It is difficult enough for most drug users to talk about their dependence to their families due to the shame and fear of being judged as immoral.
Not only that, most also dread disclosing their lifestyle to healthcare workers for fear of discrimination and being ostracised for engaging in criminal behaviour.
But it is the constant fear of arrest when injecting drugs that puts them at even greater risk of harm, “as they rush their injection, share equipment ... increasing the risk of soft tissue injury or overdose”, says Dr Andrew Scheibe, a harm reduction expert and technical adviser at TB HIV Care.
Scheibe, who has assessed needle distribution, opioid substitution therapy (OST) coverage and HIV treatment among people injecting drugs in SA, said despite the harm, discrimination and the evidence of high risk to HIV infection and hepatitis in this population, there remains a lack of political will to scale up harm reduction programmes.
The few that existed were mostly donor-funded with no government support. Lack of “policy harmony” in legal regulations that guided HIV treatment of key populations (the most-at-risk to HIV infection) and those that criminalised the possession and use of illegal drugs, often left those injecting drugs even in a more vulnerable position.
Scheibe was reacting to the release, this week, of a new report by the Global Commission on Drug Policy, which called for the decriminalisation of drug use and implementation of harm reduction strategies to reduce HIV and hepatitis infection among those using drugs.
Released ahead of World Aids Day on December 1, the report says unless there is reform in drug policies at country level, the talk of ending the HIV (and hepatitis) epidemics is premature.
The commission, made up of former political leaders and heads of state who want to inspire better drug policies — including former president Kgalema Motlanthe — called on countries to protect people who use drugs from stigma or discrimination in accessing services, including education, housing, health care, social benefits and employment.
It also called for the scale-up of HIV and viral hepatitis harm reduction and treatment programmes in prisons, and to involve people using drugs in the development and implementation of all HIV and viral hepatitis programmes.
With HIV prevalence among people who inject drugs about seven times more among adults, the commission argues that punitive drug laws and policies linked to criminalisation of drug use and possession of drugs continue to fuel the HIV and hepatitis epidemics, and often hinder treatment of those who inject drugs.
Michel Sidibé, a member of the commission and AU special envoy for the African Medicines Agency, said: “Ending Aids by 2030 will remain a pipe dream if we do not double down on our efforts to effectively reach and engage with the community of people who inject drugs and who are at extremely high risk of acquiring HIV.
“That will require, in many countries, an overhaul of their drug policies that continue to legally punish and incarcerate people for using drugs, as opposed to attending to them in the public health system like other members of the community,” he said.
In Africa it is estimated that more than 1.2-million people inject drugs. HIV prevalence among this population is about 11.2%, while the prevalence of hepatitis C is estimated to be 15.3% and the prevalence of hepatitis B about 7%.
Scheibe said despite evidence showing that hepatitis C among drug users is transmitted through sharing needles — and providing clean needles and syringes to drug users would prevent infections — little has been done by the government to scale up harm reduction programmes. The few such programmes in SA were provided by donors.
The inaction has been in spite of the country’s policies — the national strategic plan for TB, HIV and STIs (sexually transmitted disease) and the national drug master plan — being in support of harm reduction programmes.
“There has been no large-scale national government policy support for implementing needle and syringe services.”
“There has been policy support for a decision to support opioid substitution therapy (OST), but that is a policy decision that has not been implemented. There seems to be no political will to do this even though people who use drugs should have access to evidence-based care such as OST. In South Africa this is not provided in the public sector, and that’s very problematic.”
Not only did this population face constant harassment from the police and law enforcement, but even after they entered the criminal justice system there were no prevention or substitution services to manage their withdrawal symptoms, and many either “go cold turkey or continue sharing needles while in custody, remaining vulnerable to infections”.
“We also know that many people who use drugs enter the criminal justice system, and when they do, they are exposed to other health conditions, particularly tuberculosis. We know that drug use happens in prisons, people don’t have access to sterile injecting equipment because there are no programmes there.”
Shaun Shelly, policy, advocacy and human rights manager at TB/HIV Care, said with hepatitis prevalence between 50% and 93% among people who use drugs, “the country cannot address the high risk among people who inject drugs”.
Despite the benefits of harm reduction programmes, such initiatives were often rejected by communities. “These are essential, yet many communities block them without realising that they reduce the presence of needles discarded in the community,” he said.
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