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Contents lists available at ScienceDirect

International Journal of Drug Policy

j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / d r u g p o

esearch paper

pportunities for enhancing and integrating HIV and drug services for rug using vulnerable populations in South Africa

harles D.H. Parry a,b,∗, Petal Petersen a, Tara Carney a, Richard Needle c

Alcohol & drug Abuse Research Unit, Medical Research Council, South Africa Department of Psychiatry, Stellenbosch University, South Africa Pangaea Global AIDS Foundation, USA

r t i c l e i n f o

rticle history: eceived 25 July 2009 eceived in revised form 0 November 2009 ccepted 24 November 2009

eywords: apid assessment

llicit drugs ex risk IV

ntegrated services outh Africa

a b s t r a c t

Background: Little has been done to improve the integration of drug use and HIV services in sub-Saharan Africa where substance use and HIV epidemics often co-exist. Methods: Data were collected using rapid assessment methods in two phases in Cape Town, Durban and Pretoria, South Africa. Phase I (2005) comprised 140 key informant and focus group drug using interviewees and 19 service providers (SPs), and Phase 2 (2007) comprised 69 drug using focus group interviewees and 11 SPs. Results: Drug users put themselves at risk for HIV transmission through various drug-related sexual practices as well as through needle sharing. Drug users in both phases had limited knowledge of the availability of drug treatment services, and those that had accessed treatment identified a number of barriers, including affordability, stigma and a lack of aftercare and reintegration services. SPs identified similar barriers. Drug users displayed a general awareness of both HIV transmission routes and prevention strategies, but the findings also indicated a number of misperceptions, and problematic access to materials

such as condoms and safe injection equipment. Knowledge around HIV treatment was low, and VCT experiences were mixed. SPs recognized the importance of integrating HIV and substance use services, but barriers such as funding issues, networking/referral gaps and additional burden on staff were reported in Phase 2. Conclusion: A comprehensive, accessible, multi-component intervention strategy to prevent HIV risk in drug users needs to be developed including community outreach, risk reduction counselling, VCT and

substance use treatment.

ntroduction

There is growing evidence for the effectiveness of a multi- omponent approach to HIV/AIDS prevention for drug users ncluding community-based outreach; HIV risk reduction coun- elling that addresses both drug and sexual risk behaviours; HIV ounselling and testing; access to sterile injection equipment; ccess to treatment for drug dependence; and for HIV positive rug users, access to HIV/AIDS care and treatment (Des Jarlais

t al., 2004; National Institute on drug use, 2002; Weinhardt, arey, Johnson, & Bickham, 1999). However, in reality services are ften fragmented with little integration of drug treatment and IV programmes (World Health Organization, 2005). Numerous

∗ Corresponding author at: Alcohol & drug use Research Unit, Medical Research ouncil, PO Box 19070, Tygerberg, 7505, South Africa. Tel.: +27 21 938 0419;

ax: +27 21 938 0342. E-mail address: [email protected] (C.D.H. Parry).

955-3959/$ – see front matter © 2009 Elsevier B.V. All rights reserved. oi:10.1016/j.drugpo.2009.11.008

© 2009 Elsevier B.V. All rights reserved.

barriers exist, including limited capacity and training for drug treat- ment providers, drug prevention workers, harm reduction outreach workers and other service providers who work with drug users or with sub-populations of commercial sex workers (CSW) or men who have sex with men (MSM) who use drugs; and stigma, dis- crimination or policy barriers that impede access to HIV treatment for active drug users (Niang et al., 2003; Reif, Golin, & Smith, 2005). While there has been a move towards improving the integration of drug use and HIV services in some countries (Cook & Kanaef, 2008), in sub-Saharan Africa efforts in this regard have been minimal apart from one or two small scale efforts (Deveau, Levine, & Beckerleg, 2006).

South Africa is currently experiencing one of the world’s most devastating HIV epidemics and was estimated to have 5.3 mil-

lion people living with HIV in 2007 (Department of Health, 2008). Since 1994 there has been a rapid increase in local consumption of a broad range of drugs including cocaine, heroin, Ecstasy, and more recently methamphetamine (Parry & Pithey, 2006; Parry, Plüddemann, & Myers, 2007; Plüddemann, Myers, & Parry, 2008).

