Connecting with Care – South Africa

It wasn’t long ago that the people of South Africa united to bring an end to apartheid. However today in the rainbow nation it seems that many of the country’s more marginalised community members have been forgotten and pushed to the fringes of society.

Across South Africa the stigma faced by people who use drugs is severe. On regular occasions, people who inject drugs are victims of violence and unlawful body and bag search’s carried out by law enforcement. At a societal level, it is still rare to find community or religious leaders advocating on behalf of people who use drugs. Despite advocacy from some civil society organisations and health professionals, there has been very little shift in national laws or policies to enable greater access to harm reduction services – specifically needle and syringe services and opioid substation therapy – and hepatitis C treatment.

 

 

“The most challenge that I’m facing is how people treat us. Especially we women that are using drugs. The stigma that we get from our communities, they don’t treat us like human beings.”

– Mmathapelo Semono, Harmless Client.

Limited Harm Reduction Services

Notwithstanding the evidence that people who inject drugs live in urban-rural areas across the country, harm reduction services are only available in a few major cities with opioid substation therapy limited to Cape Town, Pretoria and Johannesburg and needle and syringe programs available also in Port Elizabeth, Mbombela and Ekurhuleni.

“What I normally do on a daily basis when I come to work would be, I normally help out in the field by giving out needles. And I also do BCIs, behavioural change interventions, when we normally give out the needles. We’d normally tell people about safer injecting.” – Jacob Chunda, Harmless Peer Officer

Harmless peer officers Marko Bekker and Jacob Chanda catch up in the morning at the Harmless drop-in centre (DIC). Harmless is a project offering a range of services to marginalised and vulnerable communities in Pretoria. The services include peer based outreach, a mobile unit that goes out to service clients, needle and syringe distribution, collection and disposal, HIV counselling and testing, referral for antiretroviral therapy and HIV care and support, targeted information, education and communication for PWID and their sexual partners, prevention, screening and referral for diagnosis and treatment of TB, referral for drug use disorder treatment and Opioid substitution therapy (OST) therapy as well as screening and testing for hepatitis B and C where possible.

Needle and syringe programs are linked with psycho-social counselling and education on safer drug use and safer sexual practices. Around the world, harm reduction services have been proven to lower risks associated with the transmission of infectious diseases (specifically viral hepatitis and HIV) as well as overdose. Needle and syringe programmes have few barriers to access care, and are an entry point for some of the most marginalised members of society to access health and social services.

Opioid substitution therapy is another core element of HIV and hepatitis prevention. Of notable concern in South Africa is the limited availablility of methadone and buprenorphine ( the medications used for long-term opioid substitution therapy), due to single suppliers and very high cost. Advocacy efforts are ongoing to ensure methadone and buprenorphine are listed on the essential medicine list for use at all levels of care and for cost reduction.

Unfortunately, the misconception that harm reduction services promotes substance use is common among the broader society and among some people within government and health care providers. Despite the significant evidence, on the contrary, shifting these perceptions in the future is crucial to ensure greater investment in harm reduction services and to improve the health and wellbeing of people who use drugs.

Understanding Hepatitis C in South Africa

In 2016, global deaths caused by viral hepatitis surpassed all chronic infectious diseases including HIV/AIDS, malaria and tuberculosis. This global statistic is staggering. However, few studies investigating the prevalence of hepatitis C among people who use drugs have taken place in South Africa and other low and middle income countries.

To understand more clearly the country’s hepatitis C prevalence, TB HIV Care, the University of Cape Town, OUT Wellbeing, Anova Health Institute and the National Institute of Communicable Diseases

undertook a research project in 2016 that tested people who inject drugs across Cape Town, Durban and Pretoria to learn more about hepatitis C, HIV and hepatitis B among the community of people who inject drugs in these cities. From the 943 people tested, 43% were found to have hepatitis C infection; with the largest number of infections found in Pretoria. This study provided the first data

on these infections among people who inject drugs from three major South African cities and highlighted the high prevalence of hepatitis C among people who use drugs.

“The first time I found out about it was in 2016. I knew I was HIV positive, I tested for that I think in 2014. And then we had tests again during the 2016 year and what happened is they told me I’m dually infected, I’ve got hepatitis C and HIV. Of course there wasn’t any treatment available.”

– Marko Bekker, Harmless Peer officer

During an appointment, Saya talks with Dr Kirsty at the COSUP clinic in Daspoort area of Pretoria. Dr Kirsty works for the Community Oriented Substance Use Program (COSUP). COSUP is an initiative between the University of Pretoria’s Department of Family Medicine, the City of Tshwane (which funds the program), and the Gauteng departments of Health and Social Development. It aims to provide meaningful and effective community-based support for people who use, support or are affected by harmful substance use. It focuses on evidenced-based approaches aimed at restoring functionality, improving health and reducing the social destruction of harmful substance use. Despite the evidence that there are active populations of people who inject drugs in both urban centres and rural areas across the country, harm reduction services are only available in a few major cities of Cape Town, Pretoria and Johannesburg. Today in South Africa, people who use drugs face serious stigma, discrimination and human rights violations all of which limits contributes to their exclusion from society.

