Within a ten year period South Africa has developed a substantial illicit drug market. Data on HIV risk among drug using populations clearly indicate high levels of HIV risk behaviour due to the sharing of injecting equipment and/or drug-related unprotected sex. While there is international evidence on and experience with adequate responses, limited responses addressing drug use and drug-use-related HIV and other health risks are witnessed in South Africa. This study aimed to explore the emerging problem of drug-related HIV transmission and to stimulate the development of adequate health services for the drug users, by linking international expertise and local research.
Injecting drug use is an increasing cause of HIV transmission, the number of countries in which injection of drugs has been reported has increased over the last decade. The high prevalence of HIV among many populations of injecting drug users represents a substantial global health challenge. Extrapolated estimates suggest that 15.9 million people might inject drugs worldwide. However, existing data are far from adequate, in both quality and quantity, particularity in view of the increasing importance of injecting drug use as a mode of HIV transmission in many regions such as South Africa . Although injection drug use is low in South Africa in comparison with many other countries, with the increase over time in the use of substances such as heroin, the potential exists for this to change rapidly . The rapid assessment undertaken with drug using commercial sex workers in Cape Town, Durban and Pretoria by Parry et al. in 2009 recognises the need for prioritising interventions recognising the role of drug abuse in HIV transmission, the issues of access to services, stigma and power relations . Furthermore, a study by Dos Santos, Rataemane, Fourie and Trathen (2010) notes that limited strategic public health care policies that address substance use disorder syndromes complexities have been implemented within the South African context . The study further emphasises the need for pragmatic and evidence-based public health care policies that are designed to reduce the harmful consequences associated with heroin use in particular, still needs to be implemented. According to Weich, Perkel, Van Zyl, Rataemane, and Naidoo (2008), medical practitioners in South Africa are increasingly confronted with requests to treat patients with heroin use disorders for example, but many do not posses the required skills to deal with these patients effectively . The study by Dos Santos et al (2010) further discerns the need be make HIV testing and treatment services available in places accessed by vulnerable people as fear of stigma and discrimination often keep injecting users away from public health facilities . According to Parry et al (2008) there is also a widespread lack of awareness about where to access HIV treatment and preventative services, and numerous barriers to accessing appropriate HIV and drug-intervention services such as long waits and appointments being cancelled without notice . These authors further reiterate that multiple risk behaviours of vulnerable populations and lack of access to HIV prevention services could accelerate the diffusion of HIV.
KI user participants mentioned that some of the target group would accept all the intervention mentioned, however, a proportion of users were thought to maybe not accept all interventions due to denial of their problem, and due to the fact that they do not want to get caught and face potential criminal ramifications. Evangelical rehabilitation centers were also cited as not being accepted due to their extremist fundamentalist nature of their programmes as well as rehabilitation centers in general as the target group are often not prepared to go for treatment due to resistance and feeling forced to go. The high cost of attending rehabilitation centers was also cited as a factor that makes intervention not accepted.
Heroin was cited to be most commonly injected and smoked, with blacks mostly smoking the substance and whites injecting it. Heroin was the only substance cited as being injected, however, injecting heroin remains less frequent compared to smoking heroin. Whites were also thought to engage in sexual risky behaviour and needle sharing when consuming heroin, finding of which are in agreement with the South African study of Morojele, Brook, and Kachienga (2006) and well as other international studies such as that of Semple, Patterson, and Grant (2004) [21, 22]. Crime and sex work were associated more so with heroin use than any other substance, this might be due to the fact that heroin is more pervasively used than crack cocaine in the Pretoria area and/or that this may reflect the addictive nature of heroin use and the related high cost associated with it. Cannabis and crack cocaine were mentioned as being smoked with both substances being used across racial lines and used both genders, although cannabis smoking was more commonly associated with younger African males who often consume it in groups.
State sponsored interventions are also needed, especially residential care, as well as drug awareness campaigns in schools and correctional services, outreach programmes, legal enforcement and police intervention. It was also felt that the target group might not accept all interventions due to the denial of their problem, and due to the reality that they do not want to get caught by anyone. Evangelical religious rehabilitation centre interventions were also cited as not being accepted due to their fundamentalist and extremist strategies as well as rehabilitation centres in general as the target group may not prepared to go, some of these centers remain unregisterd in South Africa and various human rights violations have been reported . The cost of residential treatment was regarded to be too high, and accessibility was regarded to be problematic. Similarly, in the study by Parry et al (2009), drug user interviewees felt that there was a shortage of drug rehabilitation centres, and suggested the opening of more drug treatment facilities in nearby areas as well as making more outreach programmes available . The concern was further raised that rehabilitation centres would not be accepted by politicians and policy makers due to a lack of information and unwillingness to provide funding. The view was held that politicians and policy makers might not be trained extensively enough in the field to make informed decisions.
The conclusions and recommendations of this article were formulated from the outcomes of both the RAR study and the FG group held after the completion of the initial study. Children, youth and young adults in particular who are not educated and who are economically disadvantaged are at a higher risk in terms of drug experimentation and drug use, education for children, youth and young adults can thus serve as a buffer again drug use. Education can also help shape proactive attitudes and behaviours amongst this high risk group. Special emphasis should be placed on prevention programmes by service providers targeting youth and young adults from abusive homes and youth that dwell in social surroundings in the Pretoria area where drug use is pervasive. Prevention programmes need to focus on HIV infection control and the development of knowledge and skills. Enhancing the efficacy of primary prevention and information campaigns aimed at different target groups; and enhancing the diversity, capacity and accessibility of prevention and treatment services, such as residential care and outreach programmes in Pretoria and nationwide, is further indicated.
As highlighted in other studies local studies a thorough assessment to inform the care plan needs to be conducted [10, 30]. Comorbidity concerns such as psychiatric illness need to be cogently taken into account, integrated in approach and addressed. Mental health and rehabilitation centres need to integrate modalities for intervention, as study outcomes indicate that some psychiatric facilities tend to see the aspects of substance dependence as not falling in their scope of practice, and vice versa relating to drug abuse rehabilitation centres. Physical, psychological, familial, social, cultural and spiritual factors need to be taken fully into account. Service providers should possess the right knowledge and skill to be of real help and needs to be applied effectively. As mirrored in the study by Dos Santos et al. (2010) the workforce needs to be expertly led, supervised and managed .
Taking into account the high prevalence of substance use within the African community, as indicated in other academic work and in the finding of this study, many African drug users consult with traditional healers, the collaboration between mental health practitioners and indigenous healers should also further explored, and specifically, what from of collaboration would be most appropriate .
Furthermore, advocacy is needed to convince politicians and policy makers of the need for rehabilitation programmes and other suitable responses. Adverse living conditions and poverty in the Pretoria area clearly needs to be addressed as this factor poses a high risk for substance misuse and also makes access to treatment more problematic.
HIV testing and treatment services in Pretoria need to be more widely advertised and made available in places accessed by vulnerable people. As corroborated in various studies, the fear of stigma and discrimination often keep (injecting) substance users away from public health facilities, and many drug users do now know where to access such treatment [10, 3]. Active systems for auditing and monitoring processes and gaining client feedback should be encouraged, while the implementation of pragmatic and evidence-based public health care policies, such as needle exchange programmes, designed to reduce the harmful consequences associated with drug use and HIV/AIDS need to be considered for high risk areas in Pretoria. 041b061a72