Andrey Rylkov Foundation
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Step up to HIV prevention among injection drug users in South Africa

Text: Ivan Varentsov

Last month, I was lucky enough to take part in the 21st International AIDS Conference (AIDS 2016) which took place in Durban, South Africa (SA). And, although harm reduction (HR), the rights of people who use drugs, and  policies limiting access by people who use drugs to health and social services  were almost not on the agenda of the conference at all, this text is about harm reduction and a harm reduction project working in Cape Town, South Africa that I managed to visit.

The Step Up project is ran by the TB\HIV Care Association, a big NGO with almost 1000 staff operating in 16 geographical areas in South Africa which focuses on prevention, diagnosis, treatment, care and adherence support for people infected and affected by TB and HIV. They started to provide harm reduction services in Cape Town at the end of June 2015 and, at the moment it is the only such project working in the city. There was one before but it operated on a very low scale targeted only men who have sex with men who use drugs. It closed before the Step Up project started. The TB\HIV Care Association supports projects similar to Step Up in Durban and Pretoria. The aim of the project is to provide mobile outreach HIV prevention services and access to other needed health care services for PWID.

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Andrea (Key Populations Programme Coordinator (PWID)) and Rudolph (Key Populations Project Coordinator (PWID)) who hosted me in the office

Harm Reduction in the region started off when UNODC conducted a rapid assessment of HIV prevalence and HIV risk among people who inject drugs in 5 South African cities in 2013. This study showed that an overall HIV prevalence among the study participants was 14% and was 9% in Cape Town in particular. It was clear that something needed to be done although many people denied (and continue to deny) that concentrated epidemic among PWIDs is an issue for South Africa. This is in spite of the fact that the most recent available modelling data (2013) estimate that 67 000 PWID live in South Africa and that HIV prevalence among them is 19.4%. Before starting the project in Cape Town the TB\HIV Care Association did a mapping (formative assessment) of a drug using locations in the city and this mapping process helped to inform where and when services should be delivered.

The project team consists of 8 people. They do outreach 4 times a week during the day time, in the afternoons and morning as, surprisingly, most PWID are less accessible in the evenings.  For those that do need services at night (e.g. those engaged in sex work), the project is looking into adding night outreach to its work.

Before the project started to deliver services, they got a bus to use for outreach work. Initially the outreach team consisted of a driver, a nurse and 5 peer educators who are mostly active users from community. The key benefit of involving so many peer educators was access to the community but there were problems with functionality and the appropriateness of an 8:00-17:00 work day for these individuals.  That is why now the current model involves 2 peer educators, a peer coordinator, a nurse, an outreach worker (someone more trained, not from community) and the driver.

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During outreach, they provide testing and counselling on HIV, TB and STIs, offer sterile injection equipment. The supplies are packed in bags each containing the standard package of 14 needle/syringes, injectable water, cotton wool filters, and 28 alcohol swabs. Also they provide containers for safe disposal of needles and syringes. Other services provided are: distribution of condoms and lubes, peer education on minimizing risky behaviors, referral to a range of health, psycho-social, paralegal and other services. They also provide education on overdose prevention and management but unfortunately no naloxone is provided although opioids are among the most popular drugs and overdoses are an issue among the community. Naloxone is available only from pharmacies on prescription or from paramedics who should (but don’t always) have it.  The project does not currently provide HCV testing and treatment referral, as they do not have the resources to test. However there is plan for participation in a 3 year study on HCV in South Africa involving testing and referral to the University of Cape Town (UCT) liver clinic at Grootte Schuur hospital. This will probably start at the end of September, 2016.

The coverage of the Step Up project is 650 people since the beginning of the project, 400 of whom use the service on regular basis (meaning they are seen every month during last 3 months). They do not provide any other office-based services like self-help groups as they don’t have enough place for that but they do organize monthly community advisory group meetings where current issues such as challenges with law enforcement or improper needle disposal are discussed. At these meetings, the clients provide their input on the project, and health education is done. Also, a few times a week, people could receive consultations on detox (an outreach worker supports clients in accessing detox, privately funded OST, in-patient treatment, and other health and psychosocial services). But, if they receive funding from the Global Fund grant, there is a plan to open the drop-in-center this year to be located in a separate building which will allow the Step Up project to expand the number of services it offers.

Step Up Project’s office

Step Up Project’s office

On a weekly basis, the project team collects dirty needles from the streets of Cape Town. Currently the Step Up Project collects and disposes approximately 10 000 per month, which includes those returned by the service beneficiaries as well as the approximately 1000 that they gather from the streets. There is a supplier who removes full sharps bins for incineration on a regular basis. There are volunteers from the community who work for approximately 2 hours to collect needles from the streets. The Step Up Project tries to involve community representatives in the work of the project as much as possible depending on their skills and abilities. They are initially involved in doing casual work (helping with cleanup) but are offered the possibility of increased involvement in other work such as peer education. This process is fairly new for the team.

During outreach anyone may receive one HR kit which includes 14 syringes unconditionally. If someone wants an additional kit, they can receive one in exchange for returning 10 used syringes. Since it not safe for drug users to carry used syringes (as police could use this to arrest them for “possession”), Step Up doesn’t require exchange for provision of syringes but uses the combined approach.

Police from time to time arrest the service beneficiaries and take the HR commodities from them.  The project team tries to build the relationships with police but the police don’t have any official policy toward harm reduction. The most negative experience was when the Chief of Police in one of the city districts refused to communicate with project and threatened to arrest the members of the outreach team for promotion of drug use. Also, there were a few cases when peer educators were arrested for possession of used syringes. But, in general, in the opinion of the project members there are no any major political barriers preventing the implementation of needle and syringe programming in South Africa.

Although OST is legal in South Africa, it is only available in private clinics and is not accessible for free for those in need. The level of coverage is very low. There is one short term (6 months) program in Cape Town that is available for free but it operates more like a prolonged detoxification program. Also, OST is available in a very limited geographic area (only the Mitchell’s Plein area). It is not possible to take Suboxone home; clients need to come every day for medication and other treatment e.g. counselling.

The main donors of the Step Up project are the CDC, PEPFAR and Mainline (a Dutch organization). They also receive some support from the government on a constant bases with additional episodic support. For example, the Department of Health provides them with test kits on a monthly basis, and occasionally also provides gloves and other materials. Once when there was a risk of interruption of in the supply of needles the government provided sufficient stock for them to continue service delivery until their normal supply could be resumed. No Global Fund funding at the moment is available, but they submitted an application to the principle recipient of GF grant and waiting for the decision. If it will be positive, they will have enough funding to ensure their work for the next three years.

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