan, in the study by Tigori-Sangaré et al. [12], polyaddiction use represented 10.2% of their sample.

Suicide attempts accounted for 19.5% of the HUM in our sample. Exhausted by the difficulties of daily life linked to heroin dependence or polyaddiction, addicts sometimes attempt to end their lives by any means, including overdose. This may partly justify the 18.0% of our patients who have a history of overdose. But it should also be added that the loss of control over the product can also justify overdoses.

Tuberculosis had been detected in 5.5% of the HUM in our sample. Our proportion of tuberculosis patients is higher than that of the study by Cissé Diallo et al. [7] in Dakar at CEPIAD, which found 1.68% of tuberculosis patients. HIV seroprevalence among the HUM in our sample was 3%. This is slightly higher than the prevalence of HIV in the general population of Togo, which is 2.3% [13]. We are still below the 5% HIV prevalence found in the study by Cissé Diallo et al. [7] in Dakar at CEPIAD. Our low proportion of HIV among the HUM is linked to the fact that we had very few heroin injectors in our sample. Nevertheless, these HUM are among the key populations in the fight against HIV and should benefit from appropriate programmes because heroin addiction often leads to HIV risk behaviours such as unprotected sex, sex work and needle sharing among heroin injectors.

Our study, a cross-sectional and descriptive study conducted from December 1st, 2020 to January 31, 2021 at the CEPIAK, focuses on heroin users on methadone substitution (HUM). This category of addicts was regular in taking methadone on a daily basis and the information collected in this population was reliable, verifiable and thus constituted a strength for our study. The weakness of our study lies in the fact that it cannot be generalized to all heroin users in the city of Lomé. Indeed, our study did not take into account heroin users who were not yet receiving methadone substitution.