GUIDELINE

 

Southern African HIV Clinicians Society guidelines for harm reduction

 

 

Andrew Scheibe^{I, II}; Goodman Sibeko^III; Shaun Shelly^{I, II}; Theresa Rossouw^IV; Vincent Zishiri^V; Willem D.F. Venter^V

^ITB HIV Care, Cape Town, South Africa
^IIDepartment of Family Medicine, University of Pretoria, Pretoria, South Africa
^IIIDepartment of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
^IVDepartment of Immunology, University of Pretoria, Pretoria, South Africa
^VEzintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

Correspondence

 

 

Table of contents

Executive summary

1.Introduction

1.1 Harm reduction

1.2 Drugs and drug use

1.2.1 Patterns of use

1.2.2 Methods of drug use

1.2.3 Drug classifications and common drugs

1.2.4 Epidemiology of drug use in southern Africa

1.2.5 Drug-related harms

1.2.6 Reasons for drug use

1.2.7 The relevance of harm reduction

1.3 Stigma, discrimination and human rights

2.Evidence-based interventions

2.1 A guiding framework

2.2 Assessing a person's needs

2.2.1 Screening and brief intervention for common mental disorders and harmful substance use

2.2.1.1 Screening

2.2.1.2 Brief interventions

2.2.1.3 Referral for treatment

2.3 HIV prevention

2.3.1 Condoms and lubricant

2.3.2 Pre- and post-exposure prophylaxis

2.3.3 Voluntary medical male circumcision

2.4 Harm reduction interventions

2.4.1 Needle-and-syringe services

2.4.2 Opioid substitution therapy

2.4.3 Overdose services

2.4.4 Emerging and ancillary interventions

2.4.4.1 Harm reduction for people who use stimulants

2.4.4.2 Drug consumption rooms

2.4.4.3 Drug-checking services

2.5 HIV testing, treatment and care

2.5.1 HIV testing and counselling

2.5.2 Antiretroviral therapy

2.5.3 Prevention of mother-to-child transmission of HIV

2.6 Prevention and management of coinfections and comorbidities

2.6.1 Tuberculosis services

2.6.2 Viral hepatitis services

2.6.3 Mental health services

2.6.4 Sexual and reproductive health services

2.7 Critical enablers

2.7.1 Supportive law and policy

2.7.2 Countering stigma and discrimination

2.7.3 Enabling community empowerment

2.7.4 Acting against violence

3.Special considerations

3.1 Young people who use drugs

3.2 Women who use drugs

3.3 Substance use in the context of sexual encounters

3.4 Prison settings

4.Recommendations

5.Acknowledgements

Glossary

References

1.Appendix 1: Common myths about drugs use

2.Appendix 2: Assessing patients during first and subsequent encounters

3.Appendix 3: Guidelines for opioid substitution therapy

4.Appendix 4: Psychosocial and mental health interventions

 

Executive summary

We support public-health-focused interventions, as opposed to recovery-focused interventions. We support the decriminalisation of drug use as much as we oppose the criminalisation of sex work, mandatory HIV disclosure and policing of sexual preferences.

In South Africa, despite existing policy that embraces drug harm reduction, population- and individual-level interventions have focused largely on the singular goal of abstinence. This greatly impacts the human rights of people who use drugs and their communities. The failure of countries to implement comprehensive harm reduction measures violates their obligations in international human rights law and public health.

These guidelines were developed to provide information for healthcare workers working in the field of HIV and related conditions to address gaps in knowledge around drug use and build capacity around harm reduction and delivery of relevant evidence-based clinical interventions. The guidelines include an emphasis on people who use drugs who are at risk of experiencing harms relative to HIV, viral hepatitis and other related conditions.

As with critical areas within HIV, the social context, including social support, stigma and structural drivers such as employment, is important for health workers to understand. Harm reduction requires clinicians to understand the broader context in which drugs are used by their patients. The traditional 'just say no' approaches to drug use are as ineffective for drug use as they are for sex. Clinicians have an ethical obligation to their patients that extends to being advocates for evidence-based harm reduction.

Drug 'harm reduction' takes a pragmatic view that is humane, effective, holistic and fundamentally concerned with the rights of people who use drugs, their socio-economic context and the provision of services that are responsive, preventive and supportive. This approach also enhances the well-being of partners, family members and society at large.

Harm reduction approaches and related interventions are supported by a large body of evidence. Explicit support for needle-and-syringe services is included in the South African National Strategic Plan for HIV, TB and STIs (2017-2022), the National Drug Master Plan (2019-2024) and the National Hepatitis Action Plan. A National Department of Health policy around opioid substitution therapy and related clinical guideline is under development.

By integrating the guidelines in clinical practice, the quality of care provided by clinicians to people who use drugs will be enhanced - benefitting individuals and communities of people who use drugs and broader society.

