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face now: fear, exclusion, stigma, prejudice, disregard of The policy landscape in South Africa has shifted, and for the
human rights, science and compassion. first time, harm reduction is described in the National Drug
Master Plan. However, this needs to be backed by political
Instead, there is the terribly misplaced invocation of the determination. We must replace the misplaced abstinence-
criminal justice system. There is an underlying and deep- based approach with an approach proven to help reduce the
rooted belief that deviance must be punished. The crude consequences of using unregulated drugs.
remedies that inflicted apartheid are reassigned to persecute
people who use drugs (the same is true in the case of sex Without addressing the underlying motivators, addressing
workers and people not conforming to traditional gender drug use in isolation will seldom help.
constructs). Criminalising people who use drugs is a
damaging distraction from the most effective means we have The guidelines are, therefore, more than a simple set
to reduce the consequences of drug use: harm reduction. of algorithms or treatment regimens. They describe the
reasons why people may develop problematic drug use,
Harm reduction is a practical and rights-informed approach the systemic and contextual issues, psychosocial and
to assist people in reducing drug-related harms and to biomedical intervention and evidence-based approaches for
support them in changes they seek to make. more vulnerable populations.

Conceived in the 1980s, from the imperative to stop the rapid Even amongst clinicians, there are gaps in understanding
spread of HIV amongst people who use drugs, the harm people who use drugs and their medical needs. The guidelines
reduction movement has been fostered by HIV activists and are timely and well-directed, in supporting clinicians who
HIV clinicians.
engage with and treat people who use drugs. It is imperative
that they are used and disseminated widely.
Therefore, it is fitting that SAHCS leads. These harm reduction
guidelines embody empirically indicated and rights-respecting
doctrine in both decriminalising drug use and adopting best South Africa is burdened in many areas by shame, including
8
clinical practice to reduce the spread of HIV and other blood- internalised shame and stigma. These hobble the power of
borne viruses amongst people who use and inject drugs. people to act fully as citizens; they isolate people and allow
anger and fear to amass.
The guidelines make sound sense. Not only do they build on
the statement supporting the decriminalisation of the use of The notion that all people who use drugs are selfish, dishonest
certain drugs, but they also take a public health approach or powerless risks becoming self-fulfilling. These guidelines
rather than an abstinence and recovery-focused approach. counter internalised stigma by including the voices of people
Also, they take into account the context, that is, what who use drugs. This step is not radical. It is elementary. And
components drive the dependent and habitual use of drugs? essential.
Valuable lessons we learned from the response to HIV apply These guidelines are most welcome. They afford an essential
to people who use drugs. Whilst people who use drugs may scientific, pragmatic and effective patient-centred resource
need health services, pathologising them inflicts significant for clinicians. They fill a critical gap in our response to HIV.
stigma and exclusion. Their sound professionalism and evidence-based wisdom
will contribute to the policy shifts we critically need, if South
We fail in our response to people who use drugs by Africa’s response to people who use drugs is to meet the
simplistically depicting them as either prisoners or patients. standards of the Constitution.
They are first and foremost people, who have the
constitutionally enshrined right to be treated with dignity Acknowledgements
and to receive the highest standard of care available.
The author would like to thank Shaun Shelly for assistance in
conducting this research.
The lessons are clear. Countries that have embraced the
principles of harm reduction have seen a reduction in the
rates of HIV infection. They have benefited from lower Competing interests
overdose deaths and reductions in the adverse health, social The author declares that no competing interest exists.
and economic consequences from the use of drugs. 7

Of course, harm reduction is not without its critics, even Authors’ contributions
within the medical community. The counter-arguments proceed I declare that I am the sole author of this research article.
principally from moral axiom. The belief that people should be
abstinent from drugs is as misguided as the belief that HIV can Ethical consideration
be prevented by teaching people to abstain from sex. To deny
people harm reduction services echoes the damage that refusing This article followed all ethical standards for research without
to make condoms available futilely inflicted. direct contact with human or animal subjects.

http://www.sajhivmed.org.za 82 Open Access