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ost drugs are smoked, but there is evidence of increasing injec- ion use of heroin in some parts of the country (Parry, Plüddemann,

Myers, 2005). There is now also emerging evidence from a grow- ng number of local research studies of the link between substance se and HIV/AIDS, mostly through substances’ effect on sexual risk ehaviour (Morojele et al., 2006; Morojele et al., 2004; Simbayi et l., 2006; Simbayi et al., 2004).

The need for a comprehensive HIV/AIDS prevention plan that ncludes drug users has been articulated in two recently released olicy documents: South Africa’s Second National Drug Master lan (Department of Social Development, 2007) and South Africa’s ational AIDS Strategy (Department of Health, 2007). There is, owever, a need to go beyond rhetoric and have information that ill facilitate the roll-out of comprehensive service delivery mech-

nisms for drug users. The aim of this study was to understand he risk behaviours of drug users, both injection drug users (IDUs) nd non-injection drug users (NIDU), the barriers and facilitators o HIV and drug treatment services, their willingness to be tested or HIV, their opinions on drug use as a coping mechanism for HIV ositive drug users, and to use this understanding to inform the evelopment of programs and services to reach vulnerable drug sing populations at risk for HIV infection.

ethods

Two cross-sectional qualitative studies were undertaken in 005 (Phase 1) and 2007 (Phase 2), with the second phase being o determine if there were any newly emerging trends in drug use nd to ask more refined questions about service delivery issues that ould be useful in informing the intervention phase that began in 007.

articipants

In Phase 1 information was gained from drug using partici- ants in known hotspots for drug use and risky sexual behaviour y undertaking 131 key informant interviews (45 in Durban, 50 in ape Town and 36 in Pretoria) and 21 focus group interviews con- tituting 109 participants (34 in Durban, 40 in Cape Town and 35 n Pretoria). The final sample of drug users comprised 78 MSM, 115 SWs, 96 IDUs as some drug users fit into more than one category, nd 45 NIDUs who were also not CSWs or MSM. Further data on hese sub-populations are provided in published articles that focus n drug-related HIV risk behaviour among these sub-populations nd that do not include service provider data or go into detail of ser- ices related issues (Needle, Kroeger, Belani, Achrekar, & Dewing, 008; Parry, Dewing et al., 2009; Parry, Petersen et al., 2008). n addition, nineteen service providers (SPs) were interviewed rom public, private and civil society (NGO/CBO) organizations hat target the general population and at-risk groups, including irectors of drug treatment agencies (3), social workers in the ubstance dependence field (2), HIV/AIDS trainers/counsellors (5), irectors/managers of various NGOs providing HIV and other risk eduction services (3), VCT nurses (3), shelter caretakers/managers 2) and a policeman. Street intercepts and snowball sampling tech- iques were used to identify the drug using populations, and the Ps were identified as a result of prior contacts members of the esearch team had and through referrals from SPs.

In Phase 2, key informant interviews were conducted with 11 Ps chosen from the substance dependence fields (6) and other

GOs (5) that currently work with vulnerable populations. They lso recruited study participants. Thirteen focus groups with drug sers were conducted in Cape Town, Durban and Pretoria. Five focus roups (n = 28 drug users) were conducted with MSM, 3 in Cape own and 2 in Pretoria. Two focus groups (n = 13 drug users) were

of Drug Policy 21 (2010) 289–295

conducted with CSWs in Durban, and 6 focus groups (n = 28) were conducted with drug users who were neither MSM nor CSWs, 3 in Cape Town and 3 in Durban.

Procedures

Data for the first phase of the study was collected over six weeks in late 2005. In Phase 1 key informant interviewees were offered free voluntary counselling and testing (VCT) for HIV by certified VCT nurses using the Smart Check Rapid HIV-1 Antibody Test (fin- ger prick) and confirmatory tests for those testing positive were performed using the Acon Rapid HIV-1/2 Antibody Test.