 

Scope and purpose of the guidelines

•Review evidence of the harm reduction approach

•Briefly review the epidemiology of drug use and its consequences

•Present clinical guidance for harm reduction interventions aligned with the framework developed by the World Health Organization

•Provide guidance around brief screening and interventions related to drug use

•For each harm reduction intervention, provide: a summary of evidence, main principles and links to related guidelines

•Highlight special considerations for young people who use drugs, women who use drugs, substance use and sexual encounters and drug use within prison settings

•Provide selected recommendations for stakeholders engaged in the delivery of harm reduction services in HIV, TB, viral hepatitis and related services.

 

Audience

These guidelines are aimed primarily at clinicians (doctors, nurses and clinical associates). Other stakeholders who will benefit from this guideline include pharmacists, HIV and health programme officers and policymakers.

 

Methods

A core writing team developed these guidelines. The process was informed by a review of evidence and guidance from the World Health Organization. A stakeholder consultation was held in August 2019, followed by international peer review. Inputs and recommendations were included.

 

1. Introduction

1.1 Harm reduction

People have always used drugs to alter health, perceptions, relationships and state of mind¹ and this is not likely to change. Globally, in 2017, more than 271 million people had used unregulated drugs in the preceding year.²

The criminalisation of people who use certain drugs increases levels of stigma, encourages misinformation and contributes to harms, including high rates of preventable deaths.³ A purely biomedical approach - that presumes that all people who use drugs require treatment, and all drug use and dependence represents a disease requiring specialist medical intervention - carries the risk of stigma and often fails to pay due attention to the social and economic context in which dependent drug use occurs.³ Criminalisation and the pathologisation of drug use may intensify social disruption and hinder the provision of effective responses.⁴

Countries that have implemented comprehensive harm reduction programmes have managed to turn around epidemics of HIV and hepatitis C virus (HCV) infection. Overdose deaths are lower in contexts where harm reduction services are in place, compared with places where they are not. Harm reduction reduces the adverse health, social and economic consequences of drug use without necessarily reducing drug consumption.⁵ In 2018, 86 countries (11 in Africa) had at least one needle-and-syringe service and 86 (nine in Africa) had at least one opioid substitution therapy (OST) programme.

Harm reduction refers to policies, programmes and practices that aim to minimise negative health, social and legal impacts associated with drug use, drug policies and drug laws. Harm reduction is grounded in justice and human rights - it focuses on positive change and on working with people without judgement, coercion, discrimination, or requiring that they stop using drugs as a precondition of support. Harm reduction encompasses a range of health and social services and practices that apply to illicit and licit drugs. These include, but are not limited to, drug consumption rooms, needle and syringe programmes, non-abstinence-based housing and employment initiatives, drug checking, overdose prevention and reversal, psychosocial support and the provision of information on safer drug use. Approaches such as these are cost-effective, evidence-based and have a positive impact on individual and community health. (Harm Reduction International).⁶

Key points

•Harm reduction is an evidence, rights and public-health-based approach that reduces risks and improves the health and well-being of people who use drugs and the broader community.

•Long-term policies and interventions are needed to address structural factors that contribute to harms related to drug use.

 

 

Harm reduction principles for healthcare settings are listed.⁷

•Humanism: Care is given without moral judgement and with an understanding that choices are contextual.

•Pragmatism: The priority is the here and now, and the mitigation of immediate risk is what matters most.

•Individualism: People are different and have their own needs and strengths.

•Autonomy: People have a right to make informed choices, even against expert advice.

•Incrementalism: Any positive change is viewed as an improvement on current circumstances.

•Accountability without termination: People have the right to make choices, without their access to services being denied in relation to their decisions.

The application of these principles can improve patient-clinician relationships. The impact of harm reduction is increased through community engagement and peer-led services as well as removing barriers and increasing support.

Key points

•Harm reduction is an evidence, rights and public-health-based approach that reduces risks and improves the health and well-being of people who use drugs and the broader community.

1.2 Drugs and drug use

1.2.1 Patterns of use

Depending on the drug, 8% - 15% of people who use drugs develop a problem with their use. Drug use occurs along a continuum and can shift according to various factors (see Table 1).

1.2.2 Methods of drug use

Drugs can be taken by different administration modes, which can lead to different effects and varying degrees of harm. For instance, intravenous (IV) administration is associated with rapid onset and peak of action, with elevated risks: for opioids, this includes overdose and for stimulants, such as cocaine, this includes arrhythmia. Common methods of drug use are summarised here.

•Smoking is the most common form of use for cannabis, methaqualone (mandrax), heroin (whoonga, nyaope, sugars) and methamphetamine (tik, crystal meth) in southern Africa. Onset of action is faster than other forms of use. Risks are related to airways and pulmonary disease.

•Nasal inhalation (snort, schnarf, toot, sniff) is often used for cocaine, but also heroin. Onset of action is quick and is associated with risk of damage to the nasal mucosa.

•Injecting (slam, spike, smoke) can be done through several routes, most commonly IV. Heroin is the most injected drug, followed by methamphetamine and cocaine. Onset of action is very rapid. Risks are largely related to the use of contaminated injecting equipment and poor hygiene practices, including local and blood-borne infections (notably HIV, hepatitis B virus [HBV] and HCV). The risk of overdose is higher if drugs are injected. A proportion of people who use opioids and/or stimulants for a long period of time will transition to injecting.

