Trends and factors associated with illicit drug use in South Africa: Findings from multiple national population-based household surveys, 2002-2017.

BACKGROUND: Illicit drug use results in considerable global morbidity, but there is little data on its trends and factors associated with it in sub-Saharan Africa. We consider these questions using national data from South Africa for 2002-2017. METHODS: We analysed data among individuals aged 15 years or older from five national population-based household surveys in South Africa (2002-2017; n = 89,113). Recent drug use was defined as the last three-months use of illicit drugs, i.e., any use of cannabis, cocaine, amphetamine, inhalants, sedatives, hallucinogens, opioids, and/or other illicit drugs. Time trends in recent drug use were assessed using logistic regression. Multivariable logistic regression assessed the association between recent drug use and socio-demographic factors and between drug use and sexual risk behaviours, HIV-related and other well-being variables. RESULTS: The prevalence of recent drug use increased from 1·5% to 10·0% from 2002 to 2017, driven by increases in cannabis use (1·5% to 7·8%) and use of opioids (0·01% to 1·6%), cocaine (0·02% to 1·8%), or amphetamines (0·1% to 1·5%). In adjusted analyses, male gender, younger age, living in urban areas, mixed-ancestry or white ethnicity (compared to black-African), and unemployment were positively associated with recent drug use. Recent drug use was associated with: multiple sexual partners (adjusted odds ratio [aOR] 2·13, 95% confidence interval [CI]: 1·80-2·51); sexual debut before 15 years old (aOR 1·70, 95%CI: 1·29-2·23); hazardous/harmful alcohol use (aOR 2·50, 95%CI: 2·14-2·93) or alcohol dependence (aOR 3·33, 95%CI 2·92-3·80); ever experiencing intimate partner violence (aOR 1·56, 95%CI 1·12-2·17); psychological distress (aOR 1·53, 95%CI: 1·28-1·82); and lower chance of ever testing for HIV (aOR 0·89, 95%CI 0·80-1·00). Recent drug use was not associated with HIV positivity, condom use or being on antiretroviral therapy. CONCLUSION: Illicit drug use has increased substantially in South Africa and is associated with numerous socio-demographic characteristics, higher sexual risk behaviours and other well-being variables.

Direct-acting antiviral therapies for hepatitis C infection: global registration, reimbursement, and restrictions.

Direct-acting antivirals (DAAs) for hepatitis C virus (HCV) infection have delivered high response rates (>95%) and simplified the management of HCV treatment, permitting non-specialists to manage patients without advanced liver disease. We collected and reviewed global data on the registration and reimbursement (government subsidised) of HCV therapies, including restrictions on reimbursement. Primary data collection occurred between Nov 15, 2021, and July 24, 2023, through the assistance of a global network of 166 HCV experts. We retrieved data for 160 (77%) of 209 countries and juristrictions. By mid-2023, 145 (91%) countries had registered at least one of the following DAA therapies: sofosbuvir-velpatasvir, sofosbuvir-velpatasvir-voxilaprevir, glecaprevir-pibrentasvir, sofosbuvir-daclatasvir, or sofosbuvir. 109 (68%) countries reimbursed at least one DAA therapy. Among 102 low-income and middle-income countries (LMICs), 89 (87%) had registered at least one HCV DAA therapy and 53 (52%) reimbursed at least one DAA therapy. Among all countries with DAA therapy reimbursement (n=109), 66 (61%) required specialist prescribing, eight (7%) had retreatment restrictions, seven (6%) had an illicit drug use restriction, five (5%) had an alcohol use restriction, and three (3%) had liver disease restrictions. Global access to DAA reimbursement remains uneven, with LMICs having comparatively low reimbursement compared with high-income countries. To meet WHO goals for HCV elimination, efforts should be made to assist countries, particularly LMICs, to increase access to DAA reimbursement and remove reimbursement restrictions-especially prescriber-type restrictions-to ensure universal access.

'I went for rehab many times and it never worked, but the harm reduction process has given me renewed hope'. Perceptions on the effectiveness of harm reduction and community-based opioid substitution therapy.