Data for Phase 2 were also collected using rapid assessment methods and included focus group interviews with drug users (IDUs and NIDUs), including female CSWs and MSM, and key infor- mant interviews with SPs. Data collection was conducted over a one week period in each site (Cape Town, Durban and Pretoria) in mid 2007.

All interviews and focus groups were facilitated by a team of two trained field workers. Interviewees gave written, informed consent at the beginning of the interview and were assured of anonymity. Ethical approval for conducting the study was granted by the University of Stellenbosch. Interviews were conducted in English, however interviewers with local level language capacity were employed.

Measures

In Phase 1 key informant interviews were conducted using a semi-structured interview guide to elicit descriptions of the context of drug use, identify drug use and other risk factors for HIV infec- tion, and explore issues around drug and HIV service needs and past experiences. Focus groups were conducted to expand on, confirm and validate risk-related themes described in earlier interviews. In Phase 2 data were again collected using a semi-structured question- naire sheet for interviewing key informant SPs and an open-ended question guideline sheet for conducting focus groups with drug users. The questions were similar to those asked in Phase 1, but with less items overall and some additional items to probe around service delivery issues, with service delivery being broadly defined to include prevention and harm reduction activities.

Coding of the transcripts and analysis of textual data was per- formed using AnSWR® (Strotman et al., 2002) to aid in qualitative data analysis. In Phase 2 data analysis utilized summary tables in which responses were manually coded for each site and sub- population for issues raised in the focus group and individual interviews. Coders who were involved in Phase 1 independently read all of the transcripts and noted down similarities with findings recorded in Phase 1, and differences in types of drugs used and their availability, mode of drug use, links to drug use and engagement in sex and issues related to drug use and HIV services.

Results

Drug user HIV risk

The most commonly used drugs across all groups were cannabis, cocaine hydrochloride (HCl), crack cocaine and heroin. Methaqualone, otherwise known as Mandrax, (a barbiturate com- monly smoked with cannabis) was also widely used. There were some inter-site differences, for example, crystal methamphetamine

was widely used in Cape Town while dipipanone hydrochloride (an analgesic known as Wellconal) was popular among persons who injected in Durban (Parry, Petersen, Carney, Dewing, & Needle, 2008). The majority of drug using interviewees across both phases of the study reported that drugs such as crystal methamphetamine,

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rack cocaine and Ecstasy increased their sexual desire by increas- ng energy which often prolonged the sexual act, heightening their enses and generally improving both foreplay and sexual inter- ourse.

In addition, most drug users reported not thinking about con- oms and safe sex or being happy to forgo condom use when hey were ‘high’. This was also the case for some CSWs if they ere offered more money for condomless sex with a client. It as common for the drug using interviewees to have riskier sex

with multiple partners/strangers, group sex and/or anal sex) while ntoxicated.

Both drug users and SPs agreed that long term heroin users enerally reported that this drug diminished their desire for sex. owever, long term heroin was often associated with injection use, nd IDUs’ injection practices were often riskier than their sexual ehaviour. A number of heroin using interviewees were unaware of heir needles’ origin. Most reported sharing equipment with regu- ar partners, using blunt needles or sharing with others if desperate or a fix. Some also reported discarding needles in public places or n garbage bins.

In Phase 2, drug using interviewees had contradictory opinions bout injection drug use as a risk. Some agreed that the increase in eroin use had led to an increase in injection use, and risks asso- iated with reuse and sharing of needles. MSM generally agreed hat IDUs shared equipment. In Cape Town needle sharing was ssociated with pushing boundaries by ‘looking for the next high’. owever, some MSM felt that injection use was not glamorous nough for the ‘gay scene’.

nowledge and experiences with drug services

While many drug users have received drug treatment of some ind, a large proportion has not. Reasons included not knowing here to access services or what they offer, not wanting to go or ot seeing the reason for treatment, or because they held the gen- ral belief that they were in control of their drug use. Drug users in hase 1 recommended that better education should be provided on he dangers of drug use, especially to hidden, vulnerable popula- ions. This was further elaborated upon by interviewees in Phase 2, ho stated that issues that put drug users at increased risk for HIV,

uch as sharing both injection and non-injection equipment as well s sexual risk, are not traditionally addressed by drug treatment roviders.

