The Bill of Rights is a cornerstone of democracy in South Africa – and South Africa is renowned for having one of the most progressive Constitution in the world. The Bill of Rights enshrines the rights of all people in our country and affirms the democratic values of human dignity, equality and freedom. The state must respect, protect, promote and fulfil the rights in the Bill of Rights. 

South Africa has become a consumer, producer and transit country for drugs. Socio-economic factors such as poverty, inequality, and unemployment remain key contributing elements to the increased use of drugs and the development of substance use disorders. An increasing demand for drugs causes an increase in drug manufacturing, smuggling through ports of entry, and dealing in and consumption of drugs. The illicit trade in psychoactive drugs and criminal enterprise is a threat to the safety and well-being of South Africans and poses a growing and significant hazard to national security, economic growth, and sustainable development.

Most seizures of drugs and precursors, including cocaine, heroin, Mandrax, and ephedrine are recorded at OR Tambo and Cape Town International Airports; crystal methamphetamine through Durban harbour, and large quantities of heroin is trafficked through Mozambique and Swaziland. The increasing trend in the illicit drug trade is likely to persist as moderating factors - such as border management processes at the ports of entry, weaknesses in the management and control of pharmaceutical front companies, identity theft, and the misrepresentation of controlled chemicals, and online anonymous trade - have enabled syndicates to purchase precursor chemicals easily. The Global Initiative against Transnational Organised Crime in 2021 flagged the arrival of meth-amphetamines from the Pakistan-Afghanistan border area as one of the key challenges of the coming years. South Africa is also one of the world’s largest producers of cannabis.

South Africa is a signatory to the Single Convention on Narcotic Drugs (UN, 1961) and a prohibitionist perspective is evident in subsequent legal documents. This includes the Drugs and Drug Trafficking Act 140 (1992) (Gray, 2019), which draws overtly on the Single Convention in that it aims ‘To provide for the prohibition of the use or possession of, or the dealing in, drugs and of certain acts relating to the manufacture or supply of certain substances or the acquisition or conversion of the proceeds of certain crimes […]’. 

The development and implementation of local drug policy frameworks is the responsibility of the national Department of Social Development. This Department houses the Central Drug Authority, the institution tasked with issuing a guiding policy document—the National Drug Master Plan—approximately every five years. 

The Central Drug Authority contains civil servants who represent different government departments and report to their respective ministers, each of whom may have different positions on aspects of policy related to alcohol, tobacco, cannabis and psychoactive substance use’ (Stein, for the ECCDA, 2016). Departments focused on law enforcement are concerned with international legal frameworks. For example, at the 2019 United Nations Commission on Narcotic Drugs, South Africa committed to strengthening relationships with other international law enforcement agencies and confirmed that its response to drug use is guided by the three major drug policy conventions, with law enforcement at the forefront (UN CND, 2019). 

The agendas of other superpowers (in addition to the USA) such as China and Russia have played out locally through the partnership between Brazil, Russia, India, China and South Africa (BRICS). Russia’s increasing influence - due to the economic incentives it has provided to South Africa - has led to its undue level of influence in the African setting, as evidenced by the Russia-Africa Anti-Drug Dialogue (RAADD).  In contrast to the principles of the constitution, South Africa abstained from the vote supporting the Resolution on Contribution to the Implementation of the Joint Commitment to Effectively Addressing and Countering the World Drug Problem with Regard to Human Rights (OHCHR, 2018). In these moves, South Africa appears to be adopting and promoting prohibition as a policy choice. 

However, different perspectives are sometimes even evident within departments and institutions. Despite the Central Drug Authority being housed within the Department of Social Development, these two institutions have not always presented a uniform perspective. During the United Nations general assembly, Deputy Social Development Minister Bogopane-Zulu called for a review of treatment protocols for drug-dependent people, and a move to a human-rights based approach. Bogopane-Zulu told social and welfare ministers from around the world that South Africa is considering plans to decriminalise personal drug use, while focusing its police resources on dealers and illicit syndicates. In the same spirit, the South African National AIDS Council has recently overtly supported a call for the decriminalisation of drug use (South African National AIDS Council, 2019b).

