Insights into the value of the market for cocaine, heroin and methamphetamine in South Africa

The illicit drug trade generates billions of dollars and sustains transnational criminal organisations. Drug markets can destabilise governance and undermine development. Data indicate increasing drug use in South Africa. However, information on the size and value of the drug market is limited. This is the first study to estimate the market value of cocaine, heroin and methamphetamine in South Africa. People who use drugs were meaningfully involved in all aspects of implementation. We used focus group discussions, ethnographic mapping, brief interviews, and the Delphi method to estimate the number of users, volumes consumed, and price for each drug in South Africa in 2020. Nationally, we estimated there to be: 400,000 people who use heroin (probability range (PR) 215,000–425,000) consuming 146.00 tonnes (PR 78.48–155.13) with a value of US$1,898.00 million (PR US$1,020.18–US$2,016.63); 350,000 people who use cocaine (PR 250,000–475,000) consuming 18.77 tonnes (PR 13.41–25.47) with a market value of US$1,219.86 million (PR 871.33–1,655.52) and 290,000 people who use methamphetamine (PR 225,000–365,000) consuming 60.19 tonnes (PR 6.58–10.68) and a market value of US$782.51 million (PR 607.12–984.88). The combined value was calculated at US$3.5 billion. Findings can be used to stimulate engagement to reform drug policy and approaches to mitigate the impact of the illicit drug trade. Additional studies that include people who use drugs in research design and implementation are needed to improve our understanding of drug markets

‘Scared of going to the clinic’: Contextualising healthcare access for men who have sex with men, female sex workers and people who use drugs in two South African cities

Background: Men who have sex with men (MSM), sex workers (SW) and people who use drugs (PWUD) are at increased risk for HIV because of multiple socio-structural barriers and do not have adequate access to appropriate HIV prevention, diagnosis and treatment services.Objective: To examine the context of access to healthcare experienced by these three ‘Key Populations’, we conducted a qualitative study in two South African cities: Bloemfontein in the Free State province and Mafikeng in the North West province.Method: We carried out in-depth interviews to explore healthcare workers’ perceptions, beliefs and attitudes towards Key Populations. Focus group discussions were also conducted with members of Key Populations exploring their experiences of accessing healthcare.Results: Healthcare workers described their own attitudes towards Key Populations and demonstrated a lack of relevant knowledge, skills and training to manage the particular health needs and vulnerabilities facing Key Populations. Female SW, MSM and PWUD described their experiences of stigmatisation, and of being made to feel guilt, shame and a loss of dignity as a result of the discrimination by healthcare providers and other community. members. Our findings suggest that the uptake and effectiveness of health services amongst Key Populations in South Africa is limited by internalised stigma, reluctance to seek care, unwillingness to disclose risk behaviours to healthcare workers, combined with a lack of knowledge and understanding on the part of the broader community members, including healthcare workers.Conclusion: This research highlights the need to address the broader healthcare provision environment, improving alignment of policies and programming in order to strengthen provision of effective health services that people from Key Populations will be able to access

Attitude shifts and knowledge gains: Evaluating men who have sex with men sensitisation training for healthcare workers in the Western Cape, South Africa

Background: Men who have sex with men (MSM) in South Africa experience discrimination from healthcare workers (HCWs), impeding health service access.Objectives: To evaluate the outcomes of an MSM sensitisation training programme for HCWs implemented in the Western Cape province (South Africa).Methods: A training programme was developed to equip HCWs with the knowledge, awareness and skills required to provide non-discriminatory, non-judgemental and appropriate services to MSM. Overall, 592 HCWs were trained between February 2010 and May 2012. Trainees completed self-administered pre- and post-training questionnaires assessing changes in knowledge. Two-sample t-tests for proportion were used to assess changes in specific answers and the Wilcoxon rank-sum test for overall knowledge scores. Qualitative data came from anonymous post-training evaluation forms completed by all trainees, in combination with four focus group discussions (n = 28) conducted six months after their training.Results: Fourteen per cent of trainees had received previous training to counsel clients around penile–anal intercourse, and 16% had previously received training around sexual health issues affecting MSM. There was a statistically significant improvement in overall knowledge scores (80% – 87%, p < 0.0001), specifically around penile–anal intercourse, substance use and depression after the training. Reductions in negative attitudes towards MSM and increased ability for HCWs to provide non-discriminatory care were reported as a result of the training.Conclusion: MSM sensitisation training for HCWs is an effective intervention to increase awareness on issues pertaining to MSM and how to engage around them, reduce discriminatory attitudes and enable the provision of non-judgemental and appropriate services by HCWs

