Trajectories of stimulant and opioid initiation in the context of sex work and HIV care in South Africa: A qualitative study

Background: Female sex workers (FSW) in South Africa remain heavily impacted by substance use, which can limit long-term engagement in HIV treatment. Understanding the timing of opioid and stimulant initiation in relation to sex work can inform strategies to address drug-related harms and improve HIV treatment outcomes.   Methods: In September-October 2024, we conducted 24 in-depth interviews with FSW living with HIV reporting past year substance use in Ehlanzeni and eThekwini, South Africa. Applying qualitative sequence analysis, we “re-storied” participant narratives to identify longitudinal patterns of opioid and stimulant initiation in relation to sex work entry, exploring common psychosocial and structural drivers.   Results: We identified four prominent opioid/stimulant initiation trajectories in relation to sex work, in order of prevalence: [1] sex work —> opioid use —> stimulant use; [2] opioid use —> sex work —> stimulant use; [3] sex work —> stimulant use; [4] sex work —> stimulant use —> opioid use. Poverty and trauma, especially the loss of financial security through familial death, were shared drivers of opioid initiation and sex work entry. Drivers of stimulant initiation were generally occupational (i.e. coping with job-related stressors, meeting client demand, and increasing work productivity). Secondary drug initiation commonly attenuated the effects of opioid or stimulant use (i.e., using opioids to counteract stimulant-induced hyperactivity, using stimulants to counteract opioid-induced sedation). Reported antiretroviral therapy adherence and timely appointment attendance were suboptimal across trajectories and frequently attributed to drug use.   Conclusion: These results suggest the need to tailor harm reduction services for FSW in South Africa, including screening for secondary drug use, adapting programs to be responsive to poly-drug use, and mitigating immediate and sustained risks associated with substance use. Future directions include optimizing HIV treatment programs through improved integration with harm reduction and substance use services. Disclosure of Interest Statement: No conflicts to disclose.

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