Overall, prohibition-inspired approaches continue to dominate the local implementation landscape and penalties are high for drug-related crimes. The penalty for dealing in dependence-producing substances is partially related to whether the drug is considered merely dependence-producing or dangerous dependence-producing (A schedule 2 drugs, Part 1 or Part 2). If you are convicted of dealing in Part 1 drugs, you face a fine or imprisonment for up to 10 years, or both. Dealing in Part 2 drugs carries a heavier penalty: up to 25 years’ imprisonment. The severity of the penalty will be determined by a number of factors, including whether or not it is your first offence. It is an offence to sell equipment, or have possession of equipment intending to sell it for use in connection with the smoking, consumption or administration of a controlled drug, or for the preparation of such a drug for smoking, consumption or administration. The maximum penalty is a fine of $10 000 or imprisonment for two years, or both.

In 2018, the South African Constitutional Court handed down a judgement that effectively decriminalised the possession and use of cannabis in private spaces (Minister of Justice et al. 2018). While this is cause for celebration, it comes with limitations. The judgement still referred to cannabis as a ‘great social evil’ and people who do not have ‘private space’ where they can consume cannabis, effectively remain criminalised for their use. Parliament is further required to determine arrest thresholds as well as the mechanisms for legal regulation within 24 months of the judgement. Furthermore, possession, growing or production of cannabis remains illegal. This continues to justify the persecution of rural populations who, for generations, have relied on cultivation for survival. These same growers stand to lose out in the future if the government issues production licenses to global cannabis businesses. 

The most recent National Drug Master Plan (2019‒2024) draws on several national strategies: 

• The Health Sector Drug Master Plan

• The Anti-Substance Abuse Programme of Action, 2017-2019

• The National Anti-Gangsterism Strategy

• Draft Narcotics Integrated Action Plan 2017-2019

• South Africa’s National Strategic Plan for HIV, TB, and STIs, 2017-2022.

The NDMP presents five key principles: human rights, scientific evidence, ‘intersectionality’, person-centred approaches, and the inclusion of people who use drugs. The National Drug Master Plan was publicly released on the 26th of June 2020.

Despite its title 'South Africa free of Substance Abuse' , the National Drug Master Plan provides support for increased coverage by harm reduction services (National Department of Health, 2018a) and opioid substitution therapy for people who use drugs (National Department of Health, 2018b). It consistently refers to harm reduction as one of the pillars of national (health) drug policy, takes on board recommendation based from the preceding plan to further harmonise efforts, mentions the evidence-base behind harm reduction and advises to seek funding for an advocacy plan to upscale harm reduction in the country. The National Drug Master Plan also states that they are moving towards a different model of understanding addiction. It states that law enforcement approaches to reduce drug supply in South Africa is moving its focus from mainly arresting the drug users (who constitute more than 80% of drug related cases currently), to the manufacturers, distributors, and traffickers of drugs. 

The policies of the South African National AIDS Council support efforts to reduce stigma and discrimination, to increase coverage of harm reduction services, and to protect human rights, and support legislative reform (South African National AIDS Council, 2017, 2019b).

South Africa's National Strategic Plan for HIV, TB and STIs (2019-2022) includes a specific goal to reach all key populations with customised and targeted interventions. People who use drugs are mentioned as a key population at risk for HIV and STIs. Inmates are identified as a specific key population and mentioned separately. The goal is to reach 90% of all KP with comprehensive services by 2022. The strategy aims to better define and scale up harm reduction. As population specific additions to the HIV/STI/TB interventions mentioned in the plan for the general population, it mentions: 

• Harm reduction counselling

• Linkage to rehabilitation centres

• Case management to ensure a continuum of care

• Needle and syringe programmes

• Opioid Substitution Therapy

• Accelerated nutritional and social grant support

• Hepatitis B screening and immunisation

• Hepatitis C screening and treatment (South Africa has recently approved National Hepatitis Guidelines, in line with the latest WHO recommendations for DAA treatment.)

Vaccination against tuberculosis and hepatitis B has been part of the routine childhood immunisation programme since 1995. According to the national strategy It should be offered to people who use drugs and who were born before 1995. There is a general vaccination strategy for COVID-19, with current (January 2022) statistics showing near 27% of the population fully vaccinated. In addition to the national policies, several provinces also have their own HIV policies. 