•Oral ingesting (pop) is the most common route for gamma-hydroxybutyric acid (GHB), alcohol, methadone and ecstasy, amongst others. Onset is slower and risks may vary depending on the food or liquids consumed.

•Rectal suppository or vaginal (booty bumping) administration are less frequent methods of substance intake.

1.2.3 Drug classifications and common drugs

Drugs can be categorised into five broad classes according to their primary effects: stimulants, depressants, hallucinogens, cannabinoids and antipsychotics. An overview of common drugs is given in Table 2.

1.2.4 Epidemiology of drug use in southern Africa

As a result of the illegal nature of drug use and associated stigma, obtaining robust data on drug use is difficult and data are limited (see Table 3). It is therefore likely that estimates of reported use and risks are under-reported. Research reflects increased trafficking of heroin in the region and a review of substance use treatment data in South Africa points to a six-fold increase in heroin-related admissions over the last decade, with marked increases seen in methamphetamines and other stimulant-related admissions during the same period.¹³

 

 

 

 

 

 

 

 

 

 

1.2.5 Drug-related harms

The harms related to drugs are embedded in social and structural circumstances, including stigma, which is often driven by the illicit nature of drug use. For a variety of reasons, the production, sale and use of certain drugs are restricted or highly regulated through international agreements.¹⁸ People who use drugs, especially those who inject drugs, are vulnerable to several health issues including HIV, viral hepatitis, cellulitis and infective endocarditis.¹⁹ People who use drugs are also at increased risk of developing tuberculosis (TB).²⁰ Long-term smoking of drugs (including cannabis, methaqualone or heroin), particularly amongst people who also smoke tobacco products, can increase risks for the development of chronic obstructive airways disease and emphysema.^21,22 Globally, the incidence of HIV infection has declined, yet infections amongst people who use drugs continue to increase.²³

The quantification of drug-related harms in South Africa, including HIV and viral hepatitis infections and overdose, is inadequate. Table 4 provides a snapshot of available data.

 

 

 

 

 

 

1.2.6 Reasons for drug use

The reasons why people are using drugs outside of supervised medical care are poorly understood. The dominant discourses to explain this phenomenon are often based on moral or political foundations rather than science. It is beyond the scope of these guidelines to provide a comprehensive analysis of the use of drugs. People use drugs for a range of reasons (Table 5),³¹ and many myths exist in the context of clinical care around people who use drugs (see Appendix 1).³²

 

 

Chronic problematic drug use is largely caused by personal, social, cultural and political pain and suffering (and at times may also include psychological, physiological and legal issues).³³

 

 

 

 

1.2.7 The relevance of harm reduction

It will take a long time to affect a significant reduction in the number of drugs used, and the harms caused because this requires structural reform, which is explored later. The historical focus on abstinence and law enforcement has been ineffective and resulted in significant harm. Harm reduction is an effective public health intervention. It keeps people alive and reduces drug-related morbidity. For individuals, harm reduction aligns with the tenets of medical ethics in that it is beneficent and patient centred. It takes a longer-term view and helps people meet their goals in a stepwise manner. Specific harm reduction interventions relevant to people who use drugs are covered in the section 'Evidence-based interventions'.

Key points

•People use drugs for many reasons, in an array of circumstances and contexts and this cannot be modified rapidly.

•Not all drug use is harmful.

•Addressing drug use in isolation will seldom result in a sustained resolution, unless the underlying motivators are addressed.

•People use drugs in different ways; drugs are mostly smoked in South Africa, but injecting is becoming more prevalent.

•Drug-related risks and effects depend on the drug, (mind-)set and setting.

•The use of opioids and amphetamine-type stimulants in the region is increasing.

•In the context of criminalisation, many people who use drugs enter and exit the criminal justice system, placing them at risk for HIV and other infectious diseases.

•The burden of HIV, viral hepatitis and TB amongst people who use drugs in the region is high.

1.3 Stigma, discrimination and human rights

Stigma is a process of exclusion; it occurs when a person - or group of people - are tainted or disgraced. When people perceive themselves as being stigmatized, they may also come to hold the same negative perceptions about themselves, leading to an internalization of stigma and acceptance of a 'spoiled identity'.³⁷

Stigma, misinformation and the lack of evidence-based harm reduction approaches are major contributing factors to the vulnerabilities people who use drugs face. Stigma is often not prioritised by healthcare professionals, yet has a profound effect on the relationships between clinicians and their patients.³⁸

The use of non-stigmatising language can enhance relationships with patients and clinical outcomes. Table 6 outlines alternative supportive language to use.

