While harm reduction interventions have increased globally, especially in sub-Saharan Africa, the latest Global State of Harm Reduction report shows that South Africa is now one of the largest methamphetamine consumer markets worldwide, writes Medical Brief.
Released by Harm Reduction International (HRI) this week, the report highlights some encouraging evidence that harm reduction interventions, like safe injection rooms, needle exchange services or opioid substitution therapy, are increasing.
The report adds that the positive changes being made by communities and civil society among drug-users drugs through evidence- and rights-based harm reduction services show that change is possible, as long as governments and donors invest in workable community-led solutions. Prohibitionist policies, among other factors, the report says, continue to hamper harm reduction efforts.
The authors said the progress has been driven by new needle and syringe programmes (NSPs) opening in five African countries, as well as four new countries having officially sanctioned drug consumption rooms (DCRs). Three countries have introduced opioid agonist therapy (OAT) for the first time.
No country has stopped the implementation of NSP, OAT or DCRs since 2020.
In 2022 they found:
• 92 countries implementing at least one NSP (up from 86 in 2020)
• 87 countries with at least one OAT programme (up from 84 in 2020)
• 16 countries with legal and operational DCRs (up from 12 in 2020).
Africa and its problems
A rough estimate from incomplete surveys indicates that about 410 000 people inject drugs in Eastern and Southern Africa, and 21.8% live with HIV. Recent available data from the region show an increase in heroin use, injecting drug use, and increased HIV and hepatitis infections among people who inject drugs.
Eastern and Southern Africa are characterised by repressive criminal laws, high estimated transmission rates of HIV and viral hepatitis among those who inject drugs, and an absence of essential health services. Punitive policies, minimal data, lack of political will, limited funding, stigma, and discrimination are among the main challenges hampering the implementation of harm reduction services.
Generally, poor data damage countries’ abilities to make good policies and data-driven decisions, and researchers found in Eastern and Southern Africa data on HIV and drug use are poor, either do not exist or lack validity and reliability.
This is driven by the criminalisation and stigmatisation of drug use, pushing drug-users into hidden spaces, discouraging them from disclosing their habits to researchers/healthcare providers. While punitive laws and policies persist, it will be difficult to obtain accurate national estimates of drug use patterns. Evidence from other countries on the effectiveness and cost-effectiveness of harm reduction, alongside co-operation and information sharing between countries and rapid, localised assessments of needs, can provide a reliable basis for implementing essential harm reduction services.
Stimulants and new psychoactive substances (NPS)
Cocaine and methamphetamine use have increased in the region since 2020. South Africa is now estimated to be one of the largest methamphetamine consumer markets worldwide: significant methamphetamine markets also exist in Botswana, Eswatini, Kenya, Lesotho, Malawi, Mozambique, Uganda, Zambia and Zimbabwe.
No civil society informants reported formal harm reduction programming for stimulants or NPS (e.g., no stimulants prescription programmes or the distribution of safer smoking kits), although civil society organisations in South Africa have been distributing safer stimulant kits since 2020 on an ad hoc basis.
Needle and syringe programmes (NSPs)
Of the 20 countries in the region, NSPs are operational in only seven (Kenya, Mauritius, Mozambique, Seychelles, South Africa, Tanzania, and Uganda). This marks an increase of two countries since 2020 (Seychelles and Uganda). Even in countries where NSPs exist, they are insufficiently accessible to those needing them and often disrupted.
Opioid agonist therapy (OAT)
OAT remains limited in the region, with programmes in only seven countries (Kenya, Mauritius, Mozambique, Seychelles, South Africa, Tanzania, and Uganda). This is an increase of two countries since 2020 (Mozambique and Uganda – Uganda opened its first OAT programme in October 2020).
Methadone is used in all seven countries, while buprenorphine is common in Kenya, Mauritius, South Africa, Tanzania and in clinical trials in Uganda. Zambia does not implement OAT, and methadone is not registered/available.