ISSUE ADDRESSED: The accessibility of opioid substitution therapy (OST), one of the recommended treatments for opioid dependence, remains low. This study sought to explore the perceived effectiveness of OST from the perspectives of peer outreach workers and OST clients in a community-based harm reduction programme. METHODS: The research was done within the Community-Oriented Substance Use Programme (COSUP) in Tshwane, South Africa. Fifteen peer educators (13 males and 2 females) took part in two focus group discussions. Thereafter, there were semi-structured interviews in which 15 OST clients (11 males and 4 females) participated. A convenience cross-sectional study was used. Interviews were audio-recorded. Using thematic analysis, themes were examined to evaluate how OST and the harm reduction approach were perceived to contribute to the improved health status of people with opioid dependence. RESULTS: Peer outreach workers and COSUP clients significantly endorsed OST as an effective treatment for opioid dependence. Participants perceived greater effectiveness of OST compared to abstinence-centred inpatient rehabilitation programmes. However, there were sentiments that more community education on OST was needed to motivate people with opioid dependence to access services and to address misconceptions about OST. CONCLUSIONS: There is a lack of multi-level and multi-sectoral engagement of various stakeholders in opioid dependence services, needed to accelerate utilisation of OST services. SO WHAT?: The research unpacks the need for an integrated approach to service use optimisation, and the need to evaluate the role that increased awareness and community education on harm reduction strategies can play in enhancing the utilisation of OST services.

Assessing cardiac safety among clients receiving methadone as part of opioid agonist maintenance therapy (OAMT) in Durban, South Africa.

Methadone is a recommended medication for opioid agonist maintenance therapy (OAMT). However, methadone can have cardiac side effects. There is limited South African cardiac safety data on methadone.To describe baseline and 12-month electrocardiographic (ECG) features and cardiac symptomology in people receiving OAMT in Durban, South Africa.Twelve-lead ECGs were conducted at baseline and 12 months. Clinical interviews were used to assess cardiac symptomatology. Baseline ECG parameters (PR interval, QRS interval, QT and QTc duration, heart rate) were analyzed using descriptive statistics. Baseline and 12-month ECG characteristics were compared using paired T-tests in retained participants. The association between QTc and methadone dose was assessed using Spearman's Rho at 12 months.Fifty-three clients (51 men, 2 women [median age 29.0]) were initiated on OAMT. Normal baseline ECG variants included 4 (7.5%) with sinus bradycardia and 3 (5.7%) with ST segment elevation. Mean baseline ECG intervals were PR interval: 156 ± 23 ms, QRS duration: 87 ± 9 ms, QT interval: 404 ± 22 ms and QTc interval: 406.9 ± 21.9 ms. At 12 months, 39 participants returned for reassessment (mean methadone dose: 37 ± 8 mg in women; 27 ± 10 mg in men). QTc intervals among male participants increased (406.4 ± 22 to 417 ± 24; p = 0.026 [-19.6; -1.4]). No significant correlation (r = 0.22; p = 0.185) between methadone dose and QTc interval at 12 months, nor reports of adverse cardiac symptomatology, were detected.Methadone at the doses provided, caused mild and clinically insignificant QTc interval prolongation in men at 12 months. We provide additional cardiac safety data for the use of methadone for OAMT among people with opioid use disorder.

Diagnosis and treatment of opioid-related disorders in a South African private sector medical insurance scheme: A cohort study.

BACKGROUND: The use of opioids is increasing globally, but data from low- and middle-income countries on opioid-related mental and behavioural disorders (hereafter referred to as opioid-related disorders) are scarce. This study examines the incidence of opioid-related disorders, opioid agonist use, and excess mortality among persons with opioid-related disorders in South Africa's private healthcare sector. METHODS: We analysed longitudinal data of beneficiaries (≥ 11 years) of a South African medical insurance scheme using reimbursement claims from Jan 1, 2011, to Jul 1, 2020. Beneficiaries were classified as having an opioid-related disorder if they received an opioid agonist (buprenorphine or methadone) or an ICD-10 diagnosis for harmful opioid use (F11.1), opioid dependence or withdrawal (F11.2-4), or an unspecified or other opioid-related disorder (F11.0, F11.5-9). We calculated adjusted hazard ratios (aHR) for factors associated with opioid-related disorders, estimated the cumulative incidence of opioid agonist use after receiving an ICD-10 diagnosis for opioid dependence or withdrawal, and examined excess mortality among beneficiaries with opioid-related disorders. RESULTS: Of 1,251,458 beneficiaries, 1286 (0.1%) had opioid-related disorders. Between 2011 and 2020, the incidence of opioid-related disorders increased by 12% (95% CI 9%-15%) per year. Men, young adults in their twenties, and beneficiaries with co-morbid mental health or other substance use disorders were at increased risk of opioid-related disorders. The cumulative incidence of opioid agonist use among beneficiaries who received an ICD-10 diagnosis for opioid dependence or withdrawal was 18.0% (95% CI 14.0-22.4) 3 years after diagnosis. After adjusting for age, sex, year, medical insurance coverage, and population group, opioid-related disorders were associated with an increased risk of mortality (aHR 2.28, 95% CI 1.84-2.82). Opioid-related disorders were associated with a 7.8-year shorter life expectancy. CONCLUSIONS: The incidence of people diagnosed with or treated for an opioid-related disorder in the private sector is increasing rapidly. People with opioid-related disorders are a vulnerable population with substantial psychiatric comorbidity who often die prematurely. Evidence-based management of opioid-related disorders is urgently needed to improve the health outcomes of people with opioid-related disorders.