The fragmented government perspectives are accompanied by varied implementation processes. Within departments, policy implementation is distributed to the nine provincial government structures, which vary between provinces, districts, and municipalities, depending on the dominant perspective in the region (Department of Planning Monitoring & Evaluation, 2016). This means that policy and action can be discrepant. Between departments differences in perspective can result in conflicting actions. For example, law enforcement agencies frequently challenge the legality of needle and syringe services, harass or arrest outreach workers, and continue to confiscate and destroy injecting equipment (TB HIV Care Association, 2017; Dada et al., 2019).

It is important to note that despite the positive policy progression, investments in the health of people who use drugs have been relatively small and focused on HIV prevention.

The substances most used in South Africa include cannabis, methaqualone, methamphetamine, and heroin (Dada et al., 2018). Approximately 3.7% of the country’s population use cannabis, followed by cocaine (1%), amphetamines (1%), opioids (0.5%), opiates (0.4%), ecstasy-type drugs (0.3%) and prescribed opiates (0.1%). 

Heroin use was introduced in the 1980s in a form called ‘brown sugar’ that is smoked (‘chasing the dragon’). Heroin users increasingly started to inject heroin when the supply of heroin shifted from the relatively inexpensive brown sugar variety to a more refined powder in the 1990s. Since that time, the heroin trade routes from Afghanistan have shifted down the East Coast of Africa, resulting in increased availability and a threefold reduction in the price of heroin (Haysom, Gastrow and Shaw, 2018). Injecting is preferred over smoking for the more expensive heroin, as a more efficient high.

It is estimated that over 75,000 people inject drugs (Setswe et al., 2015; Haysom, 2019). An estimated 10.000 people (13%) have access to harm reduction services. The other 87% would likely get their equipment via pharmacies, dealers and hospitals. According to a 2019 HCV/HBV study in three cities in, at last injection 77% (722/943) reported using a new needle and syringe and 17% (163/943) shared equipment. In an earlier study (2016) in five cities it was found that 26% of females and 13% of males reported to always share injecting equipment, while 49% of all participants had used contaminated injecting equipment the last time they injected. Only 6% of participants usually used bleach to clean their injecting equipment.

The most common way to consume drugs in South Africa however, is through inhalation. Heroin of varying quality is often smoked with cannabis (Nyaope or whoonga) and several additives/powders or nicotine. Data from rehab centres indicate that heroin-related admissions at rehabilitation services rose from less than 200 in 1998 to 1200 in 2016. 

The use of meth-amphetamines is reportedly on the rise: Tests of wastewater in two sites in the East Rand and Cape Town for residual methamphetamine in 2020 found that estimated meth use levels were among the highest reported in the world. This suggests that the number of people who use meth in South Africa, and possibly across the region, may be far higher than national drugs monitoring and health programmes currently believe. There is a strong and growing demand for crystal meth in Africa and a new flow of meth to South Africa appears to have emerged out of Afghanistan, with the aim of feeding the growing base of Southern African users. These growing international flows, and the scale of southern African meth consumption, may have longstanding impacts on urban governance in the region. The quality of this new meth can be variable, according to PWUD in South Africa, but normally is comparable to the best Mexican meth – an attribute that has increased demand for the new supply. Simultaneously, the pandemic has also lead to opioid shortages, which in turn may have resulted in people seeking out more readily available substances such as alcohol, benzodiazepines or mixing with synthetic drugs.

The biggest concerns in South Africa where it comes to drug use among youth is the use of alcohol, cannabis, prescription medication and Nyaope. The ingredients of Nyaope vary over time and per location. Mixes range from actual pharmaceutical drugs, cleaning chemicals, to any powder-based substance that can be found. Whoonga/Nayope is may lead to dependency because of the heroin content. The more dangerous problem is that there is no way of telling what other volatile, poisonous or inert elements are put into the Nyaope mix sold on the street. The ingredients vary from place to place and dealer to dealer. 