Others, however, reported that they were not interested in the essation of drug use. Some SPs stated that patients’ ‘difficult atti- ude’ or ‘lack of motivation’ hinders treatment. A number of IDUs nd a few MSM reported that they had been treated for their addic- ion ineffectively with prescription medication. Only one SP, based t a hospital, indicated that they provided methadone substitution herapy for heroin addiction, and one IDU specifically spoke about eing on methadone to stop his heroin use:

Methadone. Yes, which is actually. . . It brings you off heroin. . . You buy it at the chemist but it’s a Schedule 7 drug. You have to get it from a prescription. It’s actually - it takes the craving and the sore and the sickness away. It’s about R100 [about US$ 12] a bottle. (33 year old male IDU, Durban Phase 1)

In Phase 2, NIDUs/IDUs and SPs in Durban and Cape Town were ware of the successful provision of more than one kind of med- cation (methadone and buprenorphine in Durban) to assist with

ymptoms associated with heroin withdrawal. However, drug users entioned a number of difficulties associated with drug treatment.

ntry into public treatment was described as a lengthy process hile the alternative, private drug treatment, was not affordable.

hey felt that it was necessary for the government to provide

of Drug Policy 21 (2010) 289–295 291

free treatment, and for more community outreach programs to be implemented, especially those that deal with issues pertain- ing to specific sub-populations of drug users (such as MSM). SPs expanded on this issue, viewing state subsidized centres as over- crowded often with limited services, with private treatment being unaffordable for many.

Another barrier to receiving services for drug use was that drugs were reported to be widely available in rehabilitation centres by a few SPs but mainly by drug users who have used the services:

I have been in rehabilitation once, the first time I overdosed of heroin, and Ecstasy, then I went to rehabilitation in [Centre X]. I was there for three months and when I came out there, I felt more drugged than I have ever felt in my whole entire life. Really, because inside rehabilitation there’s even more drugs than there is, than there is outside. (24 year old male IDU, Cape Town Phase 1)

NIDUs in Durban especially spoke of the use of physical pun- ishment as treatment and the lack of foci on drug use or the risks related to HIV. Ongoing treatment was also seen as problematic, and almost all drug service users reported that they relapsed after reha- bilitation because they returned to their previous environment. While a few SPs explained that they provided support groups and meetings with patients and family after formal treatment, most agreed that there was a need to address reintegration into func- tional society:

And a lot of times that is what is going to save the patient, if someone will just trust them and give them a job. Even if it’s just wiping floors or whatever. . . No one looks at re-integration into the community. That’s still a big problem for me, ja [yes]. Because no one wants to employ someone that’s had a heroin problem. (Substance dependence social worker, Pretoria Phase 1)

Knowledge and experiences with HIV intervention services

Drug using interviewees had general knowledge of HIV trans- mission routes and prevention strategies. Many IDUs and MSM in Phase 1 were particularly aware of the importance of not sharing needles and other drug equipment. In addition, substitution ther- apy was recommended by SPs and IDUs in Phase 2 as a necessary prevention measure. However, one IDU and the majority of CSWs mentioned that sexual and other risks were more likely risk factors for drug users than injection drug use.

A number of misperceptions around HIV transmission and the prevention thereof also existed among drug users. One IDU in Phase 1 described cleaning his genitals after sex and a few CSWs in Cape Town reported eating shellfish (arikreukal) to prevent HIV, as well as cleaning needles with ineffective materials such as tap water. SPs confirmed that there was a lack of education around HIV among drug users, and one SP stated that preconceptions were also present among certain sub-populations of drug users:

. . .lots of people think because, people think it comes from the gay community, Los Angeles, so many years ago, 1982, that the gay people know how to practice safe sex. They don’t need information. . .and then all focus on the heterosexual. . .I think wrongly, yes, because, I think wrongly. Because the younger gay person [who] is now out of the closet won’t know what happened in 1982 for instance. (AIDS counsellor, Pretoria Phase

2)

Drug users that were interviewed listed community health centres and clinics, various health care professionals, the media and personal experience as their sources of information around