Managing acute opioid withdrawal with tramadol during COVID-19 lockdown in a peri-urban setting.

BACKGROUND: The coronavirus disease 2019 (COVID-19) has highlighted the scope of heroin dependence and need for evidence-based treatment amongst marginalised people in South Africa. Acute opioid withdrawal management without maintenance therapy carries risks of increased morbidity and mortality. Due to the high costs of methadone, Tshwane's Community Oriented Substance Use Programme (COSUP) used tramadol for opioid withdrawal management during the initial COVID-19 response. AIM: To describe demographics, route of heroin administration and medication-related experiences amongst people accessing tramadol for treatment of opioid withdrawal. SETTING: Three community-based COSUP sites in Mamelodi (Tshwane, South Africa). METHODS: A retrospective cross-sectional study was conducted. Data were collected using an interviewer-administered paper-based tool between April and August 2020. Descriptive statistics were used to analyse data. RESULTS: Of the 220 service users initiated onto tramadol, almost half (n = 104, 47%) were not contactable. Fifty-eight (26%) people participated, amongst whom most were male (n = 55, 95%). Participants' median age was 32 years. Most participants injected heroin (n = 36, 62.1%). Most participants experienced at least one side effect (n = 47, 81%) with 37 (64%) experiencing two or more side effects from tramadol. Insomnia occurred most frequently (n = 26, 45%). One person without a history of seizures experienced a seizure. Opioid withdrawal symptoms were experienced by 54 participants (93%) whilst taking tramadol. Over half (n = 38, 66%) reported using less heroin whilst on tramadol. CONCLUSION: Tramadol reduced heroin use but was associated with withdrawal symptoms and unfavourable side effects. Findings point to the limitations of tramadol as opioid withdrawal management to retain people in care and the importance of access to first-line opioid agonists.Contribution: This research contributes to the limited data around short-acting tramadol for opioid withdrawal management in the African context, with specific focus on the need for increased access to opioid agonists for those who need them, in primary care settings.

Personal experience and awareness of opioid overdose occurrence among peers and willingness to administer naloxone in South Africa: findings from a three-city pilot survey of homeless people who use drugs.

BACKGROUND: Drug overdoses occur when the amount of drug or combination of drugs consumed is toxic and negatively affects physiological functioning. Opioid overdoses are responsible for the majority of overdose deaths worldwide. Naloxone is a safe, fast-acting opioid antagonist that can reverse an opioid overdose, and as such, it should be a critical component of community-based responses to opioid overdose. However, the burden of drug overdose deaths remains unquantified in South Africa, and both knowledge about and access to naloxone is generally poor. The objective of this study was to describe the experiences of overdose, knowledge of responses to overdose events, and willingness to call emergency medical services in response to overdose among people who use drugs in Cape Town, Durban, and Pretoria (South Africa). METHODS: We used convenience sampling to select people who use drugs accessing harm reduction services for this cross-sectional survey from March to July 2019. Participants completed an interviewer-administered survey, assessing selected socio-demographic characteristics, experiences of overdose among respondents and their peers, knowledge about naloxone and comfort in different overdose responses. Data, collected on paper-based tools, were analysed using descriptive statistics and categorised by city. RESULTS: Sixty-six participants participated in the study. The median age was 31, and most (77%) of the respondents were male. Forty-one per cent of the respondents were homeless. Heroin was the most commonly used drug (79%), and 82% of participants used drugs daily. Overall, 38% (25/66) reported overdosing in the past year. Most (76%, 50/66) knew at least one person who had ever experienced an overdose, and a total of 106 overdose events in peers were reported. Most participants (64%, 42/66) had not heard of naloxone, but once described to them, 73% (48/66) felt comfortable to carry it. More than two-thirds (68%, 45/66) felt they would phone for medical assistance if they witnessed an overdose. CONCLUSION: Drug overdose was common among participants in these cities. Without interventions, high overdose-related morbidity and mortality is likely to occur in these contexts. Increased awareness of actions to undertake in response to an overdose (calling for medical assistance, using naloxone) and access to naloxone are urgently required in these cities. Additional data are needed to better understand the nature of overdose in South Africa to inform policy and responses.

