By Dr Fayzal
Injecting drug use (IDU) is becoming an increasingly important
mode of HIV transmission globally and available information
contradicts the prevailing view that IDU is extremely rare or
non-existent in most African countries. IDU populations within
selected countries are shown to engage in high-risk sexual and
injecting behaviours and have the potential to provide a
significant contribution to the spread of HIV and AIDS on the
the UNODC World Drug Report 2007, Mauritius has the highest
annual prevalence of opiate abuse among the population aged
15-64 in Eastern African region and the second highest
HIV/AIDS epidemic in Mauritius is experiencing rapid increase
with an annual 100% rise in new infection since 2003. In 2005,
highest annual incidence in 16 years was documented, at 921 new
HIV infections .The
prevalence in the general population is 0.5% but increases to
15-25% among vulnerable groups such as prison inmates, injecting
drug users (IDUs) and commercial sex workers (CSWs). Since 2002,
there has been a significant shift in the mode of transmission
of the disease from heterosexual to IDUs.
In the year 2000, only 2% of the new infected cases of HIV were
among IDUs. It has increased to 14% in 2002, 66% in 2003, 87% in
2004 and 92% in 2005 and 85.9% in2006.
to this challenge, the Mauritian government has taken strong
leadership and committed itself to implement a comprehensive set
of measures for HIV prevention among IDU, Prison Inmates and Sex
Workers. In January 2006, Government approved implementation of
Methadone Substitution Therapy. The Methadone
Substitution Therapy is based on the Spanish model.
Presently induction is being carried out on an in-patient basis
during a two-week period for 15 clients at each entry. Follow
up is done by NGOs who provide psycho-social support to the
methadone clients in terms of individual and group counselling.
Dispensing of methadone during follow up is done at hospital
level [seven at present] where special dispensing units have
been established to dispense methadone under supervision
[directly observed therapy (DOT)] on a daily basis. For the
time being no take home dose is being envisaged. To date 1000
IDUs (900 males and 100 females) are currently on Methadone
Substitution Therapy and less than 40 have discontinued use. The
majority have obtained regular and legal occupations, and
positive feedack has been received from IDUs’ family members.
2006, The National AIDS Committee (NAC) supported the idea of
Needle Exchange Programme as part of the comprehensive national
HIV & AIDS Act,
passed by Parliament with non-partisan consensus, on 6th
December 2006 is a national policy document & represents an
essential unprecedented contribution within a legal framework
for targeted approach to HIV prevention among IDUs in Mauritius,
with the unequivocal provision for establishment of National
Needle Exchange programme.
A Needle Exchange Programme has been officially launched
on 12th November. 2007 with NGO partners.
An audit of harm
reduction strategies to address drug-related HIV and AIDS in
majority of HIV/AIDS transmissions in southern Africa occurs
through heterosexual contact, recent studies indicate that
substance use plays a substantial role in this. For example, in
Botswana, alcohol is associated with multiple risks for HIV
transmission such as multiple partners, unprotected sex and
transactional sex. In Malawi, results from a rapid assessment
found that drug users had multiple partners, did not use condoms
and engaged in casual sex. In Cape Town, recent studies found
that both adult community populations are more likely to engage
in risky sex if they are methamphetamine users. Both adult and
adolescent methamphetamine users were more likely to have
multiple partners and less likely to use condoms, while
adolescents had a higher likelihood of having been/made someone
pregnant and been diagnosed with a STI.
also some evidence that injection drug use exists in these
countries, and is directly linked to HIV/AIDS. In a recent South
African study, Injection drug users (IDUs) engaged in risky
drug-use practices such as sharing needles, not cleaning needles
and re-using needles a multitude of times.
commonly used substance in nine of the ten Southern African
countries is alcohol. The exception is Malawi, where the primary
drug used by patients in treatment is cannabis or ‘chamba’
(80%). For the remaining countries, cannabis is the second most
commonly use substance with the exception of Mozambique, where
the percentage of patients receiving treatment for heroin use
(33.1%) was only slightly lower than those being treated for
alcohol abuse during the last available reporting period
(39.1%). South Africa has a number of substances that are widely
available and abused, including methamphetamine and heroin
(mixed with other substances).
Due to the
lack of existing data, it is difficult to conclude whether
injection drug use exists in certain countries. For example,
while it has been reported in Angola, Mozambique and Zimbabwe
there is no up to date data available on this practice. In
Botswana, Namibia, Lesotho and Swaziland there have been no
official reports of injecting drug use.