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IV/AIDS. IDUs also referred to the lack of information provided y HIV services for this specific sub-population of drug users. Many

nterviewees were aware that condom use could prevent HIV trans- ission, but access to free condoms was problematic. In Phase 2,

DUs in Cape Town suggested that injection equipment is only avail- ble through pharmacists that often do not provide the necessary quipment to customers who are suspected of being drug users. Dif- culties in getting access to clean needles and syringes after hours ere similarly raised by drug users as well as SPs:

At night time, there’s no needles. Then people start sharing needles. There’s no condoms, because the chemists [pharma- cies] are closed. They should always be available, needles and syringes, and condoms; there should always be a visibility of them, a presence where they can go and get them for free. (34 year old MSM, Cape Town Phase 1)

SPs generally agreed that needle exchange programs (NEPs) had een effective in other countries to prevent HIV risk behaviour such s sharing needles. Furthermore, NEPs could also be a place for etting into contact with and providing education to IDUs:

. . .Australia for example, you have places where people can go and shoot heroin safely. And get a clean needle and get counsel- ing at the same facility, get education, get pamphlets, get spoken to about their drugging. (Drug service director, Phase 1)

Many SPs recognized that improved service delivery was needed ecause HIV prevention was not a priority for drug users. In Phase , NIDUs and IDUs themselves agreed that HIV prevention was not priority for drug users due to their lack of finances as money as spent primarily on drugs. In Phase 1, it was established that rug using sub-populations were interested in VCT if it was avail- ble and accessible and that certain sub-populations had higher IV prevalence than others (Parry et al., 2008). Ninety-two (70%) f 131 drug using key informants agreed to be tested for HIV as art of the study and received their test results: 37 (80%) MSM, 50 74%) CSW, and 15 (71%) NIDUs (Parry et al., 2008). While a smaller roportion of IDUs (63%) agreed to testing, several reported having een tested in the past and already knew their status. Several indi- iduals partook in the study because they wanted to be tested for IV.

For those drug users who had been tested before, reasons for esting included concern about their high risk sexual and/or drug sing behaviours, having an HIV positive friend or partner and being reated for other STIs. A number of drug using interviewees that ad been tested for HIV previously had either positive or negative xperiences. A common experience was feeling stigmatized due o being a member of a vulnerable sub-population of drug users nd/or being HIV positive:

We tend to have this attitude towards testing you know because fearing that when we get there, they are going to see that you are gay. . . There is a belief that the nursing sisters at the clinic, they laugh about gay people and stuff. (MSM focus group participant, Pretoria Phase 2)

In Phase 1, drug users (including IDUs) indicated that VCT ser- ices did not seem to be accessible to people like them. Some CSWs pecifically felt that SPs and mobile clinic staff are often scared to o into the areas that they frequent. Improving accessibility was herefore indicated as an urgent need. SPs also noted that the loca-

ion and cost of HIV testing needed to be changed to promote use. CT was generally only provided by those employed at HIV/AIDS gencies, although the director of a general drug counseling organi- ation reported that their centre had a VCT site on the premises. In

of Drug Policy 21 (2010) 289–295

Phase 2, drug users and SPs alike argued that VCT should be offered routinely at drug treatment centres.

However, MSM had mixed opinions about whether VCT services should educate drug users about the possibility of their behaviour putting them at risk for HIV. While some felt that the two issues were related, due to injection and sexual risk, a few perceived drug use and HIV as two separate issues:

Listen here, if I chose, if I’m doing drugs or I am addicted that is not really, okay I’m coming in for an HIV test. I want to know if I’ve got HIV. That’s what I want to know about. . . Pushing the whole drug guilt down my throat I think that will actually make me less comfortable to come for an HIV test. (MSM Focus group participant, Pretoria Phase 2)