 

 

'Stigma in health facilities undermines diagnosis, treatment, and successful health outcomes. Addressing stigma is fundamental to delivering quality healthcare and achieving optimal health.'³⁹

The International Network of People Who Use Drugs (INPUD) recognises that language cannot be regulated, and that context can transform a term that is used to oppress into one through which emancipation is pursued … Ordinarily, however, language that may denigrate, is best avoided.⁴⁰

Discrimination, which is the enactment of stigma, also needs to be addressed and the rights of all people secured. Many governments in the region have signed the International Covenant on Economic, Social and Cultural Rights,⁴⁰ which outlines the range of rights that are relevant to people who use drugs in health settings. Some of the relevant rights are: the right to self-determination (Article 1); the right to non-discrimination based on race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth or other status (Article 2); and the right to enjoy the highest attainable standard of physical and mental health (Article 12). People who use drugs experience frequent violation of these rights, which increases the harms of drug use - including confiscation of sterile injecting equipment and medication that forms part of substance use disorder treatment or other health conditions.⁴¹

Key points

•People who use drugs frequently experience stigma, discrimination and human rights violations, which negatively affect their health and well-being.

•The use of appropriate language is an important component of providing support services.

 

2. Evidence-based interventions

2.1 A guiding framework

These guidelines are built upon the framework set out in the WHO Consolidated Guidelines on HIV Prevention, Diagnosis, Treatment and Care for Key Populations,¹⁹ including health sector interventions (Table 7) and critical enablers (Table 8).

 

 

2.2 Assessing a person's needs

The screening for substance use and offer of assistance for potentially harmful substance use can take place in a range of clinical scenarios (see Appendix 2). The integration of screening for substance use and mental health conditions, linked to brief interventions and referral for further treatment, is often the first step in supporting people within a harm reduction approach and is outlined here.

2.2.1 Screening and brief intervention for common mental disorders and harmful substance use

Substance use disorders fall into the category of common mental disorders. Harmful alcohol and other drug use and other mental health disturbance may result in an increased risk of contracting HIV and in substantial health problems amongst people living with HIV. However, it is important to note that most people who use drugs do so on an occasional basis and will not develop a substance use disorder (dependence). For this group, there may be little need for high-intensity interventions. Screening for other common mental disorders including depressive disorders and anxiety disorders should also be performed. These may arise because of psychosocial distress that may be related to the HIV diagnosis or as a consequence of infective processes, which may be primary or secondary in a patient living with HIV. Identification of these is essential as they may impact on clinical outcomes and capacity to adhere to ART. Appropriate treatment is likewise freely available, so there is no need for patients to suffer. Suicidal screening should form part of this assessment because of its association with common mental disorders and the particularly high risk within this population.⁴²

Screening, brief intervention and referral to treatment (SBIRT) for harmful substance use is an evidence-based approach to improve the detection and early intervention of harmful substance use to prevent or address dependence.⁴³ The three core components of SBIRT are (1) universal screening, followed by (2) risk triaging, to determine (3) the appropriate level of intervention and/or referral to specialty assessment and care (Figure 1).

 

 

2.2.1.1 Screening: Screening people at risk for, or living with, HIV for harmful alcohol and/or drug use is crucial and can be performed in a myriad of settings including consulting rooms, emergency units, hospital wards and community settings (see Appendix 2). Screening tools such as the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST)⁴⁴ and Alcohol Use Disorders Identification Test (AUDIT) make use of risk categories determined by screening scores to help determine the ideal intervention strategy (Table 9). Additional alternative validated tools are listed in Appendix 2.

 

 

2.2.1.2 Brief interventions: A brief intervention is a short (time-limited), often opportunistic, patient-centred strategy, where a healthcare provider provides targeted information and/or advice to individuals during the course of other health activities such as routine outpatient review or HIV testing.⁴⁵ The aim of the interaction is to increase insight and awareness of harmful substance use to facilitate a patient's motivation to modify risky behaviour. Brief interventions thus seek to reduce drug use and associated behaviours, which increase the risk of contracting or transmitting HIV, for example, risky sexual behaviour and unsafe drug injecting practices. There is little difference in the outcomes between longer, more intensive interventions and brief interventions; and brief interventions are practical, cost-effective and have a growing evidence base.^46,47

Behavioural interventions, self-regulation coaching and psychosocial counselling can support HIV harm reduction and other HIV prevention objectives for people who use substances, whilst also contributing to longer-term and broader health and wellness goals.^48,49 Brief interventions should be provided to people with moderate-to-high risk and above substance use. Clinical guides or steps for the use of common interventions follow, with details in Appendix 2.

 

 

 

 

Elements of brief interventions may be aligned to the stages as outlined in Table 10. It is important to remain mindful of patient's social and economic context, an element some reviewers have flagged as not necessarily accounted for by strictly following these stages.

 

 

2.2.1.3 Referral for treatment: People with severe risk/dependency, as identified by a screening tool, require additional and more intensive support. If these are not provided by the person conducting the screening, then the patient should be referred for further assessment and management by a substance use disorder specialist at an appropriate facility.

