Within the next five years, South Africa plans to make medicines like methadone, a safer fix for people who inject opioids like heroin, available at all government health facilities as part of the country’s goal of reducing HIV infections.
Currently, writes Zano Kunene for Bhekisisa, people can only get methadone at some state hospitals if they’re experiencing withdrawal symptoms – and only for up to 10 days. Those who want to swop heroin for methadone in the long term must pay for it themselves or get it from non-profit health organisations like TB HIV Care and NACOSA.
However, the intention is to make it available at all clinics and hospitals as part of the new plan (released in March) for services to slash HIV infections within the next five years. In 2021, South Africa recorded about 210 000 new HIV infections.
Opioids, which release feel-good chemicals, are addictive and apart from heroin, include painkillers like morphine and codeine.
Although it’s difficult to get exact numbers because of their illegality, a study among 926 users in 2019 showed that one in five people who inject drugs have HIV because of sharing or using discarded needles.
Methadone, a substitute for heroin and taken daily to help curb withdrawal symptoms and assist in breaking dependence, is known as an opioid substitution therapy (OST).
OST programmes don’t just hand out methadone; they also offer other harm reduction services, such as giving clean needles and syringes to drug users who may still be injecting, so that they won’t have to share.
Studies show that OST can halve the risk of contracting both HIV and the hepatitis C virus and help HIV-positive users to stay on antiretroviral (ARV) treatment, because people can often get their HIV medicine at the same place as where they get methadone.
The substitute drug is currently available only at district hospitals for withdrawal sufferers, and then only for only up to 10 days.
Andrew Scheibe, a public health specialist at the health organisation TB HIV Care, told Bhekisisa there are an estimated 400 000 heroin users in South Africa.
This means getting methadone to help wean them off heroin gradually is not a realistic option if they rely on public healthcare.
With the new plan, though, the aim is to give free methadone at state clinics to all opioid drug users wanting it.
But for a countrywide roll-out to work, the government has to do five things over the next five years, says Scheibe, who also helped to write guidelines for the United Nations Office on Drugs and Crime on putting OST programmes in place.
“A programme like this wouldn’t start everywhere at once; it would have to be a stepped process.”
1. Get a plan in place
There must be policies identifying people who use drugs as a focus for the public health sector. This has been done by including substance users in the new HIV plan and the National Drug Master Plan.
With this in place, medication can be added to the government’s list of essential treatments, and guidelines written up.
Earlier this year, the government started planning how a methadone programme could be rolled out and getting guidance from experts, said Kgalabi Ngako, deputy director for the Mental Health and Substance Abuse Directorate at the national Health Department.
2. Find the money
Methadone treatment is costly. To help someone stop using opioids completely, they should ideally be on OST for at least 12 months, starting with a dose of between 10mg and 30mg per day. This is then gradually upped to a level where they don’t experience withdrawal symptoms – the maintenance level. At a starting dose of, say, 20mg per day, a single dose could cost about R12.25 (if we take the lowest price at which methadone sells). A month’s supply at this price would therefore work out to almost R400 per user.
For a maintenance level, a dose of at least 60mg per day is advised. A daily fix would then cost just more than R36 at the lowest price, and for a month, about R1 080.
For comparison, it costs the Health Department around R60 for a month’s supply of the oral HIV prevention pill for one patient (this increases to about R90 when administration costs are included). In the private sector, it costs around R700 for a month’s supply, or R58 per day.
3. Get hands on deck
Methadone is a Schedule 6 medication, meaning only a doctor can prescribe it. But for a full OST programme, a whole team of health workers is needed, including nurses, social workers, pharmacists, counsellors and peer educators. And, says Scheibe, health workers would need training and support on how to prescribe methadone correctly over a treatment course and help people stay with the programme.
4. Systems to manage supply
In an OST programme, it’s possible that those receiving a free opioid substitute like methadone might sell it to others. Hospitals and clinics would therefore have to keep good records of who gets treatment and their progress.
“We already have systems (for monitoring how much of a Schedule 6 medicine, like methadone, has been given out), and we just have to strengthen them to ensure they account for the stock,” Scheibe said. “The risk of diversion exists for every Schedule 6 medication; it’s not different just because it’s methadone.”
5. A network of other services too
For OST programmes to work at community health centres, people would need to be able to dispose of needles and syringes safely. Such services are already available for patients who use injectable medicines, for example insulin, said Scheibe.
Offering HIV and hepatitis testing, handing out ARVs and making counselling part of the treatment package can also help slash HIV infections among people who inject drugs, a study from Canada has shown.
The WHO also recommends having help on hand for people who have overdosed or are dealing with withdrawal symptoms, which are already available at district hospitals.
Why swop rather than stop
Evidence shows that weaning people off opioids gradually by using substitutes works better to help them beat the addiction than using these medicines simply to treat withdrawal symptoms after they’ve suddenly stopped using (detoxification).
For example, in a 2017 study, 199 opioid users agreed to be admitted to an abstinence programme at a Cape Town health centre that does not offer substitution therapy. They were first referred for detoxification before entering the programme if they couldn’t manage their withdrawal symptoms. Only 23 participants completed the two-month treatment.
In contrast, a pilot study in the Western Cape in 2014 showed that two out of three people who got an opioid substitute called buprenorphine (similar to methadone) completed a 12-week treatment programme to curb their heroin, whereas just under half of the group stuck with the programme when they received only the normal treatment — counselling, group therapy and urine tests — to prevent relapse.
Done right, a national roll-out can work
Mauritius is a good example of how OST programmes funded mainly by the government can work well.
In 2007, this island nation had about 24 000 opioid drug users, one of the highest prevalences in Africa. Data shows that two years before, nine out of 10 Mauritians who were HIV-positive injected drugs.
After rolling out the substitution programme to 40 government sites (including healthcare facilities and prisons) in 2014 after a small pilot project, new HIV cases among this group dropped to two in 10 by 2020.
“There’s no doubt about the effectiveness of methadone. It’s just a question of whether or not our primary healthcare system can feasibly and safely deliver it,” added Scheibe.
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