In South Africa, advocacy efforts led to methadone being added to the essential medicines list, but its high price limits access to OAT. In August 2022, after sustained civil society advocacy, pharmaceuticals company Umsebe Healthcare announced a significant reduction in the price of methadone for healthcare providers from late 2022 (not yet implemented at the time of this report).
Overdose, overdose response and drug consumption rooms (DCRs)
There is little data on overdose and drug-related deaths in Eastern and Southern Africa: no country has national data on either issue. One small study in Dar-es-Salaam, Tanzania found 34% of a sample of women drug-users had experienced an overdose. Two countries in the region have at least one naloxone peer distribution programme: Kenya and South Africa. However, these are small, with minimal reach and accessibility.
For example, although a peer-run outreach programme has distributed a restricted number of intramuscular naloxone in South Africa, it remains a prescription-only medication. No nasal naloxone is available. No country in the region has a drug consumption room.
HIV and antiretroviral therapy (ART)
Eastern and Southern Africa are still heavily affected by HIV, home to 54% of all people living with HIV in the world. New HIV infections declined by 44% from 2010 to 2021 in the general population, but HIV prevalence among people who inject drugs is at 21.8%, compared with 6.2% among the general population. Criminal laws undermine efforts to engage drug-users in national HIV responses.
Indeed, civil society actors and researchers report that stigma and discrimination are major barriers for drug-users when it comes to accessing HIV-related services. Other barriers include a lack of facilities in rural areas, meaning people have to travel long distances for treatment, which is time-consuming and expensive. Homeless people also struggle to store medication safely.
Women who use drugs
Research in South Africa found women using drugs face many additional barriers accessing harm reduction services, including stigma, sexual and physical violence, law enforcement harassment and a lack of tailored services.
New programmes supported by the Dutch Ministry of Foreign Affairs’ Love Alliance grant and the United Nations Office on Drugs and Crime are being implemented in the country to improve access to HIV and sexual and reproductive health services for women drug-users, through the training of community healthcare workers.
Drugs policies, funding
In South Africa, NSPs are included in the South African National Strategic Plan on HIV, Tuberculosis and STIs 2017-2022, and activists, including the South African Network of People who Use Drugs, are providing input into the renewed plan for 2023 to 2025.
Negative developments
Governments in the region continue to promote policies associated with a failed prohibitionist approach to drugs. Kenya has introduced penalties for law enforcement officers who aid offences through “concealing the commission of any offence”, while Zimbabwe’s public health policies do not take into account drug use or identify drug-users as a key population. In Mozambique, “inciting drug use” and “abandoning drug use paraphernalia in a public place” are crimes.
In March 2022, the government in Maputo, Mozambique banned syringe distribution in the community, motivated by complaints about syringes being left in public spaces, though the ban was lifted in mid-2022. In South Africa, drug testing in schools is permitted by law; drug testing is permitted in workplaces if referenced in employment contracts or in a substance use policy.
COVID’s impact on harm reduction in Eastern/Southern Africa
The pandemic has had far-reaching consequences for harm reduction service availability in the region. In South Africa, limited coverage in NSP and OAT provision continued into 2021; access to methadone was nearly impossible outside dispensaries and treatment centres, so most people were unable to get their medication.
Nevertheless, in Eastern and Southern Africa, the realities of the COVID-19 pandemic catalysed service adaptations and advanced the debate around take-home OAT doses. Indeed, the provision of take-home OAT increased substantially in the region between 2020 and 2022. Advocacy from community and civil society groups led to the NSP programme in eThekwini, South Africa being reinstated after 18 months of COVID-19-related suspension.
There are also examples of effective, low-threshold service adaptations implemented during the pandemic being continued after the crisis had passed. This includes services at the Bellhaven Harm Reduction Centre in Durban, a low-threshold community space providing evidence-based HIV, harm reduction and health-related services, including an NSP and OAT. In 2020, Bellhaven served up to 175 people daily.
Full report (Open access)
See more from MedicalBrief archives:
Time for drug law reform in SA
‘Cautious welcome’ as Drug Master Plan puts harm reduction on SA agenda
‘Profound’ growth in South Africa’s heroin market fuels drug crisis