Knowledge about the availability and role of ARV treatment was minimal among drug using interviewees, but in Phase 2 CSWs demonstrated an understanding of how ARVs function. A few MSM correctly identified potential side effects of ARVs and some IDUs acknowledged drug interaction and adherence issues. Both SPs and drug using interviewees expanded on these two subjects in Phase 2. Drug using interviewees had mixed opinions about the function of drug use as a coping mechanism for HIV positive drug users. While the majority of interviewees felt that they would continue drug use as justification and an excuse, others believed that drug users could cease drug use depending on their perception of HIV. SPs on the other hand, generally stated the assumption that a sig- nificant proportion of drug users use drugs to cope with being HIV positive. In Phase 2, some drug using participants also reported knowing of individuals using ARVs in combination with other sub- stances such as alcohol and cannabis, a finding that did not emerge during the earlier phase. While CSWs believed that the purpose of this was for enjoyment, one MSM spoke of his experience of the use of cannabis in curbing side effects of ARVs, such as drowsiness. SPs furthermore expressed the belief that drug use interferes with HIV positive individuals’ compliance with medication.

Current and perceived need for integration between services

SPs recognized the need for addressing HIV and drug use together, as well as the possibility of integrating the two vertical programs:

What I have realized is that people, they only focus on what they are there to do. . .So what I am saying is that the first contact, either the sister or nurse whoever has the first contact with the patient, should be able to diagnose or access whether this person is a drug user. (CSW service provider, Phase 2)

A number of potential barriers to this integration were identi- fied. While the primary strategy of training and capacity building was viewed as critical to strengthen and develop links among a variety of service-providing organizations and agencies, SPs iden- tified that activities such as building networks or cross-training are rarely funded. In Phase 2, SPs therefore suggested networking with local action committees, forums and advisory boards as well as with organizations outside of their area of expertise such as law enforcement agencies.

Some HIV service providers said that they currently do coun- sel clients on drug and alcohol use in relation to HIV and ARVs. In Phase 1, VCT nurses however, argued that drug counselling would

trained to deal with drug users who are often in denial. Similarly in Phase 2, a potential obstacle identified was the increase in work- load if HIV services were to be included into drug treatment, or drug-related risk into HIV services.

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D

u c s b a a s W S t t t w O a 1

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Table 1 Operational and training objectives to facilitate more efficient and integrated deliv- ery of drug and HIV services.

Structural issues • Move away from the approach to delivering services in drug and HIV silos • Provide a government subsidy for those NGOs/CBOs that address drug

and HIV risks in a comprehensive and integrated manner

Operational issues • Tailor community-based outreach to drug users that addresses HIV/AIDS

risk • Explore risks related to safe injection use and disposal practices • Integrate education, information, and communication of HIV

drug-related risks into current HIV prevention efforts and vice versa • Provide confidential, routine HIV counselling and testing in substance

abuse programs • Adapt VCT to be more localized, mobile, and population specific • Include risk reduction counselling in counselling and testing that focuses

on HIV and drugs • Decrease stigma of SPs against vulnerable drug using populations (CSWs,

MSM, IDUs, etc.) • Provide cross-training for persons delivering drug and HIV services • Encourage and support high-quality evaluations to provide evidence for

programs that achieve behaviour change • Develop capacity to provide access and referral to substance abuse, HIV,

and other health services and treatment to vulnerable populations engaged in high risk behaviours

Capacity building and training • Scale up outreach efforts to targeted groups in high risk areas • Provide more resources to NGOs/CBOs to address both drug and HIV risks •

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SPs discussed the difficulty experienced with drug users who o not want to know their HIV status and thought that HIV preven- ion and testing was not considered of vital importance to many rug users. They therefore recommended that HIV-related preven- ion efforts should be free and drug user friendly. They reported hat additional burdens faced in coordinating services with other ectors were fears about loss of confidentiality and restrictions on he kind of information that can be shared across organizations. ther issues mentioned were staff burnout and frustration with lients who may have difficulty complying with counseling mes- ages and treatment regimens due to their drug use. The need for dditional training in how to access hidden and vulnerable popula- ions and how to handle the sensitive and potentially stigmatized ssues of drug use, sex work and MSM sexual behaviours was widely cknowledged.

iscussion

This study found similarities and differences between drug sers’ views of services and those who provided services. SPs were oncerned about drug users’ risky behaviour, and drug users them- elves reported engaging in a number of risky injecting and sexual ehaviours that put them at risk of HIV, although they were not lways aware of these risks. Drug users generally reported neg- tive experiences of drug treatment, mixed experiences of HIV ervices and several had no previous interaction with such services.

hile drug users faced a number of barriers to accessing services, Ps additionally mentioned a number of constraints that affected heir service delivery. While a few SPs reported that the services hey worked for made concerted efforts to coordinate their efforts hrough referrals and other mechanisms, HIV and drug services ere generally seen as very fragmented by both SPs and drug users. ther studies have likewise demonstrated that few programs have ttempted to integrate HIV and drug services (Ball, Rana, & Dehne, 998; Kellerman, Drake, Lansky, & Klevens, 2006).