 

Table 11

 

2.3 HIV prevention

2.3.1 Condoms and lubricant

 

Table 12

 

2.3.2 Pre- and post-exposure prophylaxis

 

Table 13

 

2.3.3 Voluntary medical male circumcision

 

Table 14

 

2.4 Harm reduction interventions

2.4.1 Needle-and-syringe services

 

Table 15

 

 

 

 

 

 

 

2.4.2 Opioid substitution therapy

 

Table 16

 

 

 

 

 

 

 

 

 

 

Box 19

 

 

Box 20

 

2.4.3 Overdose services

 

Table 17

 

 

Figure 2

 

 

Box 21

 

 

Box 22

 

 

Box 23

 

2.4.4 Emerging and ancillary interventions

Several additional interventions are important as part of comprehensive harm reduction. Some are briefly provided below, including (1) harm reduction for people who use stimulants, (2) drug consumption rooms and (3) drug checking services.

2.4.4.1 Harm reduction for people who use stimulants: Cocaine, methamphetamine (tik, ice), methcathinone (cat) and MDMA (ecstasy) are the most common unregulated stimulants seen in southern Africa, and methylphenidate is the most prescribed stimulant.

Simple harm reduction advice for people who use stimulants is to follow a few steps.

•Avoid the concurrent use of alcohol and cocaine. Cocaine use potentially compromises the cardiovascular system and is linked to several cardiovascular diseases; this risk increases with the concurrent use of alcohol.

•Rest: Sleep deprivation and stimulant use increase the chance of psychosis. People on stimulants often binge for days. People using stimulants should be encouraged to lie down in a dark space, with eyes close and relax for at least 3-4 h every 24 h.

•Hydrate: People using stimulants may be at risk of dehydration. People should be encouraged to drink 500 mL water per hour, especially if dancing.

•Eat: People using stimulants should be encouraged to eat something at least every 24 h, even if not hungry.

•Dental care: Sip water when the mouth is dry and brush teeth twice a day.

Other relevant harm reduction interventions include psychosocial support, condoms and lubricants (amphetamine-type stimulants can increase sex drive and risky sexual practice) and drug paraphernalia distribution (injecting and/or smoking kits that include mouth pieces for crack pipes), services for sexually transmitted infections, income generation and housing support. Substitution therapies for stimulant use disorders are under investigation.

2.4.4.2 Drug consumption rooms: Drug consumption rooms (also known as safe injecting facilities, medically supervised injecting sites or overdose prevention sites) are protected places for the hygienic consumption of drugs in a non-judgemental environment. They allow people to use drugs under medical supervision or in the presence of trained and equipped peers,⁸⁹ enabling an immediate response to overdose and decreasing the transmission of blood-borne diseases through access to sterile injecting equipment and education on safe injection practices.⁹⁰ Drug consumption rooms increase uptake of other health services and are an entry into care, for example, facilitating access to HIV, viral hepatitis, TB testing and treatment services and counselling.⁹⁰ In 2018, 11 countries were operating drug consumption rooms across 117 sites.⁵ An overview of drug consumption rooms is available at: http://www.drugconsumptionroom-international.org.

 

 

2.4.4.3 Drug-checking services: A means to check the quality and purity of drugs should be available to people who use drugs. This includes fixed site testing and on-the-spot testing options, the latter being mostly qualitative tests.⁹¹ For example, strips designed to identify fentanyl in drugs may help to prevent overdoses. People who use opioids can use the results of the test kit strip to inform their drug use (i.e. to use slowly, to reduce the volume of drug, to use in the company of others, to have a naloxone rescue kit nearby or not to use the substance). Test kits can be used on crushed pills or powders.⁹² Guidance around the use of fentanyl test strips is available at: https://harmreduction.org/issues/fentanyl.

Key points

•Harm reduction requires engaging with patients to identify immediate risks and develop means to reduce these.

•Screening, brief intervention and referral for treatment is an effective approach to detect and intervene in harmful substance use.

•Needle-and-syringe services are the cornerstone of HIV prevention for people who inject drugs and should be provided at all contacts with health services.

•People who inject drugs should be supported to return their used injecting equipment and locations for safe disposal of used equipment should be made widely available.

•Opioid substitution therapy is the most effective treatment for opioid use disorder. Effectiveness is maximised when patients are supported and provided with an optimal dose of medication. Voluntary psychosocial services can improve outcomes. Safety risks are greatest early on during treatment, and patients who are stable should be considered for take-home dosing. Treatment should be long term.

•Good supply chain and stock management are important to minimise diversion of opioid agonist medications.

•Opioid overdoses cause many deaths and are preventable. People likely to witness an opioid overdose should be trained to identify and respond to this, and access to naloxone should be maximised.

2.5 HIV testing, treatment and care

2.5.1 HIV testing and counselling

 

Table 18

 

2.5.2 Antiretroviral therapy

 

Table 19

 

2.5.3 Prevention of mother-to-child transmission of HIV

 

Table 20

 

Key points

•People who use drugs should be informed of their rights to confidentiality and consent and their right to refuse HIV testing if they choose.

•Uptake and retention in care are improved where ART is integrated with OST when needed.

•Pregnant women living with HIV who are not on ART should be enrolled on an ART programme urgently.

•Needle-and-syringe programmes and other evidence-based harm reduction services should be offered to all people who use drugs, irrespective of their HIV status.

