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“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”

Harm reduction in Mauritius

By Dr Fayzal Sulliman                 

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 continent. According th 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 worldwide.

The HIV/AIDS epidemic in Mauritius is experiencing rapid increase with an annual 100% rise in new infection since 2003. In 2005, the 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 respond 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.

In April 2006, The National AIDS Committee (NAC) supported the idea of Needle Exchange Programme as part of the comprehensive national strategy.  The 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 Southern Africa

By Tara Carney

While the 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.

There is 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.

The most 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 is heroin 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.

With regards 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. There is a lack of recent and reliable information on the proportion of prisoners with HIV. While recent country presentations presented at Technical 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 seven countries.

A review of policies related to harm reduction the region revealed:

&#8729    No domestic or international policy that supports or is explicitly opposed to harm reduction exists in any of the countries.

&#8729    A demand reduction approach is taken in many countries.

&#8729    All 10 countries have a national HIV/AIDS Action Framework.

&#8729    Only Angola, Botswana, Namibia, South Africa, Zambia and Zimbabwe have frameworks addressing harm reduction.

&#8729    Only South Africa, Zambia and Zimbabwe briefly mention IDUs.

With regard to harm reduction services in the sub-region:

1. Needle and syringe exchange programmes

Needle and 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”.

2. Drug treatment

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 buprenorphine is available at 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.

3. Targeted HIV prevention, treatment and care

While Table 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, as 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 drug users

·         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 will attitudes

·         Increasing the accessibility of existing harm reduction services (e.g. those in private facilities)

·         Facilitating the establishment and activities of drug user organisations.