Research paper
HIV prevalence and risk among people who inject drugs in five South African cities

https://doi.org/10.1016/j.drugpo.2016.01.004Get rights and content

Abstract

Background

Policy and programming for people who inject drugs (PWID) in South Africa is limited by the scarcity of epidemiological data.

Methods

We conducted a cross-sectional survey among 450 PWID (362 males and 88 females) from five South African cities in 2013, using outreach and peer referral to recruit participants. We carried out rapid HIV tests on participants’ saliva and assessed drug-using and sexual practices by means of a questionnaire.

Results

We found that 26% of females and 13% of males reported to always share injecting equipment, while 49% of all participants had used contaminated injecting equipment the last time they injected. Only 6% of participants usually used bleach to clean their injecting equipment. We found that half of participants reported using a condom the last time they had sex. A quarter of participants reported symptoms of a sexually transmitted infection (STI) in the previous 12 months and 22% had ever worked as a sex worker (51% of females). HIV prevalence among participants was 14% (18% among females and 13% among males). In multivariate analysis HIV was significantly associated with being 25 years and older (adjusted odds ratio (aOR) 2.1, 95% confidence interval (CI) 1.0–4.6, p = 0.06), belonging to a racial group other than white (aOR 4.2, 95% CI 1.9–9.4, p < 0.001), coming from Gauteng province (aOR 2.3, 95% CI 1.1–5.5, p = 0.023), having ever worked as a sex worker (aOR 3.4, 95% CI 1.7–7.2, p = 0.001) and the presence of STI symptoms in the last 12 months (aOR 2.4, 95% CI 1.1–4.4, p = 0.019).

Conclusions

This study highlights the need for increased access to sterile injecting equipment, education around safer injecting practices and access to sexual and reproductive health services for PWID in South Africa. Programmes for PWID should also address the specific needs of female PWID, PWID who sell sex and PWID from previously disadvantaged communities.

Introduction

In 2013 there were an estimated 12.2 million people (range: 8.5–21.5 million) who inject drugs (PWID) worldwide, and approximately 1.7 million (range: 0.9 million to 4.4 million) were living with HIV, representing a global HIV prevalence of 13.5% (United Nations Office on Drugs and Crime, 2015). In 2014, needle and syringe programmes were available in 90 of the 158 counties where injecting drug use has been documented and opioid substitution therapy was available in 80 countries (Harm Reduction International, 2014). Despite the large numbers of PWID and the high risks associated with injecting drug use, coverage and access to appropriate HIV prevention, treatment and care services remains sub-optimal (Harm Reduction International, 2014).

In 2014, only five out of 51 countries in sub-Saharan Africa had needle and syringe programmes, and only five countries had opioid substitution therapy programmes (Harm Reduction International, 2014). This is despite the dramatic increase in illegal drug availability and use in sub-Saharan Africa over the past two decades (United Nations Office on Drugs and Crime, 2015).

South African PWID data is very limited. In the last decade ten studies (six published and four unpublished) have enquired about HIV and related risk practices among PWID in South Africa (Anova Health Institute and Mainline, 2012, Baral et al., 2011, Dos Santos et al., 2011a, Lane et al., 2009, Parry et al., 2007, Plüddemann et al., 2008, Rossouw, 2009, Simbayi et al., 2007). However, only two of them recruited more than 50 PWID. In 2004, one study recruited 57 PWID in Cape Town as part of a survey among heroin users in that city (Plüddemann et al., 2008). Another study in 2005 recruited 96 PWID as part of a qualitative study around drug use and sexual risk patterns in Cape Town, Durban and Pretoria (Parry et al., 2007). Both studies used opportunistic sampling methods and highlighted the use of contaminated injecting equipment, unprotected sex and low levels of HIV-related knowledge among PWID (Parry and Pithey, 2006, Plüddemann et al., 2008).

In 2014, Petersen et al. used self-reported injecting drug use data collected in the 2008 National Household Survey to estimate the PWID population size. They estimated that there were 67,000 PWID in South Africa (approximately 0.2% of people aged 15–64 years) (Petersen et al., 2013, Statistics South Africa, 2015). HIV prevalence among South African PWID based on earlier studies was estimated to be 12.4% (Mathers et al., 2008).

No community-based HIV surveillance system for PWID exists, but history of injecting drug use is collected by substance-use disorder treatment centres that are part of the South African Community Epidemiology Network on Drug Use (SACENDU) (Harker Burnhams & Dada, 2014).

To date, no government-funded needle and syringe programmes or opioid substitution therapy for PWID exist in South Africa (Harm Reduction International, 2014), and most needles and syringes are purchased from pharmacies (Plüddemann et al., 2008). Local guidelines for the management of opioid use disorders exist, however, the high cost of medications for opioid substitution therapy and the lack of government-funded programmes for PWID are major barriers to access (Weich et al., 2013).

Our study aimed to assess HIV prevalence and risk practices among a sample of PWID from five cities in three South African provinces.

Section snippets

Methods

An advisory group including representatives from government, the national drug authority, development partners, the United Nations, technical agencies and a recovering PWID was established to oversee the planning and implementation of this cross-sectional survey. The advisory group recommended the use of opportunistic sampling methods. The sample size was informed by the amount of funding available to conduct the study, the number of organisations with links to PWID networks that were

Results

In total, 361 men (80%), 84 women (19%), 4 transgender women (1%) and 3 transgender men (1%) were recruited. One participant had never injected an illegal drug and was excluded from the analysis. Almost all (421) participants were recruited using street intercepts and snowballing with 29 participants recruited from sites linked to a drug use disorder treatment centre (25 in Johannesburg, three in Durban and one in Cape Town).

Discussion

We successfully completed the largest quantitative study on HIV prevalence and risk practices among PWID in South Africa to date. Recruiting female PWID in the southern and east African regions is known to be difficult (Bowring et al., 2013, Plüddemann et al., 2008), and indeed, this study's participants did not reflect South Africa's general population since many more males than females were recruited (Statistics South Africa, 2015). We did, however, recruit proportionately more non-white PWID

Conclusions

This study found HIV prevalence among PWID to be higher than the general adult population when stratified by race. Although HIV prevalence was not as high as among men who have sex with men or female sex workers, the combination of high-risk practices may enable the rapid spread of HIV infection between PWID and their drug using and sexual partners, as has occurred in other parts of the world (Rhodes et al., 2002). This study will provide baseline information for future comparisons of

Acknowledgements

This study was implemented by UNODC, with funding provided by UNAIDS and supported by the United Nations Joint Team on HIV and AIDS in collaboration with National Partners, the Embassy of the Federal Republic of Germany (South Africa) and Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) South Africa. The opinions expressed are those of the authors and do not represent UNODC or UNAIDS policy.

We wish to thank all the people who took part in this study. Guidance from the Advisory

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