•All people who use drugs and who are found to be HIV-negative should be provided with risk reduction information and commodities tailored to their substance use (considering their patterns and type of substance, etc.) and sexual practices.

•People who use drugs and who test HIV-negative should test regularly (every 6 weeks to 3 months) depending on their risk profile.

•An individual with a discrepant HIV test result should be referred for re-testing in 14 days.

•If a person comes for HTS within 72 h after a potential exposure, then PEP should be considered⁵² (see section 'Pre- and post-exposure prophylaxis')

2.6 Prevention and management of coinfections and comorbidities

2.6.1 Tuberculosis services

 

Table 21

 

2.6.2 Viral hepatitis services

 

Table 22

 

2.6.3 Mental health services

 

 

2.6.4 Sexual and reproductive health services

 

 

2.7 Critical enablers

2.7.1 Supportive law and policy

Clinicians, programme managers and policymakers should work together to support the decriminalisation of drug use, as well as sex work, to reduce health risks related to arrest, detention and incarceration and ensure the protection of rights.

Interventions and support to reduce drug dependence should ideally consist of a continuum of care, starting with early development strategies focusing on the delay of drug use and prevention strategies, moving to early-use interventions such as brief interventions and information. More intensive interventions should be reserved for people with dependencies that cause significant impairment.⁸⁵ A supportive and effective continuum and continuity of care service requires supportive policies. The criminalisation of people who use drugs often disrupts the provision of a continuum of care, by seeing all drug use as a criminal act, thus disrupting the continuity of services through arrest and incarceration and accelerating the development of drug dependence.^103,104 Considering the additional economic, health, social and psychological harms associated with the criminalisation, arrest and incarceration of people who use drugs, there should be a robust debate on the decriminalisation of the use of drugs and advocacy for the provision of services for incarcerated populations. The Southern African HIV Clinicians Society supports the decriminalisation of drug use: https://sahivsoc.org/Files/2019-06-03%20Drug%20Use%20%20Decrim%20statment.pdf

Clinicians should take on an advocacy role for: better care based on evidence for people who use drugs; human rights for people who use drugs; harm reduction approaches that include the activities described earlier, as well as access a safe supply of opioids (see the text Box 26 on safe supply). Clinicians should also advocate for the evaluation of current policies regarding illicit drug law and enforcement.

2.7.2 Countering stigma and discrimination

Clinicians and public health leaders should work with civil society organisations and networks of people who use drugs to monitor stigma and discrimination and advocate to change punitive legal and social norms. The development of a stigma index that includes people who use drugs and other people engaged in illegal and/or stigmatised practices could be developed to quantify stigma and measure changes over time.

 

 

 

 

Clinicians should ensure that the health services they provide are available, accessible and acceptable to people who use drugs.

Approaches to rendering services friendly to people who use drugs and other key populations:

•Ensuring adequate training of staff and develop supportive attitudes towards people who use drugs

•Integrating health services

•Providing services at times that suit patients

•Locating services strategically where patients congregate or transit

•Involving peers in the planning, promotion, delivery and monitoring of services

•Taking steps to ensure law enforcement does not interfere with access to services

2.7.3 Enabling community empowerment

Clinicians, public health leaders and civil society organisations can support the empowerment of people who use drugs by enabling their active participation in the planning and implementation of services, with a focus on peer education and training on safer drug use, harm reduction and broader issues relating to their rights and health.

2.7.4 Acting against violence

People who use drugs are at high risk for physical, sexual and psychological violence. This violence increases their risk for HIV and viral hepatitis and negatively affects their mental health. Many people who use drugs have been traumatised through their engagement with law enforcement and entry into the criminal justice system. Women who use drugs are at particularly high risk of violence and its effects.

Clinicians, public health leaders and civil society organisations should aim to prevent violence affecting people who use drugs, which can include engagement with law enforcement to sensitise them to the issues and their role to uphold the rights of all people.

The occurrence of violence should also be monitored and reported and mechanisms to access redress explored.

Clinicians should provide clinical care and initial psychological support to survivors of violence, with referral for additional support when needed. Processes following instances of rape should follow local guidelines.

There is strong evidence linking structural inequities to accessing health services with a higher risk of HIV infection, as well as continuing or everyday intimate partner- and gender-based violence.^107,108 Structural inequities in access to services hold true particularly for people who use licit drugs in countries where drug use has been criminalised and where no harm reduction services exist. To address the concerns emerging from the many interacting aspects of violence, trauma and substance use, harm-reducing systems of care need to integrate with other primary healthcare services.¹⁰⁹ Linking harm reduction services to services such as sexual and reproductive health (SRH) services, including sexually transmitted infection (STI) prevention services, and supportive primary care would allow for more effective harm reduction programming.

 

3. Special considerations

3.1 Young people who use drugs

 

 

 

Box 27

 

3.2 Women who use drugs

 

Table 26

 

 

Box 28

 

 

Box 29

 

3.3 Substance use in the context of sexual encounters

 

Table 27

 

3.4 Prison settings

 

Table 28

 

4. Recommendations

This section summarises the key role of critical stakeholders in the delivery of harm reduction services in HIV, TB, viral hepatitis and related services.