The performance of hepatitis C virus (HCV) antibody point-of-care tests on oral fluid or whole blood and dried blood spot testing for HCV serology and viral load among individuals at higher risk for HCV in South Africa.

BACKGROUND AND AIMS: To enhance screening and diagnosis in those at-risk of hepatitis C virus (HCV), efficient and improved sampling and testing is required. We investigated the performance of point-of-care (POC) tests and dried blood spots (DBS) for HCV antibody and HCV RNA quantification in individuals at higher risk for HCV (people who use and inject drugs, sex workers and men who have sex with men) in seven South African cities. METHODS: Samples were screened on the OraQuick HCV POC test (471 whole blood and 218 oral fluid); 218 whole blood and DBS paired samples were evaluated on the ARCHITECT HCV antibody (Abbott) and HCV viral load (COBAS Ampliprep/COBAS TaqMan version 2) assays. For HCV RNA quantification, 107 dB were analyzed with and without normalization coefficients. RESULTS: POC on either whole blood or oral fluid showed an overall sensitivity of 98.5% (95% CI 97.4-99.5), specificity of 98.2% (95% CI 98.8-100) and accuracy of 98.4% (95% CI 96.5-99.3). On the antibody immunoassay, DBS showed a sensitivity of 96.0% (95% CI 93.4-98.6), specificity of 97% (95% CI 94.8-99.3) and accuracy of 96.3% (95% CI 93.8-98.8). A strong correlation (R 2 = 0.90) between viral load measurements for DBS and plasma samples was observed. After normalization, DBS viral load results showed an improved bias from 0.5 to 0.16 log10 IU/mL. CONCLUSION: The POC test performed sufficiently well to be used for HCV screening in at-risk populations. DBS for diagnosis and quantification was accurate and should be considered as an alternative sample to test. POC and DBS can help scale up hepatitis services in the country, in light of our elimination goals.

Hepatitis B, hepatitis C and HIV prevalence and related sexual and substance use risk practices among key populations who access HIV prevention, treatment and related services in South Africa: findings from a seven-city cross-sectional survey (2017).

BACKGROUND: People who use drugs including people who inject drugs (PWUD/ID), sex workers (SWs) and men who have sex with men (MSM) are at increased risk of HIV and viral hepatitis infection. Limited epidemiological data on the infections exists in key populations (KPs) in South Africa. We investigated the prevalence of hepatitis B (HBV), hepatitis C (HCV) and HIV and selected risk factors among these KPs to inform effective responses. METHODS: We used convenience sampling to recruit a targeted 3500 KPs accessing HIV-related health services across Cape Town (SWs, MSM, PWUD/ID), Durban (SWs, PWUD/ID), Pietermaritzburg (SWs), Mthatha (SWs), Port Elizabeth (SWs), Johannesburg (MSM) and Pretoria (MSM and PWUD/ID) into a cross-sectional survey. An interviewer questionnaire to assess socio-demographic characteristics, drug use and sexual risk practices, was administered. HBV surface antigen (HBsAg); HCV antibody, viral load and genotype, and HIV antibody, was tested. RESULTS: Among the 3439 people included in the study (1528 SWs, 746 MSM, 1165 PWUD/ID) the median age was 29 years, most participants were black African (60%), and 24% reported homelessness. 82% reported substance use in the last month, including alcohol (46%) and heroin (33%). 75% were sexually active in the previous month, with condom use at last sex at 74%. HIV prevalence was 37% (highest among SWs at 47%), HBsAg prevalence 4% (similar across KPs) and HCV prevalence was 16% (highest among PWUD/ID at 46%). CONCLUSIONS: HBV, HCV and HIV pose a health burden for KPs in South Africa. While HIV is key for all included KPs, HCV is of particular importance to PWUD/ID. For KPs, HBV vaccination and behavioural change interventions that support consistent condom and lubricant access and use are needed. Coverage of opioid substitution therapy and needle and syringe services, and access to HCV treatment for PWUD/ID need to be expanded.

