Heroin treatment demand in South Africa: trends from two large metropolitan sites (January 1997-December 2003)

Heroin hustles: Drugs and the laboring poor in South Africa

This article sets out a political economic framework to understand South Africa's dramatic upsurge in heroin use in the 2000s. Drawing on interviews with users and their families, it shows how the opioid gained influence among men in their twenties living in apartheid-engineered townships marked by chronic unemployment. Giving particular attention to histories of work, it documents the ways that men hustle to generate an income to buy heroin, showing their relationship to families who support them and community members who may employ them. The article challenges the view that heroin users' income comes primarily from criminal activities, an assumption that feeds into punitive approaches to drugs. Instead, it insists that heroin hustlers must be seen as part of a large group of "laboring poor" who undertake low-paid work that does not enable desirable futures. As such, the article develops a framework that can contribute to understanding the political economy of heroin use in high-unemployment regions of the Global South.

The Opioid Epidemic in Africa And Its Impact

Purpose of review

Opioid use disorder (OUD) is a global phenomenon and is on the rise in Africa, denoting a shift from historical patterns of drug transport to internal consumption. In contrast, opioids for clinical pain management in Africa remain among the least available globally. This region also has the highest HIV and HCV disease burden, and the greatest shortages of health workers and addiction treatment. We undertook a systematic review of the literature to describe opioid use in Africa and how it is being addressed.

Recent findings

A total of 84 articles from 2000 to 2018 were identified. Descriptions of country-specific populations and patterns of opioid misuse were common. A smaller number of articles described interventions to address OUD.

Summary

OUD occurs in sub-Saharan Africa, with attendant clinical and social costs. Evidence-based policies and health system resources are needed to promote OUD prevention and management, and infectious disease transmission reduction.

Beyond methamphetamine: Documenting the implementation of the Matrix model of substance use treatment for opioid users in a South African setting

INTRODUCTION

The Matrix model of substance use treatment has been evaluated extensively in the United States as an effective treatment for methamphetamine use disorders. Since 2007, the Matrix model has been implemented in Cape Town, South Africa, where one in four treatment-seeking individuals are primarily opioid rather than stimulant users. Yet, there has been limited data on the application of the Matrix model for other types of substance use disorders in a resource-limited setting.

METHODS

We compared primary opioid and primary methamphetamine users seeking treatment at the first certified Matrix model substance use treatment site in Cape Town, South Africa from 2009 to 2014 (n=1863) on engagement in treatment, an important early predictor of later substance use treatment outcomes, and urine-verified abstinence at treatment exit.

RESULTS

Compared to primary opioid users, primary methamphetamine users had over 50% greater odds of initiating treatment (defined as attending at least one treatment session following intake; OR=1.55; 95%CI: 1.24-1.94), and 4.5 times greater odds of engaging in treatment (i.e., attending at least four treatment sessions; OR=4.48; 95%CI: 2.27-8.84). There were no significant differences in rates of urine-verified abstinence at treatment exit.

CONCLUSIONS

Results suggest primary opioid users may experience additional barriers to treatment initiation and engagement in the Matrix model of substance use treatment, yet those who enter treatment are equally as likely to be abstinent at treatment exit compared to primary methamphetamine users. Findings highlight the need for additional strategies to optimize treatment initiation and engagement among primary opioid users in this setting, for instance by integrating medication-assisted treatment (e.g., methadone).

Rapid assessment response (RAR) study: drug use and health risk - Pretoria, South Africa

BACKGROUND

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.

METHODS

A Rapid Assessment and Response (RAR) methodology was adopted for the study. For individual and focus group interviews a semi-structured questionnaire was utilised that addressed key issues. Interviews were conducted with a total of 84 key informant (KI) participants, 63 drug user KI participants (49 males, 14 females) and 21 KI service providers (8 male, 13 female).

RESULTS AND DISCUSSION

Adverse living conditions and poor education levels were cited as making access to treatment harder, especially for those living in disadvantaged areas. Heroin was found to be the substance most available and used in a problematic way within the Pretoria area. Participants were not fully aware of the concrete health risks involved in drug use, and the vague ideas held appear not to allow for concrete measures to protect themselves. Knowledge with regards to substance related HIV/AIDS transmission is not yet widespread, with some information sources disseminating incorrect or unspecific information.

CONCLUSIONS

The implementation of pragmatic harm-reduction and other evidence-based public health care policies that are designed to reduce the harmful consequences associated with substance use and HIV/AIDS should be considered. HIV testing and treatment services also need to be made available in places accessed by drug users.