 

Table 29

 

 

Box 30

 

5. Acknowledgements

Additional inputs received from Lize Weich, Tanya Venter, Johannes Hugo, Urvisha Bhoora, Magriet Spies, Rafaela Rigoni, Cara O'Conner, Julia Samuelson, Viriginia Macdonald, Michelle Rodolph, Shona Dalal, Nurain Tisaker and Shaheema Allie. Regional harm reduction case studies developed by Kunal Naik (PILS, Mauritius) and Bernice Apondi (VOCAL, Kenya).

Inputs from the guideline development workshop held in August 2019 are also included. Participants of the workshop included: Leora Casey, Andrew Gray, Harry Hausler, Signe Rotberga, Muhangwi Mulaudzi, Lauren Jankelowitz, Annette Verster, Busisiwe Msimanga-Radebe, Nontsikelelo Mpulo, Zukiswa Ngobo, Mpho Maraisane, Rogerio Phili, Kgalabi Ngako, Maria Sibanyoni, Yolanda Ndimande, Valencia Malaza, Johannes Hugo, Urvisha Bhoora and Cara O'Conner.

We extend our thanks to the external reviewers, including Julie Bruneau, Annette Verster, Kunal Naik, Nkereuwem William Ebiti and Ali Feizzadeh.

Competing interests

The authors confirm that no competing interests exist.

Authors' contributions

All authors contributed equally to this work.

Ethical consideration

This article followed all ethical standards for research without direct contact with human or animal subjects.

Funding information

No specific grant was received from any funding agency in the public, commercial or non-for-project sectors.

Data availability statement

Data sharing is not applicable to this article as no new data were created or analysed in this study.

Disclaimer

Specific recommendations provided here are intended only as a guide to clinical management, based on expert consensus and best current evidence. Treatment decisions for patients should be made by their responsible clinicians, with due consideration for individual circumstances. The most current version of this document should always be consulted.

The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official position of any affiliated agency of the authors.

 

Glossary

 

Table

 

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114.Auerbach JD, Smith LR. Theoretical foundations of research focused on HIV prevention among substance-involved women: A review of observational and intervention studies. J Acquir Immune Defic Syndr [serial online]. 2015 Jun 1;69 Suppl 2(3):S146-S154. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25978481        [ Links ]

115.UNODC. Were you really raped, or did you just not get paid? A needs assessment of women who use drugs in fourn cities in South Africa. Pretoria: United Nations Office on Drugs and Crime; 2019.         [ Links ]

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Correspondence:
Andrew Scheibe
andrew.scheibe@gmail.com

Received: 28 Aug. 2020
Accepted: 28 Aug. 2020
Published: 17 Dec. 2020

 

 

Appendix 1: Common myths about drugs use

 

Table 1-A1 - Click to enlarge

 

Appendix 2: Assessing patients during first and subsequent encounters

 

 

 

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Appendix 3: Guidelines for opioid substitution therapy

 

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Dosing

Optimal dosing is important for full benefits of opioid substitution therapy (OST) to be realised. Opioid substitution therapy should be used for as long as a patient requires it (at minimum, 1 year). The risk of other opioid use is decreased with longer duration of OST.

•Supervised dosing

It is recommended initially for patients starting on methadone or buprenorphine. Continuation of supervised dosing should be assessed once the patient has been on a stable maintenance dose for approximately 3-6 months and should be individualised.

Daily dosing may need to continue for patients with limited support structures or for those living in areas where safe storage and access are limited.

•Take-home dosing

Allowing take-home doses is an important component of patient autonomy and ease-of-use, which enhances retention, the strongest determinant of positive outcomes.

Take-home dosing allows for patients to focus on other areas of their life because they do not have to spend excessive time and resources to access daily dosing.

Take-home dosing can initially start over weekends, moving to longer periods of time.

Discussions with patients and their support network should include available options.

Community pharmacies are an option for dosing outside of health facilities.

Buprenorphine (± naloxone) take-home dosing is easier (if in tablet form) and is generally safer than methadone as it has a lower overdose risk.

Opioid substitution therapy projects that have used methadone report few overdose-related deaths and limited diversion.⁸⁰

Facilitate a discussion of processes that will be taken if diversion/selling of OST medications becomes apparent, including taking a restorative justice approach and maximising patient safety.

Supervised dosing should be reinstituted if the clinician has safety concerns or concerns around diversion (e.g. missed appointments, intoxicated while attending appointments, changes in clinical or social situation).

Regular monitoring of patients

•Once on a stable dose

Monthly assessment by a doctor, re-prescribing methadone/buprenorphine⁷⁵

Quarterly assessment of medical and social history

Repeat assessment of substance use history, using the same tools used at screening (in a non-judgemental manner) - providing counselling and support in relation to outcomes

Offer HIV and hepatitis C virus (HCV) testing quarterly; assess antiretroviral therapy (ART) adherence as needed

Perform regular tuberculosis (TB) screening (assess weight loss, cough, fever and night sweats)

Patients who report ongoing injecting, or injecting in the previous year, should have regular HCV testing.

