There are an estimated 75,000 people in South Africa who regularly inject drugs. And this figure is probably an underestimate, according to researcher Shaun Shelly, chairperson of the South African Network of People who Use Drugs (Sanpud). For people who take drugs, accessing care can be prohibitively difficult, with scarce or expensive services, stigmatisation and worries about being harassed or arrested stopping people from getting support. 

Most people who inject drugs in South Africa use nyaope, a low-grade form of heroin mixed with other substances (but not ARVs as is widely believed).  Nyaope is typically a drug that is smoked, but increasingly in the last few years, researchers say it is being injected.  

This is especially concerning because of the health risks for abscesses and bloodborne diseases, like hepatitis C and HIV, associated with sharing needles. Because care is inaccessible for them, these conditions have a high prevalence among people who use drugs. The substances most widely taken in South Africa are cannabis, heroin, crystal meth and Mandrax.  

Drug harm reduction interventions are pragmatic, evidence-based approaches to public health that minimise the negative health, economic and social impacts of taking drugs, but do not always require that people stop taking substances. For example, needle and syringe exchange programmes reduce the risk of bloodborne diseases, and opioid substitution therapy replaces illicit drugs like heroin with safer alternatives like methadone. 

But according to Shelly: “Harm reduction isn’t to be considered just a set of specific interventions; it changes according to context and the particular needs of the individual. It’s a philosophy about assisting people in the way they want to be assisted, that respects their autonomy and dignity, reduces harms of behaviours that they may or may not want to stop.” 

“They’ll offer you advice, they’ll tell you of the risks that are associated with you using and then the decision will come from you whether you want to quit,” said Koketso Mokubane, a community linkage officer for Sanpud in Tshwane who has experience with harm reduction for heroin use. He works to educate communities of people who use drugs about their harm reduction rights and routes to justice.  

Living on the streets

Mokubane said he spent 10 years living on the streets of Tshwane as a heroin addict, trying hard to quit. “I failed. I’ve been to rehab before, on more than four occasions.”  

Mokubane says rehab’s rigid approach and a lack of peer support from people with lived experiences of drug taking made it hard for him to open up and get the care he needed.  

In 2017, Mokubane started opioid substitution therapy with Tshwane’s then newly established Community Oriented Substance Use Programme (Cosup), South Africa’s first and only local government-funded harm reduction programme. Run by the University of Pretoria, it has 16 sites around the city where people who take drugs can exchange needles, get opioid substitution therapy, and be connected to healthcare and context-specific support to reduce the health, economic and social harms of drug use.  

Mokubane said peer support at Cosup helped him craft an individualised plan. He said his plan was: “I don’t want to quit. I just want to reduce my intake, and be able to go home and fix my broken relationships with my family. Since then, my life has changed drastically. I am living in my own house… with my fiancé.” 

Dimakatso Nonyane, a clinical associate with Cosup, emphasised that harm reduction “allows us to better understand what’s important to [people who use drugs] instead of just assuming we have interventions that would work for them.”  

In one sense, harm reduction is common sense and practised widely. Mokubane says: “We apply harm reduction in our lives on a daily basis. Seatbelts are a form of harm reduction. Do they stop the accidents from occurring? No. But they reduce the risk of them and when you do crash and you’re wearing a seatbelt, it reduces you getting those severe injuries.” 

According to Shelly, harm reduction is at once commonplace and also a radical and disruptive approach. At its core, harm reduction upends established systems that see drug use as a punishable criminal issue or solely a medical issue that pathologises people who use drugs.  

Harm reduction advocates for the decriminalisation of personal drug use and possession because decriminalisation decreases stigma, improves access to healthcare and encourages safer drug-taking practices. 

‘Highly political’

“To decriminalise is very important, but it’s highly political,” says Professor Jannie Hugo of the University of Pretoria’s Family Medicine Department who co-founded Cosup with Shelly. As a pragmatic alternative to decriminalisation, Hugo believes South Africa should have programmes to administer harm reduction in prisons or divert people who are arrested for drug use and possession away from prison to harm reduction centres.  

Harm reduction also resists a purely medical model that sometimes coerces people into traditional, often costly rehabilitation programmes against their will. 

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Shelly said: “We’ve seen the failure of other approaches. These abstinence-based, come down hard on people, criminal justice approaches just do not work.” 

