SUBSTANCE ABUSE & INJECTION TRENDS IN

Ms SIPHOKAZI DADA EMCDDA 13 th ANNUAL TDI MEETING LISBON, SEPTEMBER, 2013 BACKGROUND¹ • South Africa (SA) is home to 51.8 million people and over 26 million people (51%) of the population are female. •Black Africans are in the majority, constituting just over 79% of the total SA population . •Majority of people are between the ages of 15-64 years, and the mean age for the country is 25 years. BACKGROUND¹ •A third of the population has some secondary schooling, with only 12% of the population having higher education (i.e. post-graduate certificate, diploma or degree).

•25.5% of the population are in some form of employment and the average annual income per household is R103,204.00 (about €7,374 or €615 per month).

•The unemployed rate is 29.8%. IN SOUTH AFRICA • Substance abuse data has been limited in SA. • Information mostly come from ad hoc cross-sectional national surveys, that aimed to look at health issues in SA and generally substance abuse was squeezed in somewhere . • More recently: – national and provincial school surveys are conducted on a more regular basis. – Increased research (intervention research) into substance abuse among vulnerable populations (adolescents, pregnant women, MSM) and more select populations (workplaces). OVERALL SUBSTANCE ABUSE IN SA

• is the most common substance of abuse among adult population in SA.

• Although a relatively low proportion of South Africans report drinking alcohol (27,9%)³, those who do often drink at harmful or hazardous levels, particularly on weekend ⁴.

• use is mostly common among youth. OVERALL SUBSTANCE ABUSE…cont • Among secondary school learners, the prevalence of cannabis is 12.7% ⁵.

• was largely confined to the Western Cape Province, but is beginning to creep into provinces in SA . OVERALL SUBSTANCE ABUSE TRENDS IN SA: TX DATA INJECTING DRUG USE IN SA • Despite gradual increases in use over the last 10 years, research related to injection drug use remains limited. • Most data on heroin use comes from the SACENDU project, which is currently the best indication of heroin use patterns in the country. • Although SACENDU monitors drug abuse trends using data collected from over 60 treatment centres in SA it is limited as it reflects only those seeking treatment. INJECTING DRUG USE IN SA …. cont • The most commonly injected drug in SA is heroin . • Most heroin is smoked, either alone or in combination with other e.g.: – In Gauteng region it is mixed with cannabis and known as ‘nyaope’. – In the Durban region there have been reports of ‘Whoonga’ (mixture of illicit drugs and antiretrovirals (especially, ). • More recently patients from treatment centres also reported injecting other drugs, such as , methcathinone (CAT), methamphetamine (MA) and over- the-counter/prescription (OTC/PRE) medicines . INJECTING DRUG USE IN SA…cont

• According to a study by Wolfe et al (2010), it is estimated that there are 67,000 PWID in SA, and this is approximately 0.2% of the adult population¹º.

• Study conducted by Pluddemann et al on heroin users in Cape Town (SA), found that the majority of heroin users injected heroin and 69% of them injected daily ⁷.

• Data from treatment centres show similar findings ⁶. PROFILE OF PEOPLE WHO INJECT DRUGS IN SA TREATMENT CENTRES PROPORTIONS OF DRUGS INJECTED

Year 2010 (Total 2011 (Total 2012 (Total sample = sample = sample = 17501) 16864) 19230) Drug N%N%N% Heroin 2721 15.5 3032 17.9 3268 16.9 MA (‘Tik’) 3155 18.0 3356 19.9 4247 22.1 CAT 360 2.1 840 4.9 1073 5.6 Cocaine 1860 10.6 1970 11.7 1860 9.7 OTC/PRE 378 2.2 848 5.0 626 3.3 DEMOGRAPHICS (%) DEMOGRAPHICS(%)…. cont AGE DISTRIBUTION (%) DRUG INJECTION TRENDS (%) FREQUENCY OF INJECTING (%) HIV TESTED IN LAST PAST YEAR (%) HEALTH CONSEQUENCES ASSOCIATED WITH IDU