Retention and support for adherence

Psychosocial interventions aim to support retention within OST programmes. A broad range of interventions are available and include:

•Social support (which includes addressing basic needs)

•Psychological interventions

•Unstructured supportive therapy (e.g. motivational interviewing [MI])

•Structured interventions (e.g. contingency management [CM] and cognitive behavioural therapy [CBT])

•Group therapy

Managed opioid withdrawal (detoxification).^74,81

•The most effective treatment for opioid use disorder is opioid substitution therapy as a long-term management approach. (The South African Standard Treatment Guideline and Essential Medicine List [Adult, Hospital]¹³⁶ guidelines for the medical management of opiate withdrawal [detoxification] are available at: http://www.health.gov.za/index.php/component/phocadownload/category/286-hospital-level-adults).

•Short-term detoxification (a process that requires use of medications over several days per weeks, followed by an expectation of abstinence) is ineffective, yet it is still widely used. It has high rates of recurrent opioid use (up to 90% within 1 year), along with a likely sense of failure or shame in abstinence-focused contexts. Assisted opioid withdrawal is often done as an in-patient procedure. Performing withdrawal management in < 30 days is not recommended.⁷⁵ Withdrawal management should be imbedded within/linked to intensive rehabilitation services to minimise harms should the patient return to use. Ideally, the option to switch a patient to OST should be available if the patient is not able to achieve a goal of abstinence.

•The selection of a substitute opioid is a clinical decision that is made together with the patient after due consideration of: prior response; medical or mental health comorbidities; possible drug interactions; side-effect profile; cost/accessibility; use of other drugs and patient choice.

•Preparation of the patient for withdrawal symptoms is important, and they should be motivated to start a treatment plan, with careful explanations of what they may experience. Withdrawal carries little medical risk but can be very unpleasant. Nevertheless, most initiation can be safely done on an outpatient basis. Principles include gradual decreases in the effects of opiates, either through dose tapering and/or the use of agonists.

•Mild withdrawal reactions can be managed symptomatically, with antidiarrhoeal, antinausea, anxiolytic and analgesic medication. Whilst clonidine can be used for its rapid adrenergic agonist effects on symptoms, the evidence supporting this regimen is limited. Gradual down-titration of the relevant opioid or use of a less potent opioid, can be attempted in more severe situations.

•Benzodiazepines have been associated with fatal overdoses in people with opioid dependency, and their use in the management of withdrawal is discouraged. Risks related to return to the use of opioids after detoxification, particularly amongst people with a history of injecting, include overdose as well as blood-borne infections.

Management of acute pain in opioid use disorders

A careful history, physical examination and relevant diagnostic studies to identify the cause of the acute pain are the essential first steps.

 

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Appendix 4: Psychosocial and mental health interventions

 

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Motivational interviewing (MI) is a psychotherapeutic approach that seeks to move an individual away from a state of ambivalence towards finding motivation to make positive decisions and accomplishing established goals. These goals may include a reduction in harmful behaviour patterns such as harmful substance use or ART non-adherence. The approach to MI includes:

•using the 'spirit' of MI to engage with the patient: collaboration, evocation, acceptance and compassion

•using these principles when interacting with the patient: expressing empathy, developing discrepancy (i.e. identifying conflicts between perceptions, behaviours, personal goals and values), avoid argumentation, roll with resistance, support self-efficacy

•assessing the patient's readiness for change: pre-contemplation, contemplation, preparation, action, maintenance and relapse stages of change

•using the 'OARS' as a clinical technique: open-ended questions, affirmations, reflections and summaries

Problem-solving therapy (PST) is a cognitive-behavioural intervention geared at improving an individual's ability to cope with stressful life experiences. The underlying assumption of this approach is that symptoms of psychopathology can often be understood as the negative consequences of ineffective or maladaptive coping.¹³⁹

Cognitive behavioural therapy (CBT) is a widely used psychotherapy approach. The core theoretical premise is that maladaptive ways of thinking and behaving can generate mental and behavioural problems. The use of CBT ranges from substance use, depressive and anxiety disorders to schizophrenia. It represents a large body of related interventions. These elements include a focus on developing ways of recognising maladaptive thinking and behaviours and then building skills for positive coping to alleviate mental distress and problematic behaviours. It incorporates goal-oriented therapy and some form of talk-based therapy.¹³⁹

Contingency management (CM) is an intervention that provides patients with motivational incentives for meeting pre-determined treatment goals such as abstinence, attendance or medication adherence. The approach is based on principles of behavioural reinforcement. The goal of the treatment is to replace the positive reinforcement obtained from using alcohol and other drugs by providing positive reinforcement for productive behavioural change. Behavioural goals should be set over short time periods (typically 1 week or less) and positive reinforcement must be provided consistently and immediately after the goal has been met.⁸⁷

 

Harm reduction counselling tips

The principles of drug set and setting⁸ are very useful in reducing the harms people experience from drug use. If someone is unable to change one aspect of their drug use, then they may be able to make changes in other domains.

 

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