Hundreds of people in the City of eThekwini could be at risk of contracting HIV and hepatitis as the metro cuts the only prevention programme for drug users, says a Bhekisisa report. The city’s health unit has closed the project run by the non-profit TB/ HIV Care Association, claiming that the programme poses a public health risk and breached municipal bylaws.
The closure follows a freak wave in January that caused more than 50 needles and syringes to wash up on Durban beaches. City authorities claim the incident is proof that the programme is unable to collect and dispose of the needles it hands out properly, placing the public at risk.
But almost 70% of the needles the association gives to drug users are returned, the report says the organisation’s data shows. In contrast, there is no evidence that any of the 5 000 needles distributed to diabetic patients at Durban’s Wentworth Provincial Hospital monthly are returned, according to a 2012 study.
The hospital and association are not breaking any rules, the organisation argues.
“If that were the case, any pharmacist who sells a needle or syringe and does not account for its disposal would be breaching the same bylaw,” says the organisation’s spokesperson, Alison Best.
Experts say the city’s accusations are baseless and its decision to close the project has been a crushing blow for drug users – and national efforts to curb new HIV and hepatitis C infections among the group.
The report says a small five-city study published in 2016 found that people in South Africa who inject drugs are 40% more likely to contract HIV than the general population, primarily because they’re at risk of sharing infected needles.
Meanwhile, needle exchange programmes that provide people with clean needles to eliminate the need for dangerous sharing have been shown to cut HIV prevalence rates by almost half in just three years among British drug users, according to a 1995 study.
The report says injecting drug users are also more at risk of contracting blood-borne virus hepatitis C. A 2005 study found between 50% and 90% of injectors were also infected with the disease.
The TB/HIV Care Association programme has provided clean needles and HIV testing to more than 1,000 people since it opened its doors in Durban in 2015, the organisation’s data shows. And, the report says, within days of the programme’s closure, advocates began hearing harrowing stories from people in the injecting community. “Three times this weekend I could have been infected with HIV,” one injecting drug user told Shaun Shelly, who is a University of Pretoria researcher in family medicine. Shelly is also the policy, advocacy and human rights manager for the TB/HIV Care Association.
“When people don’t have clean needles, they’re going to share,” he says. “(Cutting the project) is no more than a political agenda – it’s a violation of rights. I’m disgusted.”
The report says City of eThekwini spokesperson Vuyo Ndlovu is adamant the project is doing more harm than good and that the city had to take action in the interest of its residents.
Needle exchange projects will be part of South Africa’s next national drug strategy, also called the National Drug Master Plan, which is expected to be released this year, Shelly says. Harm reduction programmes – or initiatives such as the one in Durban that seek to reduce the health risks associated with drug use – are also included in the latest national HIV and tuberculosis plan.
The TB/HIV Care Association has agreements with the provincial and national health departments to provide harm-reduction services, but the City of eThekwini officials argue these deals do not bind it.
“There’s no logic to what the City of eThekwini is doing,” Shelly argues.
KwaZulu-Natal Health spokesperson Agiza Hlongwane said the department would not comment on the decision to shut down the association’s project, saying it did not want to be pitted against another government body.
Meanwhile, just over 600km away, the report says Tshwane has become the first South African city to fund harm-reduction projects for drug users. The city will devote R1.5m to provide services such as HIV testing and counselling, needle exchanges and opioid substitution therapy.
Drugs such as heroin – an ingredient in nyaope – belong to a class of drugs called opioids. People who regularly take opioids experience withdrawal symptoms such as nausea and muscle cramps even within hours of their last dose. The only way to avoid these symptoms is to take more of the drug.
As part of substitution therapy for people who use these drugs doctors prescribe legal medicines such as methadone or buprenorphine, to help people to avoid withdrawal symptoms but without the high. The medication is often taken under the direct supervision of health workers or pharmacists in the case of Tshwane patients and can help to reduce people’s dependence on illegal drugs.
Tshwane has more than 4,500 injecting drug users, the South African National Aids Council’s data shows.
In Durban, TB/HIV Care Association staff say they will do “everything in their power” to get the needle programme running again and have called in legal experts. “We have the same vision as the city: We want a safe, healthy and caring society. But we need help from the government. The city needs more safe places for drug users to throw away used needles,” TB/HIV Care senior technical advisor Monique Marks is quoted in the report as saying. “Drug users can’t do this alone.”
Background: Diabetes is conservatively estimated to occur in 4 million South Africans.1 All type 1, and up to 40% of type 2, diabetic patients require insulin therapy.1 With so many patients using insulin, much medical waste is generated daily in the form of used needles and syringes. Used sharps are a biomedical hazard as incorrect disposal could lead to needle-stick injuries (NSIs),2 posing the risk of contracting human immunodeficiency virus (HIV), hepatitis B or C and other blood-borne diseases.2 An individual not protected by prior hepatitis vaccination who sustains an NSI from a needle used by an individual testing positive for hepatitis B surface antigen has a 6 – 30% chance of infection by the virus.2 The risk of HIV infection following one percutaneous exposure to HIV-infected blood is estimated to be 0.3%.2 South Africa has a high prevalence of HIV3 and, with many diabetic patients likely to have HIV or other transmittable infections, safe sharps disposal practices are essential.