• Injecting drug use is associated with health and social harms such as hepatitis and other infectious diseases, more specifically HIV². • People who inject drugs (PWID) tend to engage in sexual and other risk behaviours, including having more than one sexual partner ⁷. • The HIV prevalence among PWID in SA is estimated to be 19.4% ⁹. HEALTH CONSEQUENCES ….cont

• Pluddemann et al. (2008) in his study found 89% of injectors shared needles in the past 30 days, 6% had been paid for sex and 1% never used condoms ⁸. • Other cross-sectional surveys conducted among injecting drug users in the country found an HIV prevalence between 5% - 35%². ART & HARM-REDUCTION SERVICES FOR IDU IN SA • There are few substance abuse interventions and integrated HIV services that focus specifically on IDU including those in prison. • ART services are available in general health care facilities in SA , however the proportion of HIV+ PWID receiving ART is unknown ⁹. • IDU is surrounded by stigma and most of the time when PWID go to these public health centres they are labelled and discriminated against ². ART & HARM-REDUCTION SERVICES…cont

• Such stigma and discrimination are the main barriers to accessing medical as well as HIV services in SA ⁸. • In terms of the availability of HIV prevention services, there is only one NSP site that has been established in SA. • However this service is providing services to men who have sex with men (MSM), which indicates limited reach to PWID who are not MSM ⁹. ART & HARM-REDUCTION SERVICES …. cont • -substitution therapy (OST) sites providing maintenance therapy (MMT) and maintenance therapy are also available in SA ⁹. • However these are mostly accessible via private sector at high costs². • Even with the available OST programmes, access to safe injecting equipment has been limited; participants in Pluddemann study also reported that it was very difficult to obtain clean needles ⁷. RECOMMANDATIONS • A national prevalence study of drug practices among PWID is needed. • Harm-reduction programmes, including OST and needle syringe exchange programmes need to be scaled-up. • There is a need for integrated HIV, IDU and mental health services. • Training of health workers to reduce stigma and discrimination against PWID and build trust between health workers and PWID. REFERENCES 1. C.,Molongoana (2012). Census 2011 Statistical release – P0301.4. Statistics South Africa 2. Scheibe , A., Brown, B., et al. (2011). Key Populations, Key Responses: A Gap Analysis for Key Populations and HIV in South Africa, and Recommendations for the National Strategic Plan for HIV/AIDS, STIs and TB (2012–2016) . Desmond Tutu HIV Foundation Report, Cape Town. 3. Shisana, O., Rehle, T. et al. (2005). South African National HIV prevalence, incidence, behaviour and communication survey . Cape Town. HSRC press. 4. Parry, CHD. (2000). Alcohol Problems in Developing Countries: Challenges for the New Millennium. Presented at the Symposium: "Medicine Meets Millennium“. 5. Reddy SP., James S., et al. (2010). Umthente Uhlaba Usamila – The South African Youth Risk Behaviour Survey 2008. Cape Town: South African Medical Research Council. 6. Dada, S., Plüddemann, A., Parry, C.D.H., et al . (2012). Monitoring alcohol and drug abuse treatment admissions in South Africa: July 1996 – December 2012. SACENDU Research Brief, 15(1), 1-12. 7. Plüddeman, A., Parry, CDH., et al. (2008). Heroin users in Cape Town, South Africa: Injecting practices. HIV- related risk behaviors and other health consequences. Journal of Psychoactive drugs, Vol 30 (3): 273-76. 8. Dos Santos,M., Rataemane, ST. et al (2010). An approach to heroin use disorder intervention within the South African context: a content analysis study. Journal of Substance abuse treatment, prevention, and policy . Vol 5: 13. 9. Petersen, Z., Myers, B. et al . (2013). Availability of HIV prevention and treatment services for people who inject drugs: findings from 21 countries. Journal , 10:13, pages 2-7. 10. Wolfe, D., Patrizia, M. et al. (2010). Treatment and care for injecting drug users with HIV infection: review of barriers and ways forward. Lancet , 376: 355-66. THANK YOU VERY MUCH FOR YOUR ATTENTION!!!!

Ms Siphokazi Dada, MPH South African Medical Research Council Alcohol & Drugs Research Unit Frans Van Zijl drive Tygerberg, Cape Town T: +2721 9380604 F: +2721 9380342 Email: [email protected]