The epidemiology of addiction in Sub-Saharan Africa: a synthesis of reports, reviews, and original articles

Use of alcohol and other psychoactive substances is associated with serious social and public health problems, but the extent of the problem in Sub-Saharan Africa is not well known. We set out to review epidemiological publications on alcohol and other psychoactive substances in Sub-Saharan Africa by performing a systematic search of electronic databases and paper records. Ten Sub-Saharan African countries are among the 22 in the world with the highest increase in per capita alcohol consumption. Cannabis, tobacco, and khat are widely used, and use of cocaine, stimulants, and heroin is increasing. More epidemiological research and implementation and evaluation of interventions is needed. Collaboration between African researchers and those in developed countries could help. 

Illicit drug use and treatment in South Africa: a review

This review synthesizes available epidemiological data on current drug use and substance user treatment admissions in South Africa since 1994, and how changes in the political, economic, and social structures within South Africa, both before and after Apartheid, has made the country more vulnerable to drug use. Based on national surveys, current use of cannabis ranged among adolescents from 2% to 9% and among adults it was 2%, cocaine/crack (0.3%), mandrax/sedatives (0.3%), club drugs/amphetamine-type stimulants (0.2%), opiates (0.1%), and hallucinogens (0.1%). The use of primary illicit substance at admission to South African drug user treatment centers was cannabis 16.9%, methamphetamine (tik) 12.8%, crack/cocaine 9.6%, cannabis and mandrax 3.4%, heroin/opiates 9.2%, and prescription and OTC drugs 2.6%. An increase in substance user treatment admissions has increased. While the prevalence of illicit drug use in South Africa is relatively low compared to the United States and Australia, prevention and intervention policies need to be designed to reduce these levels by targeting the more risky subpopulations identified from this review.

The association between poly-substance use, coping, and sex trade among black South African substance users

The current study examined the relationship between poly-substance use and sex trade among 343 black South African substance users recruited from the Pretoria region between 2002 and 2006 (57% males; mean age 24 years). The assessment comprised a HIV-risk behavior interview, urinalysis to confirm self-report of drug use, and an HIV test. Logistic regression analyses indicated poly-substance use was positively associated with sex trade among persons using drugs to cope with stress. Results indicate the importance of considering coping strategies as modifiable psychosocial factor related to sexual risk-taking behaviors and substance use. The study's implications and limitations are discussed.

HIV seroprevalence in a sample of Tanzanian intravenous drug users

Injection drug use has recently emerged in sub-Saharan Africa. The purpose of this study was to assess the factors associated with increased risk of testing HIV-positive in a sample of injection drug users (IDUs) in Dar es Salaam, Tanzania. Participants were recruited by a trained outreach worker or were referred by IDUs who had completed the study. Blood specimens and self-reported socioeconomic and behavioral data were collected from 315 male and 219 female IDUs. Data were analyzed using univariate odds ratios and multivariate logistic regression modeling. Forty-two percent of the sample tested HIV-positive. Several socioeconomic, injection, and sexual factors were found to be associated with increased odds of testing HIV-positive. Multivariate analysis showed that having had sex more than 81 times in past 30 days, earning less than 100,000 shillings (US$76) in the past month, residency in Dar es Salaam for less than 5 years, and injecting for 3 years were independently associated with the greatest risk of infection. The rate of HIV infection in this sample of IDUs was found to be very high, suggesting that injection drug use may be a factor in the continuing epidemic in sub-Saharan Africa. The factors associated with increased risk of HIV infection suggest further research is needed on the needle use and sexual networks of IDUs.

Injection drug use, unsafe medical injections, and HIV in Africa: a systematic review

The reuse of injecting equipment in clinical settings is well documented in Africa and appears to play a substantial role in generalized HIV epidemics. The U.S. and the WHO have begun to support large scale injection safety interventions, increased professional education and training programs, and the development and wider dissemination of infection control guidelines. Several African governments have also taken steps to control injecting equipment, including banning syringes that can be reused.However injection drug use (IDU), of heroin and stimulants, is a growing risk factor for acquiring HIV in the region. IDU is increasingly common among young adults in sub-Saharan Africa and is associated with high risk sex, thus linking IDU to the already well established and concentrated generalized HIV epidemics in the region. Demand reduction programs based on effective substance use education and drug treatment services are very limited, and imprisonment is more common than access to drug treatment services.Drug policies are still very punitive and there is widespread misunderstanding of and hostility to harm reduction programs e.g. needle exchange programs are almost non-existent in the region. Among injection drug users and among drug treatment patients in Africa, knowledge that needle sharing and syringe reuse transmit HIV is still very limited, in contrast with the more successfully instilled knowledge that HIV is transmitted sexually. These new injection risks will take on increased epidemiological significance over the coming decade and will require much more attention by African nations to the range of effective harm reduction tools now available in Europe, Asia, and North America.