Harm reduction in an emergency response to homelessness during South Africa's COVID-19 lockdown.

BACKGROUND: Caledonian Stadium, the main mass temporary shelter for homeless people in the City of Tshwane, was created as a local response to the imperatives of the novel coronavirus disease (COVID-19) National State of Disaster lockdown in South Africa. This is a case study of the coordinated emergency healthcare response provided by the University of Pretoria's Department of Family Medicine between 24 March and 6 April 2020. METHODS: This study uses a narrative approach to restory situated, transient, partial and provisional knowledge. Analysis is based on documented data and iteratively triangulated interviews on the operational experiences of selected healthcare first responders directly involved in the shelter. RESULTS: The impending lockdown generated intense interactions by UP-DFM to prepare for the provision of COVID-19 and essential generalist primary with partners involved in the Community Oriented Substance Use Programme (COSUP). With approximately 2000 people at the shelter at its peak, the numbers exceeded expectations. Throughout, while government officials tried to secure bedding, food and toilets, the shelter was poorly equipped and without onsite management. The COSUP clinical team prioritised opioid substitution therapy using methadone and COVID-19 screening over generalist healthcare to manage withdrawal and contain tension and anxiety. COSUP and its partners helped the city plan and implement the safe re-sheltering of all Caledonian residents. CONCLUSION: The Caledonian shelter is an account of organisational resilience in the face of homelessness and substance use emergencies triggered by lockdown. Through community-oriented, bottom-up self-organisation, a clinically led team navigated a response to the immediate needs of people who are homeless and/or use drugs that evolved into a more sustainable intervention. Key lessons learnt were the importance of communicating with people directly affected by emergencies, the value of using methadone to reduce harms during emergencies and the imperative of including OST in essential primary healthcare.

Harm reduction in practice - The Community Oriented Substance Use Programme in Tshwane.

BACKGROUND: The Community Oriented Substance Use Programme (COSUP) is the first publicly funded, community-based programmatic response to the use of illegal substances in South Africa. It is founded on a systems thinking, public health and clinical care harm reduction approach. AIM: To describe the critical components, key issues and accomplishments in the initiation and delivery of evidence-based, community-oriented, substance-use health and care services. SETTING: The Community Oriented Substance Use Programme is implemented by the University of Pretoria in four of seven Tshwane Metropolitan Municipality regions. METHODS: Quantitative and qualitative data were extracted and triangulated from plans, reports, minutes and other documents. RESULTS: Between 2016 and 2019, COSUP engaged in national and local policy and guidelines development. In Tshwane, it created practical working relations with 169 organisations and institutions and set up 17 service sites. These provide counselling, linkage to care and opioid substitution therapy services to 1513 adults (median age of 30 years), most of whom are male (90%), with similar proportions of clients who smoke (51%) or inject (49%) heroin. It also offers needle and syringe services (approximately 17 000 needles distributed/month) and has built human resource capacity in harm reduction among staff, clients and personnel in partner organisations. CONCLUSION: The Community Oriented Substance Use Programme offers an evidence-based, public-health informed, feasible alternative to an abstinence-based approach to substance use. However, to translate the programme's achievements into sustainable outcomes at scale requires health system integration; generalist, patient-centred care; affordable medication in a comprehensive package of harm reduction services; multisectoral partnerships; systematic, continuous capacity development; financial investment; and sustained political commitment.

Motivations, facilitators and barriers to accessing hepatitis C treatment among people who inject drugs in two South African cities.