In developing a more comprehensive, multi-component pproach, based on findings from the current study and specifically oming out of a workshop held in August 2006 to review the find- ngs of the first phase in relation to international best practice, we ropose a number of important structural, operational and train-

ng objectives to facilitate better integration and delivery of drug nd HIV services to vulnerable drug using populations as well as mprove referrals and networking to establish better links between rganizations (Table 1). Firstly, we recommend that there needs to e a move away from the common approach of delivering services

n drug and HIV vertical programs (National Institute on drug use, 002).

A number of agencies attributed their failure to provide a com- rehensive array of services to a lack of time, staff and money. herefore we propose that an increased subsidy be provided by gov- rnment to those NGOs/CBOs that address both drug and HIV risks n a comprehensive and integrated manner. Such funding could be sed for training, possibly hiring and accommodating new staff, to upport the building and maintenance of referral networks, and ncreased costs related to management and supervision of staff

ith enlarged job descriptions or new specialists with skills dif- erent from their current staff complement.

The core interventions in a comprehensive approach include ommunity outreach (essentially peer education and outreach that ncludes risk assessment and reduction counselling); supplies pro-

ision (condoms/lubricant and access to safe injection equipment nd referrals to services); risk reduction counselling that addresses oth injection and non-injection drug- and sexual risk taking; safe

njection and disposal (needle cleaning skills, access to bleach, otton, and needles); VCT; and substance dependence treatment

Incorporate HIV drug-related risks into tertiary training of health professionals

• Sensitize SPs to issues affecting “most at-risk groups”

(National Institute on drug use, 2008). A specific recommendation emerging from drug users interviewed in the study was for con- fidential, routine HIV counselling and testing to be provided in substance dependence treatment settings. Previous studies have shown that it is possible to effectively bring HIV education (Strauss, Astone, Des Jarlais, & Hagan, 2005) and testing (Friedmann, Lemon, Durkin, & D’Aunno, 2003; Strauss, Des Jarlais, Astone, & Vassilev, 2003) into drug treatment as part of a comprehensive plan.

We also propose an integration of education, information and communication of HIV drug-related risks into current HIV preven- tion efforts, and vice versa. Drug users realized to some extent that injection and other drug use practices increase their risk of con- tracting HIV, and several requested improved education to inform them about drug-related HIV risk behaviour and where to get assistance. Most drug users acknowledged their risky behaviours, as some had HIV tests in the past, but others seemed relatively ignorant about the dangers of their own behaviour. This also demonstrates a need for basic awareness raising through peer- and other forms of education and outreach activities to draw in drug users who might not be fully aware of the risks of their behaviour and where to access services. Specifically VCT should address both sexual and drug taking risks associated with HIV (Des Jarlais & Semaan, 2005; Kellerman et al., 2006; Semaan, Des Jarlais, & Malow, 2006).

The drug using interviewees’ risky injection practices identified in this study included disposal of needles and syringes in ways that potentially place themselves and others at risk for getting pricked. There is now a growing recognition of the importance of addressing such practices and in the UK and elsewhere technologies have been developed to assist IDUs in safe disposal practices. These should be explored and made more available in South Africa where such technologies are almost unheard of.

Drug using interviewees pointed out that numerous barriers prevent them from accessing existing VCT services. Previous stud- ies have shown similar barriers such as staff attitudes, engagement in risky behaviours and fear of testing HIV positive (Downing et al.,

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001; Kellerman et al., 2002). Accessibility to VCT in particular has een shown to be one of the more challenging barriers (Kellerman t al., 2002), and the relatively high rate of participants willing to e tested as part of this study indicates that persons engaged in igh risk behaviours may be willing to receive VCT if this service

s available in an accessible venue. Therefore, an important rec- mmendation is to adapt VCT to be more localized, mobile and opulation specific.