Rapid assessment of drug use and sexual HIV risk patterns among vulnerable drug-using populations in Cape Town, Durban and Pretoria, South Africa

This exploratory study examines the links between drug use and high-risk sexual practices and HIV in vulnerable drug-using populations in South Africa, including commercial sex workers (CSWs), men who have sex with men (MSM), injecting drug users (IDUs) and non-injecting drug users who are not CSWs or MSM (NIDUs). A rapid assessment ethnographic study was undertaken using observation, mapping, key informant interviews and focus groups in known 'hotspots' for drug use and sexual risk in Cape Town, Durban and Pretoria. Key informant (KI) and focus group interviews involved drug users and service providers. Purposeful snowball sampling and street intercepts were used to recruit drug users. Outcome measures included drug-related sexual HIV risk behaviour, and risk behaviour related to injection drug use, as well as issues related to service use. HIV testing of drug-using KIs was conducted using the SmartCheck Rapid HIV-1 Antibody Test. Non-injection drug use (mainly cannabis, methaqualone, crack cocaine and crystal methamphetamine) and injection drug use (mainly heroin) was occurring in these cities. Drug users report selling sex for money to buy drugs, and CSWs used drugs before, during and after sex. Most (70%) of the drug-using KIs offered HIV testing accepted and 28% were positive, with rates highest among CSWs and MSM. IDUs reported engaging in needle sharing and needle disposal practices that put them and others at risk for contracting HIV. There was a widespread lack of awareness about where to access HIV treatment and preventive services, and numerous barriers to accessing appropriate HIV and drug-intervention services were reported. Multiple risk behaviours of vulnerable populations and lack of access to HIV prevention services could accelerate the diffusion of HIV. Targeted interventions could play an important role in limiting the spread of HIV in and through these under-reached and vulnerable populations.

Surge in treatment admissions related to methamphetamine use in Cape Town, South Africa: implications for public health

INTRODUCTION AND AIMS

In the past decade, methamphetamine has become increasingly a drug of concern globally. The purpose of this study is to describe the changing trends in treatment admissions for methamphetamine abuse in Cape Town, South Africa and to highlight the implications of these changes for policy, practice and research.

DESIGN AND METHODS

Data were collected on admissions for drug abuse treatment through a regular monitoring system involving drug treatment centres and programmes in Cape Town every 6 months as part of the South African Community Epidemiology Network on Drug Use (SACENDU). A one-page form was completed by treatment centre personnel to obtain demographic data, the patients' primary and secondary substances of abuse, the mode, frequency and age of first use of substance and information on prior treatment.

RESULTS

The results indicate that between 2004 and 2006 a dramatic increase in treatment admissions for methamphetamine abuse occurred, a large proportion of the methamphetamine patients are adolescents and that the drug is almost exclusively smoked.

DISCUSSION AND CONCLUSIONS

The rapid increase in admissions for methamphetamine abuse is of great concern, particularly as the drug has a number of serious, often chronic, side effects and that a large proportion of the patients are adolescents. The implications for public health are discussed.

Prevalence and correlates of substance use among high school students in South Africa and the United States

OBJECTIVES

We compared prevalence rates and correlates of substance use among high school students in South Africa and the United States.

METHODS

We used weighted data from 2 nationally representative surveys of high school students. We conducted bivariate and multivariate analyses and examined between-country differences in rates and correlates of substance use were examined.

RESULTS

Rates of past-month alcohol and marijuana use were lower among South African students than among US students, but rates of illicit hard drug use were higher. Correlates of use in the 2 countries differed. For example, female gender was protective against tobacco, alcohol, and marijuana use in South Africa, whereas in the United States it was protective only against marijuana use. Black race/ethnicity was associated with lower rates of past-month cigarette and alcohol use in both countries, but the protective effect for alcohol use was stronger in South Africa.

CONCLUSIONS

Crosscultural studies can elucidate common and culturally unique pathways to drug use. Our results can inform future research, policies, and behavioral interventions in South Africa.