HIV prevalence among people who inject drugs is estimated at 21 per cent (Scheibe et al., 2016; University of California San Francisco, Anova Health Institute and National Institute for Communicable Diseases, 2018; Scheibe, Young, Moses, et al., 2019). There are no accurate estimates on prevalence of TB among PWID, but people who use drugs are defined as a population at increased risk (South African National AIDS Council, 2017). An assessment of TB and people who use drugs found that of the eight people who use drugs and acknowledged that they had received TB diagnoses, only one had started treatment (while incarcerated), only to cease on release from prison (TB HIV Care and StopTB Partnership, 2018). Hepatitis C prevalence among IDUs is estimated at 55 percent (UCSF and Anova Health Institute and National Institute for Communicable Diseases, 2018; Scheibe, Young, Moses, et al., 2019). In a recent viral hepatitis study among 1,200 people who use drugs across three cities, less than 1 per cent of participants diagnosed with hepatitis C were linked to treatment. Fear of the public health sector were some of the reasons for not accessing care (TB HIV Care et al., 2018; Scheibe, Young, et al., 2019).

The COVID-19 pandemic, created opportunities for ongoing innovation for enhanced access to harm reduction services. While each city responded differently according to their context, the innovations in each city resulted in notable change. These included shifting to a harm reduction-centred approach to substance use in Cape Town; scaling up best practices to take-home Opioid Substitution Therapy (OST) in Pretoria; providing long-term withdrawal management in Durban; and safe-guarding human rights and advocacy for harm reduction in Johannesburg. Following the first cases of Covid-19, and the resultant announcement of the National State of Disaster Regulation stated that all people experiencing homelessness must be provided with temporary shelter. This regulation also required that prevention measures against Covid-19 and access to health care services and treatment be provided. Unfortunately, the conditions in most temporary shelters were poor and many people left. During lock down people struggled to get enough income and there was a shortage of heroin on the market, although supply recovered quickly.

Dialogues with people who use drugs revealed that emergency services frequently discriminated against people who use drugs—either not arriving for an overdose if reported, or arriving only after several hours (Shelly et al., 2017). Data on drug-related deaths are limited by the large number of medical–legal autopsies that should be carried out (ca 70,000 per annum) in the context of limited forensic pathology and toxicology services (Du Tooit-Prinsloo and Saayman, 2012). There is most likely a significant underreport. Between 2016 and 2019, at least 13 people who inject drugs who accessed harm reduction services in two South African cities died as a result of overdose. None of these deaths, however, were captured and reported in the country’s formal surveillance system. Moreover, people who use drugs often die prematurely from other causes, often linked to lack of access to appropriate services (Shelly et al., 2017).

A 2020 article on overdose risks during COVID mentions that after leaving the temporary shelters that were provided during the lockdown in South Africa, the overdose risk will be elevated due to reduced tolerance and the concurrent use of other central nervous system depressants (e.g. alcohol and benzodiazepines). The trauma of leaving a 'formal' safe shelter and ongoing drug criminalisation further increase overdose vulnerability. The potential for poisoning from potent synthetic opioids, such as fentanyl and its analogues, in light of the changed drug market is unknown.

After the Government of South Africa, the US President’s Emergency Plan for AIDS Relief (PEPFAR) has been the largest investor in the HIV/TB response (over USD 5.6 billion since 2004), accounting for a quarter of costs (United States Embassy and Consulates, 2017), followed by the Global Fund to Fight AIDS, TB and Malaria (Global Fund). Apart from a project (COSUP) in the city of Tshwane, no other harm reduction services are funded by the South African Government (Scheibe et al., 2018). Between 2016 and 2019, South Africa’s Global Fund programme for HIV prevention allocated 1 per cent of its budget to people who inject drugs (Global Fund, 2015).

The two major donors for harm reduction - PEPFAR via CDC South Africa and Global Fund - have both selected their principle recipients for a next three year grant for harm reduction services. The PEPFAR/CDC grant newly assigned TB/HIV Care as their principle recipient. They will be implementing harm reduction programmes directly in Tshwane (Pretoria) and Mbombela. 

The Global Fund recently (re-)selected NACOSA as their principle recipient. The sub-grants for harm reduction programmes are yet to be defined. In the 2020-2022 grant cycle the grant included work in 7 districts across 4 provinces. The following targets were set for the 3d year of the programme, each time compared against the estimated size of the population of people who inject drugs: 

• Eastern Cape - Nelson Mandela Bay 350 out of 500, 

• Gauteng - City of Johannesburg 4779 out of 6827, Sodibeng 350 out of 500, Ekurhuleni 350 out 500, 

• Kwa-Zulu-Natal - Ethekwini 872 out of 1245, Umgungundlovu 350 out of 500, 

• Western Cape - City of Cape Town 1062 out of 1517. 

