Step up to HIV prevention among injection drug users in South Africa

12 August 2016

Last month, I was lucky enough to take part in the 21st International AIDS Conference (AIDS 2016), which took place in Durban, South Africa. And, although harm reduction, the rights of people who use drugs, and policies limiting access by people who use drugs to health and social services were almost not on the agenda of the conference at all, this text is about harm reduction and a harm reduction project implemented in Cape Town, South Africa that I managed to visit.

The Step Up project is run by the TB\HIV Care Association, a big NGO with almost 1000 staff operating in 16 geographical areas in South Africa, which focuses on prevention, diagnosis, treatment, care and adherence support for people infected and affected by TB and HIV.

The project started to provide harm reduction services in Cape Town at the end of June 2015 and, at the moment it is the only such project working in the city – a similar project, though on a much smaller scale, targeting only men who have sex with men and use drugs, closed down before the start of the Step Up project. The TB\HIV Care Association supports projects similar to Step Up in Durban and Pretoria. The aim of the project is to provide mobile outreach HIV prevention services and access to other needed health care services for PWID.

Harm reduction was introduced to the region after UNODC conducted a rapid assessment of HIV prevalence and HIV risk among people who inject drugs in 5 South African cities in 2013. This study showed that an overall HIV prevalence among the study participants was 14%, in Cape Town – 9%. It became evident that something had to be done, although many people denied (and continue to deny) the fact that concentrated epidemic among PWIDs is an issue for South Africa. This is in spite of the fact that the most recent available modeling data (2013) estimate that 67 000 PWID live in South Africa and that HIV prevalence among them is 19.4%. Before starting the project in Cape Town, the TB\HIV Care Association did a mapping (formative assessment) of drug use locations in the city, which helped to inform where and when services should be delivered.

The project team consists of 8 people. They do outreach work 4 times a week during the daytime, in the afternoons and in the morning since, surprisingly, most PWID are less accessible in the evenings. The project is looking into adding night outreach to its work for those that need services at night (e.g. those engaged in sex work).  

Before the project started to deliver services, they acquired a bus to use for outreach work. Initially, the outreach team consisted of a driver, a nurse and 5 peer educators who are mostly active users from community. The key benefit of involving so many peer educators was access to the community but there were problems with functionality and the appropriateness of an 8:00-17:00 work day for these individuals.  That is why now the current model involves 2 peer educators, a peer coordinator, a nurse, an outreach worker (someone more trained, not from community) and the driver.

During outreach, they provide testing and counseling on HIV, TB and STIs, offer sterile injection equipment. The supplies are packed in bags each containing the standard package of 14 needle/syringes, injectable water, cotton wool filters, and 28 alcohol swabs. They also provide containers for safe disposal of needles and syringes. Other services provided are: distribution of condoms and lubes, referral to a range of health, psychosocial, paralegal and other services, peer education on minimizing risky behaviors, education on overdose prevention and management. Unfortunately, no naloxone is provided, although opioids are among the most popular drugs and overdoses are an issue among the community. Naloxone is available only from pharmacies on prescription or from paramedics who should (but don’t always) have it.  The project does not currently provide hepatitis C (HCV) testing and treatment referral, as they do not have the resources to test. Although, there is a plan for participation in a 3 year study on HCV in South Africa involving testing and referral to the University of Cape Town (UCT) liver clinic at Grootte Schuur hospital. This will probably start at the end of September 2016.

The coverage of the Step Up project since its start is 650 people, 400 of whom use the services on the regular basis (they are seen every month during last 3 months). The project does not provide any other office-based services, like self-help groups, as they don’t have enough space for such purposes but they do organize monthly community advisory group meetings where current issues, such as challenges with law enforcement or improper needle disposal, are discussed. At these meetings, the clients give their feedback on the project, and health education is provided. Also, a few times a week, consultations on detox are provided: an outreach worker supports clients in accessing detox, privately funded OST, in-patient treatment, and other health and psychosocial services. If a grant form the Global Fund is received, a drop-in-center should be open this year, which will allow the Step Up project to expand the number of services it offers.

Currently, the Step Up Project collects and disposes of approximately 10 000 dirty needles per month – it includes those returned by the service beneficiaries as well as the approximately 1000 that community volunteers gather from the streets of Cape Town on a weekly basis.

The Step Up Project tries to involve community representatives in the work of the project as much as possible depending on their skills and abilities. They are initially involved in doing casual work (helping with cleanup) but are offered the possibility of increased involvement in other work such as peer education. This process is fairly new for the team.

During outreach work, anyone may receive one HR kit, which includes 14 syringes. If someone wants an additional kit, they can receive one in exchange for returning 10 used syringes. Since it is not safe for drug users to carry used syringes (as police could use this to arrest them for “possession”), the Step Up doesn’t require exchange for provision of syringes but uses the combined approach.

From time to time, the police arrest the service beneficiaries and take the HR commodities from them.  The project team tries to build the relationship with police but the police don’t have any official policy toward harm reduction. The most negative experience was when the Chief of Police in one of the city districts refused to communicate with project representatives and threatened to arrest the members of the outreach team for promotion of drug use. Also, there were a few cases when peer educators were arrested for possession of used syringes. However, in general, according to the project members, there are no any major political barriers preventing the implementation of needle and syringe programs in South Africa.

Although OST is legal in South Africa, it is only available in private clinics and is not accessible for free for those in need – level of coverage is very low and it functions in a very limited geographic area. There is one short-term (6 months) program in Cape Town that is available for free, but it operates more like a prolonged detoxification program. It is not possible to take Suboxone home – the clients need to come every day for medication and other treatment, e.g. counseling.

The main donors of the Step Up project are the Centers for Disease Control and Prevention, PEPFAR and Mainline (a Dutch organization). They also receive some support from the government on a constant bases with additional episodic support. For example, the Department of Health provides them with test kits on a monthly basis, and occasionally also provides gloves and other materials. Once when there was a risk of interruption in the supply of needles, the government provided sufficient stock for them to continue service delivery until their normal supply could be resumed. No Global Fund funding at the moment is available, but they submitted an application to the principle recipient of GF grant and are waiting for the decision. If it is positive, they will have enough funding to ensure their work for the next three years.

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