BACKGROUND: Treatment of hepatitis C (HCV) among people who inject drugs (PWID) is a critical component of efforts to eliminate viral hepatitis. A recent study found high HCV prevalence among PWID in two cities, Pretoria (84%) and Cape Town (44%). Very few (< 5%) HCV-infected individuals attended follow-up appointments. This sub-study explores differences between stated desire for cure and appointment attendance in light of perceived facilitators and barriers to HCV treatment and care access among PWID. METHOD: Two sets of semi-structured interviews were implemented in a group of HCV-infected participants opportunistically sampled and recruited at harm reduction service sites. Initial interviews, conducted before the planned hospital appointment date, asked participants (N = 17, 9 in Pretoria and 8 in Cape Town) about past experiences of healthcare provision, plans to attend their referral appointment and perceived barriers and facilitators to seeking hepatitis treatment. Second interviews (n = 9, 4 in Pretoria, 5 in Cape Town), conducted after the planned referral appointment date, asked about appointment attendance and treatment experience. Trained social scientists with experience with PWID conducted the interviews which were recorded in detailed written notes. Data was thematically analysed in NVivo 11. RESULTS: Despite routine experiences of being stigmatised by the healthcare system in the past, most participants (n = 16, 94%) indicated a desire to attend their appointments. Attendance motivators included the desire to be cured, fear of dying and the wish to assist the research project. Perceived barriers to appointment attendance included fear of again experiencing stigmatisation and concerns about waiting periods and drug withdrawal. Perceived facilitators included the knowledge they would be treated quickly, and with respect and access to opioid substitution therapy. In the end, very few participants (n = 5) went to their appointment. Actual barriers to attendance included lack of finances, lack of urgency and forgetting and fatalism about dying. CONCLUSIONS: South Africa can learn from other countries implementing HCV treatment for PWID. Successful linkage to care will require accessible, sensitive services where waiting time is limited. Psychosocial support prior to initiating referrals that focuses on building and maintaining a sense of self-worth and emphasising that delayed treatment hampers health outcomes is needed.

High retention in an opioid agonist therapy project in Durban, South Africa: the role of best practice and social cohesion.

BACKGROUND: Moral conservatism within government and communities has resulted in a reluctance to support the provision of opioid agonist therapy for people with opioid use disorders in South Africa. In April 2017, South Africa's first low-threshold opioid agonist therapy demonstration project was launched in Durban. The project provided 54 low-income people with heroin use disorders methadone and voluntary access to psychosocial services for 18 months. At 12 months, retention was 74%, notably higher than the global average. In this paper, we aim to make sense of this outcome. METHODS: Thirty semi-structured interviews, two focus groups, ten oral histories and ethnographic observations were done at various project time points. These activities explored participants' pathways into drug use and the project, their meaning attributed to methadone, the factors contributing to project success and changes they experienced. Recordings, transcripts, notes and feedback were reviewed and triangulated. Key factors contributing to retention were identified and analysed in light of the existing literature. RESULTS: The philosophy and architecture of the project, and social cohesion were identified as the main factors contributing to retention. The use of a harm reduction approach enabled participants to set and be supported to achieve their treatment goals, and was shown to be important for the development of trusting therapeutic relationships. The employment of a restorative justice paradigm provided a sense of acceptance of humanity and flaws as well as an imperative to act responsibly towards others, fostering a culture of respect. Social cohesion was fostered through the facilitation of group sessions, a peace committee and group sport (soccer). In concert, these activities provided opportunities for participants to demonstrate care and interest in one another's life, leading to interdependence and care, contributing to them remaining in the project. CONCLUSIONS: We believe that the high retention was achieved through attraction. We argue that opioid agonist therapy programmes should take the principles of harm reduction and restorative justice into consideration when designing low-threshold opioid agonist therapy services. Additionally, ways to support cohesion amongst people receiving agonist therapy should be explored to support their effective scale-up, both in low-middle income countries and in high-income countries.

Six-month retention and changes in quality of life and substance use from a low-threshold methadone maintenance therapy programme in Durban, South Africa.

BACKGROUND: Emerging data points to a potential heroin use epidemic in South Africa. Despite this, access to methadone maintenance therapy and other evidence-based treatment options remains negligible. We aimed to assess retention, changes in substance use and quality of life after 6 months on methadone maintenance therapy provided through a low-threshold service in Durban, South Africa. METHODS: We enrolled a cohort of 54 people with an opioid use disorder into the study. We reviewed and described baseline socio-demographic characteristics. Baseline and 6-month substance use was assessed using the World Health Organization's Alcohol Smoking and Substance Use Involvement Screening Test (ASSIST) and quality of life, using the SF-12. We compared changes at 6 months on methadone to baseline using the Wilcoxon signed rank test and paired-tests for the ASSIST and SF-12 scores, respectively. McNemar's test was used for comparisons between paired results of categorical variables relating to injecting frequency. RESULTS: The majority of the participants were young, Black African males, with a history of drug use spanning over 10 years. Retention after 6 months was 81%. After 6 months, the median heroin ASSIST score decreased from 37 to 9 (p < 0.0001) and the cannabis ASSIST score increased from 12.5 to 21 (p = 0.0003). The median mental health composite score of the SF-12 increased from 41.4 to 48.7 (p = 0.0254). CONCLUSIONS: Interim findings suggest high retention, significant reductions in heroin use and improvements in mental health among participants retained on methadone maintenance therapy for 6 months. Further research into longer term outcomes and the reasons contributing to these changes would strengthen recommendations for the scale-up of methadone maintenance therapy in South Africa.