The most commonly injected drug
while diazepam is also injected in Angola and Zambia, cocaine
and methamphetamine reportedly injected in Mozambique and South
Africa, and dipipanone hydrochloride is injected in South
Africa. Of those in treatment for heroin use, up to 40% inject.
to HIV prevalence among those who inject drugs, this information
for the most part is unavailable. The exceptions are Malawi,
where a recent rapid assessment found that HIV prevalence was 0%
amongst a small subgroup of IDUs, and 25.5% for other drug
users. In South Africa, a review of previous studies indicates a
prevalence rate between five and 20% amongst IDUs. According to
Zambia’s National HIV and AIDS Strategic Framework,
injection drug use accounts for <1% of HIV transmissions. No
information is available regarding Hepatitis C except for one
study conducted with IDUs in juvenile centres in Cape Town that
found that seven percent were HCV positive.
is a lack of recent and reliable information on the proportion
of prisoners with HIV. While recent country presentations
meeting on HIV in prisons in Sub-Saharan Africa and a recent
report indicated the prevalence rate to be between 60 and 75%
for Malawi, and a recent report on HIV and prisons in
sub-Saharan African provides reviewed numbers for Zambia (27%)
and South Africa (45%), there are no statistics on the other
A review of
policies related to harm reduction the region revealed:
or international policy that supports or is explicitly opposed
to harm reduction exists in any of the countries.
reduction approach is taken in many countries.
countries have a national HIV/AIDS Action Framework.
Angola, Botswana, Namibia, South
Africa, Zambia and Zimbabwe have frameworks
addressing harm reduction.
South Africa, Zambia and Zimbabwe
briefly mention IDUs.
to harm reduction services in the sub-region:
and syringe exchange programmes
syringe exchange programmes do not exist in these Southern
African countries. A current debate exists around whether or not
countries that are already resource poor, and do not have
reported rates of injection drug use, should focus on obtaining
the political will and developing capacity to start these. It is
known that in South Africa at least, pharmacies do provide
injection equipment but as mentioned in a recent study: the
majority of pharmacies are not open at night when users are more
likely to need new needles, and if they do purchase their
equipment at pharmacies, staff are likely to be judgmental and
see them only as “junkies”.
In general, opioid substitution therapy (OST) is not available
in Sub-Saharan Africa. OST is only available in Botswana for
detoxification from alcohol, and in South Africa for
detoxification from a number of drugs, such as heroin. Methadone
is available as high alcohol-content syrup (Physeptone) while
a few private facilities.
In general, the provision of OST in Sub-Saharan Africa is
impeded by legislation prohibiting the prescription of methadone
and buprenorphine, a lack of political will, and weakened health
care systems in many countries.
HIV prevention, treatment and care
2 indicates that South Africa ($446 461 994) and Botswana ($165
000 000) allocate by far the most funding to HIV prevention,
treatment and care, it is unknown how much of this budget (if
any) is dedicated to IDUs.
Only South Africa currently has targeted programmes for IDUs,
information and awareness programmes run by government and civil
society that address the link between drug use and HIV are in
the early stages of implementation.
HIV prevention, care and treatment services are limited in
prisons throughout the region. VCT is available in prisons for
most of 10 countries but to varying extents. For example in
Botswana, VCT is available to most prisoners while there is just
one pilot VCT site operating in Zomba Central prison, Malawi.
The availability of condoms also varies widely. For example,
they are available in some prisons in Lesotho and most prisons
in South Africa (676 621 distributed), but in Botswana,
distribution of condoms in prisons is prohibited until release
by prison policy, as it is believed that this will promote
sexual behaviour in prisons. ART is available in some prisons,
such as Botswana (302 people are receiving ART), Lesotho, South
Africa (2323 people receiving ART) and Zambia. PMTCT and STI
testing and treatment are also reportedly available in
Botswana’s prisons. In Zambia, a number of NGOs support HIV
prevention and care programmes in prisons and in South Africa,
there are NGOs and research initiatives that focus on HIV within
prisons, which include the provision of harm reduction
information for prisoners using drugs.
In conclusion, there is growing evidence of progress in terms of
provision of harm reduction services in the sub-region:
Establishment of SAHRN in Kenya, October 2007.
Research projects are being undertaken that will provide more
information on harm reduction needs and influence service
provision for drug users, for example, the rapid assessment,
response and evaluation is in South Africa and Mozambique.
A pilot project to provide VCT two prisoners has been rolled out
at the Zomba Central Prison in Malawi.
In order to increase the provision of harm reduction services
in southern Africa there is a need for:
Increasing surveillance to provide information on intravenous
Learning from the implementation of harm reduction programmes in
other resource poor settings
Lobbing governments to introduce legislation and policy support
of harm reduction, rather than criminalising drug users
Addressing the stigma faced by drug users, but changing cold
Increasing the accessibility of existing harm reduction services
(e.g. those in private facilities)
Facilitating the establishment and activities of drug user