The total target accumulates to 8112 people of the estimated 11.589 PWID to be reached with harm reduction services. Subrecipients to NACOSA in this period were TB/HIV Care (4 sites), ANOVA Health Institute (2 sites) and Tintswalo Home Based (1 site). As said, the sub-recipients for the next round are yet to be selected. An evaluation of the first NACOSA harm reduction programme is expected for February/March 2022.

To date, donor support has been insufficient to enable the provision of the full WHO package of harm reduction services for people who inject drugs, with neither naloxone nor hepatitis services available. In 2019, 7316 people accessed the needle and syringe programmes (361 in Port Elizabeth, 541 in Durban, 700 in Cape Town, 1365 in Johannesburg, 4349 in Pretoria). In 2019, needle and syringe services distributed an average of 76 needles per person using the service per year, ranging from 52 per person in Pretoria to 174 in Cape Town. 

Before Covid-19, needle and syringe services therefore needed to double and OST coverage to be increased more than ten-fold to meet the WHO coverage targets. 

The harm reduction programmes report a 70-80% exchange rate of used needles. For people who cannot access harm reduction programmes there is no safe alternative to dispose of needles. People might use cans or bottles. The new Global Fund funding round is looking into piloting the placement of public sharps bins.

In 2016, two of PEPFAR’s support sites transitioned to being funded by the Global Fund, which also established two additional OAT sites in the same year and started two small opioid substitution therapy pilots shortly thereafter (Global Fund, 2019). Between 2016 and 2019 the City of Tshwane funded South Africa’s largest methadone programme via Community Oriented Substance Use Programme (COSUP). The OST dosing approach includes daily directly observed treatment (DOT) with take-home doses on weekends, and once stable, OST is entrusted to a family member or support person to take home for longer periods of time. In a 2020 evaluation of the COSUP programme it was mentioned that at the end of the programme’s third year, 5861 people had used a COSUP service at least once. More than half (57%) of OST clients were retained for at least 6 months. Although this rate is similar to OST retention rates in other low- and middle-income settings, it continues to be adversely influenced by the fact that OST is neither free nor affordable. 

Even after demonstrating early successes, the COSUP project did not expand. One factor is limited political effort to reduce the high price of methadone (Hermansen, 2015). Fear of diversion is a second factor (Adult Hospital Technical Sub-Committee of National Essential Medicine List Committee, 2019), and the favoured models informed by American policy often impose a level of social control (Bourgois, 2000) in an attempt to prevent diversion. Various stakeholders in South Africa argue that a more effective approach is to ensure that there is sufficient coverage through low threshold community-based services. 

The funding of the largest opioid substitution therapy programme in South Africa by the City of Tshwane was an important step towards government investing in effective interventions. While the remaining harm reduction interventions remain donor-funded, it is possible that another round of PEPFAR and Global Fund support for HIV prevention for people who inject drugs and harm reduction will be available and provide the opportunity to plan for the transition towards government support.

Currently, naloxone is registered and available – via prescription only - as a hydrochloride solution in an ampule, typically 0.4mg per 1ml injection. Youth Rise and SANPUD decided to go ahead with a Naloxone training session about the drug, its active ingredients and how to deal with overdoses across South Africa, with part of this rollout being the distribution of Naloxone kits to our field workers early in September 2021. At least one life has been saved as a result of this training and the organisation seeks to further role out this effort. 

According to a 2019 Aidsmap report, HIV testing among people who inject drugs ranged from 15% in Pretoria and 26% in Johannesburg to 49% in Port Elizabeth and 57% in Cape Town. Of those tested, an average of 33% (598 of 1773) were diagnosed with HIV. Diagnosis rates ranged from 3% in Cape Town to 45% in Johannesburg. On average, only 20% of those diagnosed with HIV had started antiretroviral therapy (ART). This again ranged from 6% in Durban to 65% in Johannesburg. A high loss to follow-up in the cascade between testing HIV positive to viral suppression was found: of the 598 people who tested HIV positive, only 82 (14%) were confirmed to be on ART. Viral suppression data were unavailable across the cities. In Durban, only 1 of the 16 people diagnosed with HIV was confirmed to be on ART. In Gauteng Province (Johannesburg and Pretoria combined), 11% were confirmed to be on ART (62 of 546 who tested HIV positive), 20% in Cape Town (2 of 10) and 65% in Port Elizabeth (17 of 26).

