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Background:
Opioids are a major global drug problem, impacting vulnerable populations. South Africa faces significant heroin use and injection drug use, despite national policies supporting opioid substitution therapy (OST) and harm reduction. However, public healthcare implementation of these strategies remains limited.
Description of model of care:
The NACOSA PWUD harm reduction program uses peers to deliver harm reduction in four South African provinces. Its methadone-based OST aims to reduce opioid dependence, HIV and hepatitis transmission, as well as the negative health and human rights outcomes among intravenous opiate users through a hybrid model of drop-in or clinic facility-based, and mobile outreach OST services in 5 districts. Effectiveness was assessed via a mixed-methods approach using routine programme data from 2019-2024, surveys, interviews, focus groups, and a contribution analysis model to map activities to outcomes.
Effectiveness:
The OST programme demonstrates effectiveness with high beneficiary satisfaction, shown by positive feedback (97.2%, m=317) and service uptake. However, methadone access faces regulatory and funding challenges. Beneficiaries value comprehensive care, yet desire economic empowerment (55%, n=180), transport support (47%, n=152), and community reintegration (39%, n=128). OST initiation rates are at (74.1% (95%CI 72.0-76.0), and on average PWID were retained on OST longer than PWUD, with a mean retention of 15.9 months (SD9.5). Dosing aligns with WHO guidelines, though variations exist (mean maintenance at 60-80mg). Take-home doses raise minimal diversion concerns (6.1%, n=20 sharing), pointing to the robust social support interventions. Treatment breaks are managed flexibly, but hospital and incarceration access remain problematic.
Conclusion and next steps:
Th OST programme has established a solid foundation of policies, interventions, and infrastructure, leading to substantial positive outcomes for beneficiaries, including enhancements in social functioning, health outcomes, and overall quality of life. The programme delivers value for money and offers a promising pathway towards long-term sustainability.
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