‘I went for rehab many times and it never worked, but the harm reduction process has given me renewed hope’. Perceptions on the effectiveness of harm reduction and community-based opioid substitution therapy

DATA AVAILABILITY STATEMENT : The data that support the findings of this study are available from University of Pretoria. Restrictions apply to the availability of these data, which were used under license for this study. Data are available from the author(s) with the permission of University of Pretoria.ISSUE ADDRESSED : The accessibility of opioid substitution therapy (OST), one of the recommended treatments for opioid dependence, remains low. This study sought to explore the perceived effectiveness of OST from the perspectives of peer outreach workers and OST clients in a community-based harm reduction programme. METHODS : The research was done within the Community-Oriented Substance Use Programme (COSUP) in Tshwane, South Africa. Fifteen peer educators (13 males and 2 females) took part in two focus group discussions. Thereafter, there were semistructured interviews in which 15 OST clients (11 males and 4 females) participated. A convenience cross-sectional study was used. Interviews were audio-recorded. Using thematic analysis, themes were examined to evaluate how OST and the harm reduction approach were perceived to contribute to the improved health status of people with opioid dependence. RESULTS : Peer outreach workers and COSUP clients significantly endorsed OST as an effective treatment for opioid dependence. Participants perceived greater effectiveness of OST compared to abstinence-centred inpatient rehabilitation programmes. However, there were sentiments that more community education on OST was needed to motivate people with opioid dependence to access services and to address misconceptions about OST. CONCLUSIONS : There is a lack of multi-level and multi-sectoral engagement of various stakeholders in opioid dependence services, needed to accelerate utilisation of OST services. SO WHAT? The research unpacks the need for an integrated approach to service use optimisation, and the need to evaluate the role that increased awareness and community education on harm reduction strategies can play in enhancing the utilisation of OST services.http://wileyonlinelibrary.com/journal/hpjaam2024Family MedicinePsychologySDG-03:Good heatlh and well-bein

Motivations, facilitators and barriers to accessing hepatitis C treatment among people who inject drugs in two South African cities

Background Treatment of hepatitis C (HCV) among people who inject drugs (PWID) is a critical component of efforts to eliminate viral hepatitis. A recent study found high HCV prevalence among PWID in two cities, Pretoria (84%) and Cape Town (44%). Very few (< 5%) HCV-infected individuals attended follow-up appointments. This sub-study explores differences between stated desire for cure and appointment attendance in light of perceived facilitators and barriers to HCV treatment and care access among PWID. Method Two sets of semi-structured interviews were implemented in a group of HCV-infected participants opportunistically sampled and recruited at harm reduction service sites. Initial interviews, conducted before the planned hospital appointment date, asked participants (N = 17, 9 in Pretoria and 8 in Cape Town) about past experiences of healthcare provision, plans to attend their referral appointment and perceived barriers and facilitators to seeking hepatitis treatment. Second interviews (n = 9, 4 in Pretoria, 5 in Cape Town), conducted after the planned referral appointment date, asked about appointment attendance and treatment experience. Trained social scientists with experience with PWID conducted the interviews which were recorded in detailed written notes. Data was thematically analysed in NVivo 11. Results Despite routine experiences of being stigmatised by the healthcare system in the past, most participants (n = 16, 94%) indicated a desire to attend their appointments. Attendance motivators included the desire to be cured, fear of dying and the wish to assist the research project. Perceived barriers to appointment attendance included fear of again experiencing stigmatisation and concerns about waiting periods and drug withdrawal. Perceived facilitators included the knowledge they would be treated quickly, and with respect and access to opioid substitution therapy. In the end, very few participants (n = 5) went to their appointment. Actual barriers to attendance included lack of finances, lack of urgency and forgetting and fatalism about dying. Conclusions South Africa can learn from other countries implementing HCV treatment for PWID. Successful linkage to care will require accessible, sensitive services where waiting time is limited. Psychosocial support prior to initiating referrals that focuses on building and maintaining a sense of self-worth and emphasising that delayed treatment hampers health outcomes is needed