There are a considerable number of addiction treatment centres in South Africa that offer drug detoxification, both private and state funded. Foreign patients are increasingly going to South Africa’s private clinics to deal with their dependency on substances and for behaviours ranging from gambling to sex. South Africa’s rehab industry is growing due to the affordability and the quality of care. Addiction care is 65% cheaper in South Africa than in Europe. This allows people to get treatment for twice as long for the same price. Nationally, the programmatic responses to drug use are seldom evaluated, and when they are, the results tend to be poor. In the Western Cape, the Matrix Model outpatient programme for people who use stimulants (Center for Substance Abuse Treatment, 2006) was adapted to include people who use opioids. However, after 12 weeks, only 7 per cent of people using opioids were retained at ‘graduation’ (Magidson et al., 2017). Despite the absence of data, there is continued government support for expanding the availability of abstinence-based drug rehabilitation (Zulu, 2019).

Most harm reduction services are outreach-based and target people who use drugs and are homeless. Some cities have drop-in centres that offer services for people such as a shower, a meal, support groups and counselling.

From the start, peers have been very involvement in the establishment of harm reduction services in South Africa. Implementing partners worked with Community Action Groups (CAGs) to understand local health needs, to ensure programmes would fit these needs and to get feedback on services once established. Many of the people involved in the CAG later also became involved as peer workers in the programmes. A 2019 track record documents the important role of peers in South Africa's programmes (involvement in programme planning, evaluation, as peer workers/educators). 

Mainline's 2021 guideline 'Reducing Harms in the Work Environment' looked closely at the role of peer workers within the various harm reduction services. It echo's the great value of peer workers, but also has some clear recommendations: 

1. Pay attention to recruitment

2. Offer diverse work engagement levels. 

3. Promote a harm reduction approach to drug use among staff. 

4. Foster a supportive work environment. 

5. Provide and foster mental health care. 

6. Build and sustain boundaries. 

7. Invest in team care by promoting diversity and respect. 

8. Promote meaningful involvement of staff who uses drugs at all levels, not only on service delivery.

A 2017 article describes how peers were included in mapping exercises to inform programming and concludes that this is an effective method. In 2020 a community-led research was implemented among young key populations and in particular among young people who use drugs (30 out of 85 respondents). The assessment recommends programmes to set up youth friendly services and addresses some of the key needs of this population.

The 2019 'Community Matters' report includes a case study on peer involvement in South Africa. It mentions that peer contributions to the programme are highly valued by beneficiaries and even deemed of higher quality compared to contributions provided by other outreach workers. It is also worth to mention the important role of peers in the COSUP programme in the city of Tshwane. In COSUP, OAT is dispensed using a community model and each of the dispensing sites has peers present to help people who inject drugs to navigate into the OAT programme. 

In addition, people who use drugs played a very important role during the service disruption that lasted for almost two years in Durban. The city closed down the harm reduction service, including the needle and syringe programme, when needles washed up the beach. The programme was closed for nearly two years and peers took up the role of disseminating clean needles amongst themselves.

In particular the Global Fund-funded programmes work with peer models for outreach, referred to as 'micro-planning'. Using this model, outreach workers coordinate several peer workers, who cover the drug scenes of which they are themselves a part. This method has several advantages from both a programmatic point of view (credibility, bigger reach) and an individual perspective (an opportunity to get paid work, empowerment). However, peers are often very poorly paid, although they work long hours. There is high staff turnover and a divide between staff that actively uses drugs and staff that do not.

The 2020 guide 'Reducing Harms in the Work environment’ highlights the distinction between peer staff and management and the difficulties of climbing the career ladder within a harm reduction programme. As a result, there are few to no active drug users working on management level in harm reduction programmes. 

At the start of the harm reduction programmes in Pretoria, Cape Town and Durban, the outreach workers were trained to document human rights violations and an advocacy officer compiled all violations into a report. This was a powerful tool and easy to implement for outreach staff and peers. It is unclear whether this is still applied in a similar systematic manner to date.

