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DRUG USE, HIV AND HARM
REDUCTION IN AFRICA
Isidore S. Obot
Professor, Department of Psychology,
University of Uyo
& Director, Centre for Research and
Information on Substance Abuse (CRISA)
Uyo, NIGERIA
21st International AIDS Conference, 18-22
July 2016, Durban, South Africa
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Outline
•
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•
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•
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Drug use and drug policy in Africa
IDU and HIV
Responses to HIV among PWID
What is harm reduction?
The value of harm reduction
Support for HR and challenges to adoption and
implementation
• HR in post-UNGASS 2016 Africa
• Conclusion
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Drug policy in Africa
• Focus of drug control policy is on law enforcement
– In many countries drug control bodies are under the
supervision of Ministry of Justice not Health
– Success is measured in terms of arrests and seizures
– Laws are severely punitive; the “war on drugs” fuels the
HIV epidemic in various ways
• Policies are not guided by evidence of effectiveness
• There is inadequate availability of drug dependence
treatment and harm reduction services.
• Data on drug use and related problems are generally
lacking; reported estimates are largely unreliable.
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Drug use
• Cannabis and alcohol are the most consumed drugs in
Africa.
• Use of cannabis is much higher (12.4%) in West and
Central Africa than rest of Africa (7.6%) and globally
(3.9%).
• Cannabis is primary drug of abuse among people in
treatment for drug use disorders.
• Less than 0.5% of adult Africans (15-64 years of age)
had used cocaine or heroin in the 2014 (WDR 2016).
• Use of amphetamine type stimulants (ATS) is growing
(especially injection of methamphetamine).
• Increasing use of opioid analgesics reported in West
Africa (especially tramadol, Pentazocine, and codeine
containing cough syrups).
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Annual prevalence of illicit drug use (2014)
in African Regions
Region
Cannabis
Cocaine
Opiates
Opioids
ATS
East
4.2
-
0.15
0.17
-
North
4.4
-
0.25
0.25
0.57
South
5.1
0.7
0.34
0.40
0.71
West &
Central
12.4
0.7
0.43
0.44
-
Total
7.6
0.4
0.31
0.33
Source: WDR 2016
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Injecting drug use
• Globally 12 million drug users have injected (WDR 2016)
• More than 1 million people in Africa report injecting drugs;
Prevalence of injection: 0.16% (global – 0.26%)
• First assessment of IDU in Nigeria in 2000 (1 city), with
studies in 2003 (3 cities), and 2006 (5 cities).
– 23% of 546 drug users in five cities had injected at least
once; significant increase over previous years.
– Drugs injected were heroin, pentazocine, cocaine.
– Profile of injector: male (90%), mean age of 31 years,
single (60%), self-employed, less than secondary school
education (54%), 30% had been in jail.
– No strong association of IDU with HIV then (and now).
• Injecting reported in many other African countries
with significant populations of PWID in South Africa,
Mauritius, Kenya, Tanzania, Senegal, Mozambique
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Estimates of People who inject drugs in
African Countries
Country
Seychelles
Senegal
Mauritius
Nigeria
Kenya
Tanzania
South Africa
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No. PWID
345
1324
10,000
11,692
18,327
30000
67000
HIV among PWID
Globally 12 million people injected a drug in 2014. “Among
people who inject drugs, one in seven [14%] is living with
HIV and one in two [50%] is living with hepatitis C” (WDR
2016)
• An estimated “140,000 … people who inject drugs were
newly infected with HIV globally in 2014” (UNAIDS 2016)
• Number of HIV cases among PWID in Africa:
112,000
• Prevalence: 11.2%
• Women who inject drugs are much more likely than
men to be HIV+.
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Prevalence of HIV among PWID in
Africa
Country
Seychelles
Senegal
Mauritius
Nigeria
Kenya
Tanzania
South Africa
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No. PWID
HIV%
345
1324
10,000
11,692
18,327
30000
67000
5.8
9.1
44.3
4.2*
18
33.9
19.4
Incidence of HIV infection among PWID and
population size estimate (2014)
Region
Eastern and
southern Africa
Middle East and
North Africa
Western and
central Africa
Incidence per
year (%)
2.9
Population size
estimate
333,000
1.2
462,000
1.4
155,000
Source: UNAIDS, 2016
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Harm Reduction
Response to HIV Among PWID
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What is Harm Reduction?
"Policies and programs which attempt
primarily to reduce the adverse health, social
and economic consequences of mood altering
substances to individual drug users, their
families and communities, without requiring
decrease in drug use." (IHRA)
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Harm Reduction Interventions
In HR, the focus is not on eliminating drug use but on reducing
the health and social harms caused by drug use.