South Africa’s constitution states: ‘Everyone has the right to an environment that is not harmful to their health and well-being.’4 Sharps disposal is a problem in South Africa because of accidental NSI to garbage removers or other persons handling domestic waste.5 The 2009 Health Care Waste Summit6 recognised the problems with sharps disposal in South Africa. The safe disposal of needles and lancets used by insulin-dependent diabetic patients is not only a problem in South Africa; in 1989, 109 NSIs were formally reported by garbage collectors in the Atlanta metropolitan area,2 and other studies in Atlanta and European countries have highlighted the problem of incorrect sharps disposal practices by patients at home.2, 7
In 1998, Macalino et al. investigated community-based programmes for safe disposal of used needles in the USA, Canada and Australia;8 these included using puncture-resistant containers such as hot-chocolate or coffee containers with a secure lid and discarding these in the household rubbish. Other safe disposal methods included using community drop-boxes where used sharps could be deposited, and the use of sharps containers sent for safe biohazard disposal at community sites, hospitals and pharmacies.
In 1990, the American Diabetes Association, and in 2002 Diabetes UK, issued recommendations that all needles and lancets used by diabetic patients be placed into a puncture-resistant container before discarding into household waste.2 The South African Metabolic and Endocrine (SEMDSA) Guidelines9 and the South African Standard Treatment Guidelines (STG)10 do not provide recommendations on the safe disposal of used needles and stylets. Many studies highlight the need for healthcare workers to provide the necessary skills and education to diabetic patients for safe disposal of needles.2, 5, 11
We investigated current methods of sharps disposal by diabetic patients attending Wentworth Hospital (WWH)’s outpatient department, to compare these practices with the education received by patients about correct sharps disposal, and to make recommendations regarding the safe disposal of sharps by diabetic patients.
Methods: Wentworth Hospital is a district-level hospital in Durban that sees almost 12 000 outpatients per month. The hospital pharmacy dispenses monthly just under 5 000 insulin pensets, each with a needle, to patients. There is no record of any sharps being returned to the hospital for disposal.
The study included insulin-dependent diabetic patients over the age of 18 years attending WWH OPD who consented to participate. In consultation with a biostatistician, a sample of 132 diabetic patients using insulin was chosen. The sample size was based on the assumption that the population prevalence of incorrect needle disposal was 90% and was calculated to give a precision level of 5%. To ensure representation of all the racial groups treated at WWH, the sample was stratified into 45 Indian, 44 black, 36 coloured and 7 white patients. It was assumed that patients present in a random order to OPD, so convenience consecutive sampling from the OPD bench was used to collect data from diabetic patients using insulin. The study took place from October to December 2010. Questionnaires on current practices regarding insulin needle disposal and on education received regarding sharps disposal were administered to each participant by the principal investigator. Data were entered onto an Excel spreadsheet and the SPSS computer software package used to analyse the data. Factors associated with correct disposal methods were analysed using Pearson’s chi square tests. A p-value <0.05 was considered to be statistically significant. Results: The ages of the study population ranged from 18 to 86 years (mean 58.3 years); most had type 2 diabetes; 29% were male and 71% were female; 4 (3%) were younger than 25 years, 3 (2.2%) were 25 – 39 years old, 64 (48%) were 40 – 59 years old, and 62 (46.2%) were >60 years old. Nine patients had received no formal education; 31 had only attended primary school, 84 attended secondary school, and 8 had tertiary education.
Each month, 850 needles were generated by the 132 patients. Needles were re-used 2 – 20 times by patients; 117 (88%) patients disposed of used needles directly into their household rubbish bins, 8 (6%) flushed used needles down the toilet into the sewage system, and 4 (3%) used other methods such as burying the needles (Fig. 1). Only 3 (2.2%) patients returned their needles in puncture-resistant containers to the hospital for disposal. No associations were found between race, gender, education levels and correct disposal of used sharps. Forty-six (35%) patients were aware of the potential health risks associated with injury caused by the incorrect disposal of used needles.
Of the participants, 91% (120/132) had received diabetic education and counselling regarding insulin use, storage and administration; 68% (89) rated the diabetic education as good, 22.7% rated it average, and 9.7% as poor. Despite the positive response to the education provided on use and storage of insulin, only 5 (3.8%) patients stated that they had received education and counselling regarding correct methods of sharps disposal. All 3 patients who were correctly disposing of their needles had been educated about how to do so.
There was a highly significant association between education received by patients and correct needle disposal methods (p<0.001). Of the 5 who were educated in disposal, 60% correctly disposed of the needles whereas, of the 127 who were not educated in disposal, none correctly disposed of the needles.