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

BACKGROUND : Drug overdoses occur when the amount of drug or combination of drugs consumed is toxic and negatively affects physiological functioning. Opioid overdoses are responsible for the majority of overdose deaths worldwide. Naloxone is a safe, fast-acting opioid antagonist that can reverse an opioid overdose, and as such, it should be a critical component of community-based responses to opioid overdose. However, the burden of drug overdose deaths remains unquantified in South Africa, and both knowledge about and access to naloxone is generally poor. The objective of this study was to describe the experiences of overdose, knowledge of responses to overdose events, and willingness to call emergency medical services in response to overdose among people who use drugs in Cape Town, Durban, and Pretoria (South Africa). METHODS : We used convenience sampling to select people who use drugs accessing harm reduction services for this cross-sectional survey from March to July 2019. Participants completed an interviewer-administered survey, assessing selected socio-demographic characteristics, experiences of overdose among respondents and their peers, knowledge about naloxone and comfort in different overdose responses. Data, collected on paper-based tools, were analysed using descriptive statistics and categorised by city. RESULTS : Sixty-six participants participated in the study. The median age was 31, and most (77%) of the respondents were male. Forty-one per cent of the respondents were homeless. Heroin was the most commonly used drug (79%), and 82% of participants used drugs daily. Overall, 38% (25/66) reported overdosing in the past year. Most (76%, 50/66) knew at least one person who had ever experienced an overdose, and a total of 106 overdose events in peers were reported. Most participants (64%, 42/66) had not heard of naloxone, but once described to them, 73% (48/66) felt comfortable to carry it. More than two-thirds (68%, 45/66) felt they would phone for medical assistance if they witnessed an overdose. CONCLUSION : Drug overdose was common among participants in these cities. Without interventions, high overdoserelated morbidity and mortality is likely to occur in these contexts. Increased awareness of actions to undertake in response to an overdose (calling for medical assistance, using naloxone) and access to naloxone are urgently required in these cities. Additional data are needed to better understand the nature of overdose in South Africa to inform policy and responses.http://www.harmreductionjournal.comam2022Family Medicin

‘We must treat them like all the other people’: Evaluating the Integrated Key Populations Sensitivity Training Programme for Healthcare Workers in South Africa

Background: Sensitisation training can reduce judgemental and discriminatory attitudes amongst healthcare workers. The ‘Integrated Key Populations Sensitivity Training Programme for Healthcare Workers in South Africa’ aimed to improve access to appropriate and non-judgemental health services for ‘key populations’, specifically men who have sex with men, sex workers and people who use drugs, through the sensitisation of healthcare workers. Objectives: The aim of this study was to evaluate the effects of the integrated key population sensitisation training intervention for healthcare workers, conducted between 2013 and 2014 in South Africa. Methods: This study used a combination of qualitative and quantitative methods. Qualitative methods compared attitudes between healthcare workers who received the training intervention and those who did not. Quantitative methods were used to compare similar changes in awareness amongst healthcare workers before and after receiving the training. We explored shifts in attitudes towards key populations, changes in awareness of health issues related to stigma, discrimination, and changes in capacity to manage sexual health and HIV risk behaviours, including substance use and anal sex. Results: The findings indicate that the training intervention resulted in a shift in attitudes, increased empathy for key populations, a reduction in negative and discriminatory moral-based judgements towards key populations and their behaviours, and increased self-perceived capacity to provide appropriate health services to key populations. Over 70% of healthcare workers trained in this programme strongly agreed that this intervention helped to increase awareness of psychosocial vulnerabilities of key populations, and address stigmatising attitudes. Conclusion: The findings suggest that sensitisation training increases healthcare workers’ knowledge and awareness about specific HIV-related health needs and psychosocial vulnerabilities of key populations, reduces moralising and judgemental attitudes, and results in healthcare workers feeling more skilled to provide appropriate and sensitive services

The prevalence and characteristics of moderate- to high-risk regulated and unregulated substance use among patients admitted to four public hospitals in Tshwane, South Africa