'We must treat them like all the other people': Evaluating the Integrated Key Populations Sensitivity Training Programme for Healthcare Workers in South Africa.

BACKGROUND: Sensitisation training can reduce judgemental and discriminatory attitudes amongst healthcare workers. The 'Integrated Key Populations Sensitivity Training Programme for Healthcare Workers in South Africa' aimed to improve access to appropriate and non-judgemental health services for 'key populations', specifically men who have sex with men, sex workers and people who use drugs, through the sensitisation of healthcare workers. OBJECTIVES: The aim of this study was to evaluate the effects of the integrated key population sensitisation training intervention for healthcare workers, conducted between 2013 and 2014 in South Africa. METHODS: This study used a combination of qualitative and quantitative methods. Qualitative methods compared attitudes between healthcare workers who received the training intervention and those who did not. Quantitative methods were used to compare similar changes in awareness amongst healthcare workers before and after receiving the training. We explored shifts in attitudes towards key populations, changes in awareness of health issues related to stigma, discrimination, and changes in capacity to manage sexual health and HIV risk behaviours, including substance use and anal sex. RESULTS: The findings indicate that the training intervention resulted in a shift in attitudes, increased empathy for key populations, a reduction in negative and discriminatory moral-based judgements towards key populations and their behaviours, and increased self-perceived capacity to provide appropriate health services to key populations. Over 70% of healthcare workers trained in this programme strongly agreed that this intervention helped to increase awareness of psychosocial vulnerabilities of key populations, and address stigmatising attitudes. CONCLUSION: The findings suggest that sensitisation training increases healthcare workers' knowledge and awareness about specific HIV-related health needs and psychosocial vulnerabilities of key populations, reduces moralising and judgemental attitudes, and results in healthcare workers feeling more skilled to provide appropriate and sensitive services.

Understanding hepatitis B, hepatitis C and HIV among people who inject drugs in South Africa: findings from a three-city cross-sectional survey.

BACKGROUND: People who inject drugs (PWID) are at high risk for hepatitis C (HCV), hepatitis B (HBV) and HIV without accessible harm reduction programmes. Coverage of needle and syringe and opioid substitution therapy (OST) services in South Africa is below global recommendations and no hepatitis services exist for PWID. We assessed HCV, HBV and HIV prevalence and risk factors among PWID accessing harm reduction services in Cape Town, Durban and Pretoria to inform policy and programming. METHODS: We conducted a cross-sectional survey among PWID in these cities between August 2016 and October 2017. Participants were opportunistically sampled while accessing services. Study team members administered a questionnaire that assessed sociodemographic characteristics, drug use and sexual risk practices. We tested for HCV (antibody, viral load and genotype), HBV surface antigen (HBsAg) and HIV. Bivariate and multivariate analyses assessed associations with HCV serostatus. RESULTS: Nine hundred and forty-three PWID were included in the per protocol analysis. The majority (87%, 819/943) were male, the overall median age was 29 and most lived on the street (66%, 626/943). At last injection, 77% (722/943) reported using a new needle and syringe and 17% (163/943) shared equipment. HIV prevalence was 21% (196/926), HBsAg positivity 5% (47/936), HCV seroprevalence 55% (513/937), HCV viraemic prevalence (proportion tested with detectable HCV) 43% (404/937) and HCV viraemic rate (proportion HCV antibody positive with detectable HCV) 79% (404/513). HCV genotype 1a (73%, 270/368) was the most prevalent. In multivariate analysis, HCV infection was positively associated with residing in Pretoria (adjusted odds ratio (aOR) 1.27, 95% CI 1.21-1.34), living on the street (aOR 1.90, 95% CI 1.38-2.60), frequent injecting (aOR 1.58, 95% CI 1.15-2.16) and HIV infection (aOR 1.69, 95% CI 1.15-2.47), and negatively associated with black race (aOR 0.52, 95% CI 0.36-0.74) and sexual activity in the previous month (aOR 0.61, 95% CI 0.42-0.88). CONCLUSIONS: HCV and HIV are major health threats affecting PWID in these cities. Access to OST and needle and syringe services needs to be increased and integrated with HCV services. Social and structural factors affecting PWID who live on the street need to be addressed.