HR interventions include the following:
• Opioid substitution therapy (as in methadone maintenance
therapy),
• Use of other substitute medications, e.g., buprenorphine
• Needle and syringe programmes (community based and in
prisons),
• Bleach distribution
• Medical prescription of heroin
• Provision of safe injection sites/drug consumption rooms
• Overdose prevention (with naloxone)
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Comprehensive package of services,
endorsed by WHO, UNODC, UNAIDS
• Needle and syringe programmes
• Opioid substitution therapy and other evidence-based
drug dependence treatment
• HIV testing and counselling
• Antiretroviral therapy (for HIV)
• Prevention and treatment of sexually transmitted
infections
• Condom programmes
• Targeted information, education and communication
• Prevention, vaccination, diagnosis and treatment for viral
hepatitis
• Prevention, diagnosis and treatment of tuberculosis
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Availability of NSP and OST globally in
2014
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Number of countries with NSP and OST,
globally and in Africa, 2008-2014
Year
NSP, global
OST, global
NSP, Africa
OST, Africa
2008
2010
2012
2014
77
82
85
78
63
70
78
80
1
1
3
5
2
4
5
5
Source: HRI, 2014
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Number of PWID, prevalence of HIV and
availability of Harm Reduction
interventions in African countries
Country
Seychelles
Senegal
Mauritius
Nigeria
Kenya
Tanzania
South Africa
No. PWID
HIV%
NSP
avail.
No. of
NSP
Sites
OST
avail.
No. of
OST
sites
345
1324
10,000
11,692
18,327
30000
67000
5.8
9.1
44.3
4.2*
18
33.9
19.4
Y
Y
Y
Y
Y
1
52
10
7
1
Y
Y
Y
16
3
-
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Y
Y
“Harm reduction works”
“I feel better and look better than I did a few
months before coming here”
-- Client at CEPIAD, Dakar, Senegal
“I’m alive today because of harm reduction”
-- NGO representative at UNGASS
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The truth about substitution therapy
Participation in MM is associated with a large number of
desirable outcomes.
• Reduction in HIV risk behaviours, e.g, exposure to
infections
• Reduction in the use of heroin
• Longer stay in treatment
• Reduction by up to one-third in death rate compared to
people not in treatment,
• Higher employment rates and better income,
• Reduction in criminal activities of up to 50% after only
one year in treatment.
HR services serve as an entry points to treatment. There is
clear evidence it is effective and cost-effective and no
evidence it promotes drug use.
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WHO speaks
“There is overwhelming evidence that
increasing the availability and utilisation of
sterile injecting equipment to injecting drug
users contributes substantially to reductions in
HIV transmission, and that there is no
convincing evidence of major unintended
negative consequences of such programs”-WHO, 2004.
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Ribbon Cutting at Official Launch of the
Tanzanian MAT Programme, Feb. 2011
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Support for HR is growing
• Recent reports: Global Commission on Drug Policy, West
Africa Commission on Drugs, Lancet/JHU Commission
• Globally, growing number of countries support harm
reduction
• Endorsement of focus on health in addressing drug
problems
– Action Plans: ECOWAS and African Union
– National Master-plans (e.g., Nigeria NDCMP 2105-2019)
– UNGASS Common African Position
• Support from development partners and international
NGOs (e.g., IDPC)
• More interest in the role of drug use among HIV/AIDS
professionals
• Active role of CSOs and networks of NGOs
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Role of civil society
• One of the early efforts to introduce harm
reduction to African health professionals was in
1991 with the formation of a group in Nigeria.
• In October 2007 the IHRA helped launch the SubSaharan Africa Harm Reduction Network (SAHRN)
in Nairobi to promote HR in SSA; 10 countries were
represented.
• Today several coalitions, networks and youth
groups are active in harm reduction work
(informational, outreach) and policy advocacy.
• However, CSO capacity is generally weak;
strengthening these organizations is an essential
post- UNGASS 2016 activity.
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Hope for the Future:
HR in Africa post-UNGASS 2016
• Greater acceptance of a public health perspective on drug
control in African countries
• With more knowledge about HR fear will begin dissipate.
• Need for HR will grow with growing recognition of link of drug
use with HIV/AIDS, tuberculosis, hepatitis and other blood
borne infections.
• More overdose deaths and risky behaviours like “flashblood”
will lead to search for pragmatic solutions.
• The language of evidence is growing and might influence
acceptability of harm reduction services.
• More attention to the human rights of PWUD
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Many challenges remain
• Legal barriers to adoption and implementation of HR and
lack of policy frameworks that recognize HR as part of a
comprehensive package of care
• Cultural and moral attitudes which affect social
acceptability of treatment for drug problems and see HR as
“encouraging” drug use
• Stigma and discrimination which inhibit help seeking
behaviour and provision of care
• Continued denial that there is a drug problem or that the
problem is one that responds to natural interventions
• Doubts about the “effectiveness” of HR in Africa.
• General lack of manpower and opportunities to access
treatment and other types of intervention
• The disruptive role of law enforcement
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Conclusion
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Drug use will not be eliminated, but the harms associated with use can be
substantially reduced.
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Dependence is a biological condition influenced by psychological and social factors; it
is not “a failure of will or strength of character” (WHO, 2006, p. 248).
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The harm caused by psychoactive substances are dependent on how, where and how
much the substance is taken. Social response to each substance of abuse should take
into consideration the level of harm imposed on individuals and society by that drug.
•
Drug use and dependence are a public health problem. A public health approach calls
for support of harm reduction methods and discourages “rigid, judgmental attitudes
based on the concept of morality” (Goldstein, 2001).
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Drug policy should focus more on demand reduction as a strategy for controlling the
spread of drug problems in society. In selecting and implementing demand reduction
strategies, emphasis should be placed on those strategies that have been tested and
shown to be effective and not those that are merely attractive and easy to implement.
•
Several harm reduction services have been tested and found to be effective and cost
effective; there is no justification for not making these services available to people
who will benefit from them.
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Thank you
[email protected]
www.crisaafrica.org
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