Discussion: The race groups recruited for the study are representative of the patient population with diabetes seen at WWH. The data show that over 97% of the study population discarded their sharps inappropriately. The lack of association between race, gender or education levels and correct needle disposal practices was surprising, as those with a higher level of education could be expected to be better educated about their disease and recognise the hazardous nature and need for safe disposal of their medical waste.
No recent studies were found on safe disposal of sharps by diabetic patients. However, our findings are consistent with studies in the early 1990s in Europe and the USA,2 highlighting the fact that needle disposal is a global problem in the developed and developing world.
The large number of patients who dispose of their needles incorrectly is of concern. The National Environmental Management Act of 1998 states that the duty of care principle requires the generator of hazardous waste, under all circumstances, to carry the responsibility of the ultimate fate of the generated waste.4 Patients, healthcare workers or healthcare facilities could be liable for costs associated with treating garbage collectors who can prove that they were infected from contaminated needles. This serious issue requires urgent attention from health professionals, who have a responsibility to provide information to patients about safe disposal of needles.
Deficiencies in diabetic education and counselling provided to diabetic patients have been highlighted. Emphasis is placed on knowledge regarding storage and administration of insulin, but very little counselling is provided on correct sharps disposal. Less than 4% (5/132) of our patients had received any counselling about correct sharps disposal practices. It is disappointing to note that since 2009, when disposal of needles and other hazardous material was identified as a serious issue at the Health Care Summit,6 more emphasis has not been placed on safe needle disposal.
Despite much work on needle-free products for the administration of insulin, progress has been slow and inconsistent,12 and no significant needle-free alternative method of insulin administration is available. As needles will continue to be part of diabetic care by all patients requiring insulin for some time to come in South Africa and other countries, their safe disposal must therefore form an integral part of diabetic education.
Although this study’s numbers are small and the results must be treated with caution, they suggest that appropriate education and knowledge on sharps disposal is the most important determining factor in correct disposal methods.
D Govender, A Ross
Background: Policy and programming for people who inject drugs (PWID) in South Africa is limited by the scarcity of epidemiological data.
Methods: We conducted a cross-sectional survey among 450 PWID (362 males and 88 females) from five South African cities in 2013, using outreach and peer referral to recruit participants. We carried out rapid HIV tests on participants’ saliva and assessed drug-using and sexual practices by means of a questionnaire.
Results: We found that 26% of females and 13% of males reported to always share injecting equipment, while 49% of all participants had used contaminated injecting equipment the last time they injected. Only 6% of participants usually used bleach to clean their injecting equipment. We found that half of participants reported using a condom the last time they had sex. A quarter of participants reported symptoms of a sexually transmitted infection (STI) in the previous 12 months and 22% had ever worked as a sex worker (51% of females). HIV prevalence among participants was 14% (18% among females and 13% among males). In multivariate analysis HIV was significantly associated with being 25 years and older (adjusted odds ratio (aOR) 2.1, 95% confidence interval (CI) 1.0–4.6, p = 0.06), belonging to a racial group other than white (aOR 4.2, 95% CI 1.9–9.4, p < 0.001), coming from Gauteng province (aOR 2.3, 95% CI 1.1–5.5, p = 0.023), having ever worked as a sex worker (aOR 3.4, 95% CI 1.7–7.2, p = 0.001) and the presence of STI symptoms in the last 12 months (aOR 2.4, 95% CI 1.1–4.4, p = 0.019).
Conclusions: This study highlights the need for increased access to sterile injecting equipment, education around safer injecting practices and access to sexual and reproductive health services for PWID in South Africa. Programmes for PWID should also address the specific needs of female PWID, PWID who sell sex and PWID from previously disadvantaged communities.
Andrew Scheibe, David Makapela, Ben Brown, Monika dos Santos, Fabienne Hariga, Harsheth Virk, Linda-Gail Bekker, Olga Lyan, Nancy Fee, Margarete Molnar, Alina Bocai, Jason Eligh, Riku Lehtovuori
Injection drug users (IDUs) are the largest group of persons infected with hepatitis C virus (HCV), with a prevalence of 50%–90%. The transmission of HCV is not the effect of the drug injected but of sharing contaminated equipment. For the sake of prevention, we have to know which factors are more likely to lead to HCV seroconversion and which particular situations and environments are risk factors for equipment sharing. As far as therapy is concerned, some studies have shown that treatment for HCV infection in IDUs during substitution treatment for drug dependency is as successful as is treatment of patients who are not IDUs. Screening and early treatment of IDUs could play an important role in controlling HCV infection. The rate of reinfection may not as high as supposed. All studies dealing with treatment for HCV infection in IDUs have stressed the necessity of collaboration among hepatologists and specialists in addiction medicine, social workers, and psychotherapists.
Markus Backmund, Jens Reimer, Kirsten Meyer, J Tilman Gerlach, Reinhart Zachoval