BACKGROUND. Alcohol, tobacco and unregulated substance use contributes to the global burden of disease. Admission to hospital provides an opportunity to screen patients for substance use and offer interventions. OBJECTIVES. To determine the prevalence and nature of substance use and treatment as well as interest in harm reduction among inpatients from four hospitals in the City of Tshwane, South Africa. METHODS. In a cross-sectional study, sociodemographic and substance use data were collected from 401 patients using the World Health Organization’s Alcohol, Smoking and Substance Involvement Screening Test. Demographic characteristics were analysed using descriptive statistics. Bivariate and multivariate analyses of moderate- to high-risk tobacco and unregulated substance use in relation to demographic characteristics were also done. RESULTS. Most patients were South African (88%) and black African (79%), over half were female (57%), and they were relatively young (median age 38 years). Most (82%) lived in formal housing. Over half (56%) had completed high school, and 33% were formally employed. Bivariate analysis found substance use-related admission to be higher where scores for tobacco and unregulated substance use were moderate to high (13% v. 0.3%, p<0.05). A notably higher (p<0.1) proportion of participants with no/low tobacco and unregulated substance use had completed high school, were employed and were cohabiting/married compared with those with moderate to high scores. Across the hospitals, 32% (129/401) of the participants had moderate- to high-risk use of at least one substance: tobacco (28%, 111/401), alcohol (10%, 40/401), cannabis (7%, 28/401), opioids (2%, 9/401) and sedatives (2%, 9/401). Of these 129 participants, 10% had accessed professional help, many (67%, 78/129) wanted to learn more about harm reduction, and most (84%, 108/129) said that they were willing to participate in a community-based harm reduction programme. Multivariate analysis found moderate- to high-risk tobacco and unregulated substance use to be positively associated with male sex (adjusted odds ratio (aOR) 7.9, 95% confidence interval (CI) 2.9 - 21.5), age <38 years (aOR 3.3, 95% CI 1.2 - 8.9), moderate- to high-risk alcohol use (aOR 3.1, 95% CI 1.1 - 8.4; p=0.027) and being admitted to Tshwane District Hospital (aOR 3.6, 95% CI 1.1 - 12.2). It was negatively associated with employment (aOR 0.2, 95% CI 0.1 - 0.6). CONCLUSIONS. Moderate- to high-risk substance use is an undetected, unattended comorbidity in the hospital setting in Tshwane, particularly among young, single, unemployed men. Clinicians should identify and respond to this need. Further research is required on the implementation of in-hospital substance use screening and treatment interventions.The City of Tshwanehttp://www.samj.org.zaam2020Family Medicin

Community oriented substance use programme in the City of Tshwane : a cross-sectional survey of stakeholder perceptions

The City of Tshwane and University of Pretoria’s Community Oriented Substance Use Programme (COSUP) is an applied research intervention to address drug use-related harms in the city by using a harm reduction community-oriented primary care approach. This is a study of stakeholder perceptions of South Africa’s first publicly funded community-based harm reduction programme. In late 2021, purposively sampled respondents were surveyed using a cross-sectional survey. Electronically captured data were collected on respondent demographic characteristics, familiarity with COSUP and perceptions of COSUP’s effect on service users’ well-being, access to drug use services, family relationships, community integration, and on effective approaches to managing drug use. Frequencies and proportions were analysed as a total and by the degree of familiarity with COSUP, using descriptive statistics. Overall, 338 (93.1%) of the 363 stakeholders who consented to participate in the study had some familiarity with COSUP. Socio-demographically, 68.1% were female and over half (52.4%) were aged between 25–39 years. Most (70–80%) thought COSUP improved client well-being, family relationships and community re-integration. Most (80–84%) perceived COSUP to have increased service provider willingness to support people who use drugs, improved stakeholder networking and raised awareness of drug-related services. Most (76%) considered harm reduction to be the best approach to manage harmful drug use in the city. Stakeholders exposed to the work of COSUP perceive the intervention to be beneficial for individuals, families and service-providing organisations. Most favour a harm reduction approach to drug use and believe COSUP should be sustained and expanded.https://unisapressjournals.co.za/index.php/SWPR/indexhj2023Family MedicineSocial Work and Criminolog

Southern African HIV Clinicians Society guidelines for harm reduction

We support public-health-focused interventions, as opposed to recovery-focused interventions. We support the decriminalisation of drug use as much as we oppose the criminalisation of sex work, mandatory HIV disclosure and policing of sexual preferences.Additional inputs received from Lize Weich, Tanya Venter, Johannes Hugo, Urvisha Bhoora, Magriet Spies, Rafaela Rigoni, Cara O’Conner, Julia Samuelson, Viriginia Macdonald, Michelle Rodolph, Shona Dalal, Nurain Tisaker and Shaheema Allie. Regional harm reduction case studies developed by Kunal Naik (PILS, Mauritius) and Bernice Apondi (VOCAL, Kenya). Inputs from the guideline development workshop held in August 2019 are also included. Participants of the workshop included: Leora Casey, Andrew Gray, Harry Hausler, Signe Rotberga, Muhangwi Mulaudzi, Lauren Jankelowitz, Annette Verster, Busisiwe Msimanga-Radebe, Nontsikelelo Mpulo, Zukiswa Ngobo, Mpho Maraisane, Rogerio Phili, Kgalabi Ngako, Maria Sibanyoni, Yolanda Ndimande, Valencia Malaza, Johannes Hugo, Urvisha Bhoora and Cara O’Conner. We extend our thanks to the external reviewers, including Julie Bruneau, Annette Verster, Kunal Naik, Nkereuwem William Ebiti and Ali Feizzadeh.http://www.sajhivmed.org.za/am2021Family MedicineImmunolog