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Page 6 of 34 Guideline

1.2.5 Drug-related harms 1.2.6 Reasons for drug use
The harms related to drugs are embedded in social and The reasons why people are using drugs outside of
structural circumstances, including stigma, which is often supervised medical care are poorly understood. The
driven by the illicit nature of drug use. For a variety of dominant discourses to explain this phenomenon are often
reasons, the production, sale and use of certain drugs are based on moral or political foundations rather than science.
restricted or highly regulated through international It is beyond the scope of these guidelines to provide a
agreements. People who use drugs, especially those who comprehensive analysis of the use of drugs. People use
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inject drugs, are vulnerable to several health issues including drugs for a range of reasons (Table 5), and many myths
HIV, viral hepatitis, cellulitis and infective endocarditis. exist in the context of clinical care around people who use
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drugs (see Appendix 1).
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People who use drugs are also at increased risk of developing
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tuberculosis (TB). Long-term smoking of drugs (including Chronic problematic drug use is largely caused by
cannabis, methaqualone or heroin), particularly amongst personal, social, cultural and political pain and suffering
people who also smoke tobacco products, can increase risks (and at times may also include psychological, physiological
for the development of chronic obstructive airways disease and legal issues). 33
and emphysema. 21,22 Globally, the incidence of HIV infection
has declined, yet infections amongst people who use drugs TABLE 5: Insights into reasons for drug use amongst people with unstable
housing, South Africa (2015). 31
continue to increase. 23
Reasons Comments
Trauma and loss ‘I grew up in an abusive family, being
The quantification of drug-related harms in South Africa, sexually abused by my grandfather and
having alcoholic parents.’
including HIV and viral hepatitis infections and overdose, ‘I lost my husband and the will to live.
Instead of killing myself outright I was
is inadequate. Table 4 provides a snapshot of available data. slowly killing myself with the taking of
drugs and once again to numb the pain
and to forget what I had lost in my life.’
TABLE 4: Overview of infectious disease prevalence and morbidity amongst Exclusion from society and connection ‘When my family rejected me because of
people who inject drugs (latest data). with other people who use drugs my gender of being a transwoman, I
started hanging out with people who
Health issue Mozambique (%) South Africa (%) Comments used.’
HIV 46 24 21 (8 – 56) 25,26 HIV prevalence estimates ‘The community calls us names and we
amongst people who inject are [a] disgrace to the society, people are
drugs in South Africa from very judgemental of us.’
major metropolitan areas Self-preservation and self-medication ‘I have got to the point where I no longer
TB ND ND consider what I am using to be drugs – it
is now a medicine.’
STIs 8 – 29 24 ND Self- reported genital ulcer ‘I do not feel well or function properly
HCV 67 24 55 26 unless I have had heroin. I need it to fuel
my creativity.’
HBV 32 – 36 24 5 26 ‘It keeps me warm on the street. It keeps
HIV–HCV 12 – 45 24 9 – 57 25 Includes HBV or HCV me awake for my service that I deliver as
a transgender sex worker.’
coinfection co-infection
Number of ND 10 17 Ten drug-related deaths
drug-related included in the formal BOX 8: Overlapping vulnerabilities and intersectionality.
deaths surveillance system, reported
in 2012 Many people engage in multiple activities that may increase their risk of being
Mental health ND ND Between a quarter and half exposed to HIV, STIs and viral hepatitis, as well as onward transmission of these
of patients with an opioid use infections (e.g. someone who injects drugs and also sells sex, or a man who has sex
disorder in public in-patient with other men and uses drugs in the context of sexual encounters). Furthermore,
substance use treatment some of the vulnerabilities that are related to social constructs may interact and
centres have been found to compound risk. Clinicians should avoid stereotyping people and openly enquire
have co-occurring mental about gender identity, as well as sexual and drug-using practices.
illness 27,28
STIs, sexually transmitted infections.
HBV, hepatitis B virus; HCV, hepatitis C virus; STIs, sexually transmitted infections; TB,
tuberculosis; ND, no data.
BOX 9: Harm reduction case studies.
Mauritius: In the 2000s, Mauritius had one of the worlds’ highest levels of opiate
BOX 6: Drug scheduling. use, and the HIV epidemic is highly concentrated amongst people who inject drugs.
The schedule of a drug determines the level of regulation and access. The WHO In 2006, it was the first African State to launch a needle-and-syringe service and
Expert Committee on Drug Dependence provides recommendations based on provide OST. Services have expanded and include OST provision within prison. In
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rigorous scientific review to the CND, which then decides on drug scheduling. 2020 there are 47 needle-and-syringe services sites (36 operated by the government
Scientific approaches to assess the relative risks of drugs do not inform the and 11 by civil society) with around 3000 clients. There are 44 OST sites (12 in Area
scheduling decided by the CND. The scheduling of drugs by the CND has historically Health Centres, 4 in prisons and 28 outside of police stations), servicing 5300
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been based on political agendas. For example, cannabis, LSD and MDMA are in the people. HIV incidence amongst people who inject drugs decreased from 92% in
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‘most dangerous’ schedule, but are linked to low levels of harm. 2005 to 31% in 2014. Opioid substitution therapy has enhanced the quality of life,
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family environment and self-esteem of OST patients. Moreover, during the same
CND, Commission on Narcotic Drug; LSD, lysergic acid diethylamide; MDMA, 3,4-methyl period, a decrease in criminality rates was observed, from 2650 cases in 2007 to
enedioxymethamphetamine; WHO, World Health Organization. 1085 in 2012. 36
Kenya: Kenya is recognised as a regional leader in the implementation of harm
reduction. Needle-and-syringe services were provided in five pilot sites between
BOX 7: Restricting access can render drugs more dangerous. 2012 and 2015 and saw a four-fold reduction in needle-sharing practices
Drugs are influenced by market forces, with supply developed to meet a (from 48% to 12%), drastically reducing HIV incidence amongst people who
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inject drugs. Methadone has been available since 2014, and by 2018, over
demand. Restricting access to potentially harmful drugs can make them more 2000 people across seven treatment sites were receiving OST. Programmes
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dangerous. Quality control is often absent in the illicit drug trade. For example, provide holistic HIV prevention and treatment, SRH and mental health services
although diamorphine and heroin are the same drug, street heroin is twice as for people who use drugs.
dangerous as morphine. That risk increases significantly if the heroin is
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contaminated with a stronger opioid like fentanyl. Furthermore, bulking agents Source: Mauritian case study developed by Kunal Naik; Kenyan case study developed by
are used to increase the volume of drugs to increase profit, some of which can Bernice Apondi
cause harm.
OST, opioid substitution therapy; SRH, sexual and reproductive health.
http://www.sajhivmed.org.za 89 Open Access