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Page 3 of 34 Guideline

Executive summary Scope and purpose of the guidelines

We support public-health-focused interventions, as opposed • Review evidence of the harm reduction approach
to recovery-focused interventions. We support the • Briefly review the epidemiology of drug use and its
decriminalisation of drug use as much as we oppose the consequences
criminalisation of sex work, mandatory HIV disclosure and • Present clinical guidance for harm reduction interventions
policing of sexual preferences. aligned with the framework developed by the World
Health Organization
In South Africa, despite existing policy that embraces drug • Provide guidance around brief screening and
harm reduction, population- and individual-level interventions related to drug use
interventions have focused largely on the singular goal of • For each harm reduction intervention, provide: a
abstinence. This greatly impacts the human rights of people summary of evidence, main principles and links to related
who use drugs and their communities. The failure of guidelines
countries to implement comprehensive harm reduction • Highlight special considerations for young people who
measures violates their obligations in international human use drugs, women who use drugs, substance use and
rights law and public health. sexual encounters and drug use within prison settings
• Provide selected recommendations for stakeholders
These guidelines were developed to provide information engaged in the delivery of harm reduction services in
for healthcare workers working in the field of HIV and HIV, TB, viral hepatitis and related services.
related conditions to address gaps in knowledge around
drug use and build capacity around harm reduction and Audience
delivery of relevant evidence-based clinical interventions.
The guidelines include an emphasis on people who use These guidelines are aimed primarily at clinicians (doctors,
drugs who are at risk of experiencing harms relative to HIV, nurses and clinical associates). Other stakeholders who will
viral hepatitis and other related conditions. benefit from this guideline include pharmacists, HIV and
health programme officers and policymakers.
As with critical areas within HIV, the social context,
including social support, stigma and structural drivers such Methods
as employment, is important for health workers to
understand. Harm reduction requires clinicians to A core writing team developed these guidelines. The process
understand the broader context in which drugs are used by was informed by a review of evidence and guidance from the
their patients. The traditional ‘just say no’ approaches to World Health Organization. A stakeholder consultation was
drug use are as ineffective for drug use as they are for sex. held in August 2019, followed by international peer review.
Clinicians have an ethical obligation to their patients that Inputs and recommendations were included.
extends to being advocates for evidence-based harm
reduction. 1. Introduction
1.1 Harm reduction
Drug ‘harm reduction’ takes a pragmatic view that is
humane, effective, holistic and fundamentally concerned People have always used drugs to alter health, perceptions,
1
with the rights of people who use drugs, their socio- relationships and state of mind and this is not likely to
economic context and the provision of services that are change. Globally, in 2017, more than 271 million people had
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responsive, preventive and supportive. This approach also used unregulated drugs in the preceding year.
enhances the well-being of partners, family members and
society at large. The criminalisation of people who use certain drugs
increases levels of stigma, encourages misinformation and
Harm reduction approaches and related interventions are contributes to harms, including high rates of preventable
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supported by a large body of evidence. Explicit support for deaths. A purely biomedical approach – that presumes that
needle-and-syringe services is included in the South African all people who use drugs require treatment, and all drug
National Strategic Plan for HIV, TB and STIs (2017–2022), the use and dependence represents a disease requiring specialist
National Drug Master Plan (2019–2024) and the National medical intervention – carries the risk of stigma and often
Hepatitis Action Plan. A National Department of Health fails to pay due attention to the social and economic context
policy around opioid substitution therapy and related in which dependent drug use occurs. Criminalisation and
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clinical guideline is under development. the pathologisation of drug use may intensify social
disruption and hinder the provision of effective responses. 4
By integrating the guidelines in clinical practice, the quality
of care provided by clinicians to people who use drugs will Countries that have implemented comprehensive harm
be enhanced – benefitting individuals and communities of reduction programmes have managed to turn around
people who use drugs and broader society. epidemics of HIV and hepatitis C virus (HCV) infection.

http://www.sajhivmed.org.za 86 Open Access