Women's knowledge and attitudes related to cervical cancer and cervical cancer screening in Isiolo and Tharaka Nithi counties, Kenya: a cross-sectional study.

BACKGROUND: Cervical cancer is the most common cancer among women in Kenya. However, only 3% of women are routinely screened. This study aimed to assess women's knowledge and attitudes towards cervical cancer and cervical cancer screening in Kenya's Isiolo and Tharaka Nithi counties. METHODS: A cross-sectional survey was conducted between January and March 2017. Using a multistage cluster sampling methodology, 451 women 18 years of age and older participated in the study. Interviewers administered a 35-item questionnaire collecting demographic information, knowledge of risk factors and attitudes towards cervical cancer and cervical cancer screening. Bivariate and multivariate analyses of cervical cancer knowledge and demographic characteristics were conducted. RESULTS: The response rate for the study was 98% (451/460). Two-thirds of the study participants originated from Tharaka Nithi county (n = 318). Respondents reported a median age of 32; 70.5% were married; and 35.0% had primary education. Eighty percent of the participants were aware of cervical cancer, 25.6% of whom had previously undergone a cervical screening examination, and 44.4% had above-average knowledge of risk factors of cervical cancer. Knowledge of cervical cancer risk factors was significantly associated with employment status (adjusted odds ratio = 1.6; 95% CI: 1.0-2.6) and county of origin (adjusted odds ratio = 2.8; 95% CI: 1.6-5.0). Almost all (89.2%) of those who had heard of cervical cancer categorised it as "scary". There was a marginal significant difference in the overall attitude assessment score towards cervical cancer between participants from Isiolo and Tharaka Nithi counties; the mean (SD) score was 2.13 (0.34) and 2.20 (0.30) respectively. The score was comparatively higher among participants residing in Tharaka Nithi (95% CI: 0.002-0.146; p = 0.043). CONCLUSIONS: Interventions to increase cervical cancer knowledge are needed in Isiolo and Tharaka Nithi counties, Kenya. Additional research is needed to further understand and assess the effectiveness of different strategies to improve attitudes regarding cervical cancer in order to increase the uptake of screening services, particularly among less-educated women and those in hard-to-reach areas.

'Scared of going to the clinic': Contextualising healthcare access for men who have sex with men, female sex workers and people who use drugs in two South African cities.

BACKGROUND: Men who have sex with men (MSM), sex workers (SW) and people who use drugs (PWUD) are at increased risk for HIV because of multiple socio-structural barriers and do not have adequate access to appropriate HIV prevention, diagnosis and treatment services. OBJECTIVE: To examine the context of access to healthcare experienced by these three 'Key Populations', we conducted a qualitative study in two South African cities: Bloemfontein in the Free State province and Mafikeng in the North West province. METHOD: We carried out in-depth interviews to explore healthcare workers' perceptions, beliefs and attitudes towards Key Populations. Focus group discussions were also conducted with members of Key Populations exploring their experiences of accessing healthcare. RESULTS: Healthcare workers described their own attitudes towards Key Populations and demonstrated a lack of relevant knowledge, skills and training to manage the particular health needs and vulnerabilities facing Key Populations. Female SW, MSM and PWUD described their experiences of stigmatisation, and of being made to feel guilt, shame and a loss of dignity as a result of the discrimination by healthcare providers and other community. members. Our findings suggest that the uptake and effectiveness of health services amongst Key Populations in South Africa is limited by internalised stigma, reluctance to seek care, unwillingness to disclose risk behaviours to healthcare workers, combined with a lack of knowledge and understanding on the part of the broader community members, including healthcare workers. CONCLUSION: This research highlights the need to address the broader healthcare provision environment, improving alignment of policies and programming in order to strengthen provision of effective health services that people from Key Populations will be able to access.