Harm reduction is not entirely opposed to rehabilitation, nor is it intended to entirely replace abstinence treatment and prevention approaches to drug dependency. 

“Harm reduction is giving people who use substances options to choose from,” Nonyane explained. “It is not against abstinence. If anything, it’s actually trying to ensure that that process is more feasible by realising there’s a gap between where we are at and where we want to be.” 

Peer support is a critical component of harm reduction. Mannie Sigmony, who has lived experience of addiction, is an activist who runs a rehabilitation centre in Lenasia, Gauteng, focused on abstinence that also uses harm reduction approaches. 

He emphasises: “There are addicts that are saving lives. They are saving the lives of other addicts.” 

Harm reduction is inextricably linked to South Africa’s inequality. Hugo said that wealthier people who take drugs have better protections, “but those who are poor, they incur much more harm”. 

Lutske Newton, who works in the Office of the Executive Mayor of Tshwane and also serves on the newly formed Local Drug Action Committee says: “The research that we have on drug use in Tshwane is that it primarily affects young black men who are unemployed.”  

Building up support for harm reduction programmes has been challenging. Hugo said: “It’s easier for a politician to say, we will come down hard on drugs than for her to say, we’re going to spend your tax money on helping them to get clean needles, because of the narrative of the link between drugs and crime.”  

Big breakthroughs

Shelly explained that, “In South Africa, there is a reluctant acceptance of harm reduction, but some big breakthroughs have been made.” Notable is the endorsement of harm reduction approaches in South Africa’s 2019 to 2024 National Drug Master Plan and in the TB and HIV National Strategic Plan.  

Nyameka Nandi Mayathula-Khoza, chairperson and spokesperson of the Department of Social Development’s Central Drug Authority, which oversees the National Drug Master Plan (NDMP), said: “The NDMP recognises that reducing the potential harm associated with drug use is a pragmatic approach and aims to reduce the potentially harmful effects of substance use.”  

However, in the South African Health Review 2017, Shelly and other researchers wrote: “Enforcement and punishment remain the dominant response, with the country only paying lip service to the provision of harm-reduction programmes.” 

Hugo says that there is still significant resistance to harm reduction among people who work in social development and rehabilitation centres. In many rehab centres, “harm reduction is frowned upon because you need to be clean to be successful”, he said. Nevertheless, the approach is being accepted by a growing number of healthcare professionals.  

Several NGOs, mostly funded by international donors, provide harm reduction services in South Africa: TB HIV Care provides harm reduction in the Eastern and Western Cape, and the Bellhaven Harm Reduction Centre supports people who use drugs in eThekwini. The HarmLess Project operates in Tshwane and in Ehlanzeni in Mpumalanga, while Anova Health Institute and Tintswalo Home Based Care provide harm reduction services in Gauteng. 

Promising numbers

The numbers of people that these organisations serve are promising but are only a fraction of the total number of people who take drugs regularly. 

In the face of the scale of risky drug use in South Africa, harm reduction needs to be scaled up to a far greater degree, says Hugo. 

“Harm reduction services should be a part of primary healthcare like ARVs are a part of primary healthcare. We haven’t succeeded in Tshwane to have harm reduction services available in primary healthcare. It’s available in our centres, but that doesn’t cover everybody,” he said.  

Newton agreed: “The level of attention and care that people with substance use disorder need, whether it’s [opioid substitution therapy], or harm reduction, way exceeds what we have to offer as a city and our NPOs.” 

But there is hope for harm reduction in South Africa to be scaled up. A huge obstacle is the high price of methadone, a drug essential for opioid substitution therapy. Hugo says the cost of methadone in South Africa is at least 10 times higher than in peer countries, but South Africa will probably soon have more competition introduced in the methadone market.  

“So the cost of methadone could come down over time, which would make it more sustainable to scale.” 

Mayathula-Khoza said that the responses to the Covid-19 pandemic helped to build up some harm reduction capacity as the government had to provide some harm reduction services to people during lockdowns. She confirmed that increasing harm reduction services for people who use drugs will continue to be a priority for the Central Drug Authority. 

Mokubane reflected: “I won’t dispute that drugs are bad for us. But we have to accept that drugs will always be here and people will always be using them. We need to have constructive solutions to deal with them rather than just avoiding the fact that they are here.” DM/MC