Charlene Matafin (black shirt) talks with Jennifer Smith. Charlene is a skills facilitator and a crucial member of TB HIV Care’s drop-in centre located in down-town Cape Town. Jennifer Smith is a client of TB HIV Care and has had challenges with substance use and homelessness for the past thirty years. Across South Africa people like Jennifer face stigma and ostracization on a daily basis. At a societal level it is still not common to find community and religious leaders advocating on behalf of people who use drugs and at a political level there has been very little shift in national laws or policies to enable greater access to harm reduction services, opioid substation therapy and hepatitis C treatment. TB HIV Care is one of the few organisations providing harm reduction services to people who use drugs. Their services include needle syringe exchange programs, access to psycho-social counselling and education on safe practices associated with using injecting equipment.

Currently, none of the direct-acting antivirals (DAA) – easy to take and well tolerated medications that cure hepatitis C infection – are registered. As a result they are not on the Essential Medicines List and are not widely available.

However small steps forward are emerging. In Pretoria, Sediba Hope Medical Centre in partnership with Doctors without Borders and the University of Pretoria’s Community Orientated Substance Use Programme is providing DAA treatment to a few hundred people living with hepatitis C, including Peer Officers Marko Bekker and Koketso Mokubane.

Koketso and Marko are among the first few patients taking DAA medications which is normally 1-2 tablets for just 3 months.

Krevasen Kanniappen and Koketso Mokubane catch up inside the Sediba Hope Medical Clinic in downtown Pretoria. Krevasen Kanniappen (blue shirt) is the Peer Coordinator and Koketso Mokubane a peer officer of the Community Oriented Substance Use Program (COSUP). COSUP is an initiative between the University of Pretoria’s Department of Family Medicine, the City of Tshwane (which funds the program), and the Gauteng departments of Health and Social Development. It aims to provide meaningful and effective community-based support for people who use, support or are affected by harmful substance use. It focuses on evidenced-based approaches aimed at restoring functionality, improving health and reducing the social destruction of harmful substance use. Despite the evidence that there are active populations of people who inject drugs in both urban centres and rural areas across the country, harm reduction services are only available in a few major cities of Cape Town, Pretoria and Johannesburg. Today in South Africa, people who use drugs face serious stigma, discrimination and human rights violations all of which limits contributes to their exclusion from society.

 

“It started in January of 2020, and then I was patient zero. I’m the first patient in the project. I’m so excited because there are many diseases out there you, you just get medication to manage them. But with hep C, you get cured. That’s why I’m so much excited, because I will be free of hep C because I’ll be free.”

– Koketso Mokubane, COSUP Peer Officer.

A Brighter Future for all

People who inject drugs are at high risk for hepatitis C, hepatitis B and HIV without accessible harm reduction programmes. In South Africa, coverage of needle and syringe and opioid substitution therapy (OST) services are well below global recommendations and to date no routine hepatitis C testing and treatment services exist.

When considering a response to the high rates of hepatitis C across the country, South Africa has significant experience with HIV that can assist the government in developing an appropriate response.

A brighter future for all South Africans must include marginalised communities such as people who use drugs. Investment in harm reduction services and hepatitis C treatment is crucial. Equally important is changing societal perceptions to reduce stigma towards people who use drugs and in turn push for political change that can lead to more progressive government policies towards harm reduction services and decriminalisation of drug use. However, this requires an ideological shift among many South Africans.

Dr Andrew Scheibe (left) meets with Hepatologists Dr Mark Sonderup and Professor Wendy Spearman from the Liver Clinic in Cape Town. Dr Andrew Scheibe undertook a research project in 2016 that tested people who inject drugs across Cape Town, Durban and Pretoria to learn more about hepatitis C, HIV and hepatitis B among the injecting community. From the 943 people tested, 43% of people tested were positive with hepatitis C with Pretoria having the highest average rate among the three cities. These results were significant in that for the time in the country, data from three major South African cities all pointed to the reality that the country does have a high prevalence of hepatitis C among people who use drugs.

 

“I believe we are sitting at a juncture in South Africa and unless you actually realize that if you don’t climb in now, the longer you sit on your hands and do nothing, it only becomes a bigger problem. We learnt the hard way with HIV. We must not do the same error.”

– Dr Mark Sonderup, Hepatologist, Groote Schuur Hospital Liver Clinic and University of Cape Town.

An African Declaration

INHSU Africa 2020 was the first event of its kind to bring together regionally-based advocates, policy champions, civil society leaders and representatives of the community of people who use drugs, to highlight best practices and contribute to enhancing drug user health and the elimination of HIV and hepatitis C in Africa.

At this historic meeting an African Declaration was made to eliminate hepatitis C and improve the health of people who use drugs.

 

 

The Africa Declaration calls on African political leaders and all global partners to:

  • Scale up harm reduction services
  • Make health services accessible for people who use drugs
  • Support community empowerment and community-based programmes
  • Improve access to affordable diagnostics and medicines
  • Eliminate stigma, discrimination and violence
  • Reform drug policies
  • Enhance funding for harm reduction and hepatitis C elimination efforts.

 

Photos, story and images by visual storyteller Conor Ashleigh https://www.conorashleigh.com/