The majority of drug users felt that they needed increased access o all services beyond just VCT, and that outreach efforts that atered for hard-to-reach populations would best serve this need. ailoring community-based outreach that address HIV/AIDS risks o drug users has shown to be effective as part of a comprehensive IV model (Academy for Educational Development, 2000; Needle t al., 2005) and would systematically increase access to services. A urther recommendation, therefore, is that NGOs involved in work- ng with vulnerable drug using populations should be encouraged nd, if possible, supported to conduct or increase outreach activi- ies.

This study furthermore provided strong evidence of the need for ncreased capacity building and training in order to implement the ore components of a comprehensive plan for drug users (Needle t al., 2005). Community health workers need further training on ccessing hidden populations, providing risk reduction counselling nd VCT that addresses both drug and sexual risk behaviours. If ser- ices are to communicate and collaborate across existing vertical rograms, one of the key issues identified by the SPs themselves as training. If health professionals are trained at the tertiary level

bout HIV drug-related risks, services could be improved. Current Ps should also receive sensitivity-training to respond to issues of iolence, drug use, and HIV, including issues of confidentiality and tigma related to hidden and vulnerable populations (such as MSM rug users, CSWs and IDUs) which were identified as somewhat roblematic in this study. A number of previous studies conducted ith members of vulnerable populations have also shown negative erceptions of certain providers (Downing et al., 2001; Neale, 1998; eal et al., 2000). Efforts need to be made to address stigma reduc- ion among service providers who work with high risk populations. ross-training of SPs working in different sectors is also needed Sylla, Bruce, & Kamarulzaman, 2007), to increase sensitivity and he use of non-judgmental language when working with persons ho engage in stigmatized drug using and sex work behaviours,

nd to carry out sexual risk assessments that do not assume het- rosexuality. Furthermore, additional training should demonstrate ppropriate ways to facilitate interaction between drug, HIV and ther service sectors.

The findings of this assessment are subject to the limitations f the study design. Firstly, the findings may not be generalizable o all drug users or to particular subgroups of drug users as the ocus of the study was only on populations in selected hotspots. econd, the findings are based on small numbers of respondents n certain subgroups in some sites and this limited the breadth of nterview material obtained in these sites. With regards to the ser- ice providers, because of their various positions they had different evels of knowledge about the agencies that they worked for and his might have impacted on their competence to comment on dif- erent issues. Although a comparison between drug users’ and SPs’ xperiences and needs was made, the SPs interviewed were not ecessarily the ones to whom the drug users had exposure.

Overall, findings pointed to the numerous barriers that vul- erable drug using populations face in accessing and utilizing

isk reduction, substance dependence and HIV services. Program- atic implications of the findings included the identification of

he need to tailor community-based outreach to drug users in igh risk areas that address HIV/AIDS risks; improve linkages with ppropriate drug and HIV/AIDS treatment, prevention and harm

of Drug Policy 21 (2010) 289–295

reduction services; ensuring provision of confidential, routine HIV counselling and testing in substance dependence programs; and adapting VCT to be more localized, mobile, population specific and include risk reduction counselling that focuses on drug-related risks; and addressing constraints in terms of the availability of opiate substitution therapy and NEPS in South Africa.

Acknowledgements

The research was funded by the US President’s Emergency Fund for AIDS Relief (PEPFAR) through the US Centers of Disease Con- trol and Prevention (CDC) (PO S-SF750-06-M-0781). Its contents are solely the responsibility of the authors and do not necessar- ily represent the official views of the CDC or PEPFAR. The authors would also like to acknowledge the support of our field work staff and NGOs in Cape Town, Durban and Pretoria; Angeli Achrekar and Thelma Williams who assisted the project as part of the CDC Inter- national Experience and Technical Assistance (IETA) Program; as well as our colleagues at the CDC in Atlanta (Karen Kroeger) and in Pretoria (Latasha Treger) for their technical support and encour- agement throughout the project.

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