SANPUD is one of the few national networks of people who use drugs with a reasonable level of funding. They advocate for better service access and the scale-up of harm reduction, were actively involved when the Durban-based programmes were interrupted, they call out for special measures during COVID and for peer distribution of naloxone. Attempts at inter-sectoral collaboration around drug use are taking place at the local and national level. This includes the development of technical working groups that include members of the South African Network of People Who Use Drugs, which have informed national policy (Shelly and Howell, 2018), and the participation of networks of people who use drugs in some regional and local drug action committees (Scheibe, Shelly, et al., 2020). These relationships can be nurtured to influence future policy.

People who use drugs in South Africa report persistent and extensive human rights violations. Between July 2015 and May 2019, 1,105 rights violations were reported by 403 people across three cities as part of the human rights reporting system implemented by TB HIV Care—54 per cent (598) due to the confiscation or destruction of sterile injecting equipment by law enforcement officers, resulting in significant trauma.

Healthcare providers in South Africa are often representative of dominant moral positions around drug use. They are neither sensitised nor equipped to manage the realities and needs of people who use drugs (TB HIV Care and Stop TB Partnership, 2018; Duby et al., 2019). Consequently, stigma and discrimination towards people who use drugs is widely accepted in healthcare facilities. This includes denial of care, conditional access to care, shaming, lack of confidentiality and privacy and being made to wait disproportionately long periods for services (Shelly et al., 2017, Versfeld et al., 2020). Moreover, there are currently no effective accountability mechanisms within healthcare facilities to manage these rights abuses, nor is there easy access to legal recourse for people who use drugs whose rights have been violated (TB HIV Care and Stop TB Partnership, 2018). Stigma does not have to be personally experienced to impact on individuals. Peers’ experiences of stigma are powerful disincentives for individuals to access healthcare in South Africa. Stigma in the healthcare system also reinforces low self-worth, which in turn inhibits health-seeking behaviour (Versfeld et al., 2020).

Drug testing at work is allowed in South Africa when it is mentioned in the employment contract, or in a separate Substance Abuse Policy that needs to be circulated to staff. There are also two laws that are on the side of the employer, Act 140 of 1992 (Drugs and Drug Trafficking Act) and OHSA (Occupational Health and safety Act). Since 2001, when regulations for safety Measures at Public schools (gg 22754) was published, all South African schools have been declared drug-free zones. No person may possess illegal drugs on school premises. When policies are in place, schools are allowed to perform drug tests and to search for drugs (e.g. in lockers). Regulations for Safety Measures at Public Schools (Government Gazette 1040), are designed to make sure that students do not feel shamed, and are designed to help principals and teachers use drug testing in a thoughtful and careful manner that supports the health and dignity of all young people. According to the law, no one can be forced to take a drug test, but it can be a reason for disciplinary action if you do not submit a drug test.

The Prevention Of and Treatment Of Substance Abuse Act 2008 is the Act which sets out how and under what circumstances a person can be forced to attend a rehab treatment centre. The Act recognizes the harm associated with substance abuse and looks at how rehabilitation institutions can assist a drug user and allow for his or her eventual reintegration into society. With regard to children, (under 18 years) the Act says that: If a child displays behaviour which cannot be controlled by the parent or caregiver, or lives or works on the streets or begs for a living, or is addicted to a dependence-producing substance and is without any support to obtain treatment for such dependency, that child is said to be in need of care and protection. A social worker will be required to place the child in a temporary shelter. If the addict is a child then their best interests, as enshrined in Section 28 of our Constitution, remain paramount.

Compulsory testing for HIV has been a topic in South Africa, but it is not being implemented. However, there have been reports of mandatory or compulsory testing (e.g. in antenatal care), violations of privacy and confidentiality.

In 2019 an action plan to counter human rights violations and barriers that stand in the way of HIV and TB treatment was launched. One of the strategies in this plan: access to a wide range of legal support services will be strengthened in an effort to reduce rights violations and promote access to healthcare. Efforts should be made to strengthen the sensitisation of Chapter 9 institutions and existing legal and paralegal support services and to advocate for a cadre of human rights defenders at community level who are able to make referrals for addressing legal disputes and to monitor arrests and court appearances of people who use drugs, and sex workers.

A history of alcohol or drug abuse can significantly affect your custody agreement and influence the Court’s decision when granting access to your child. That does not mean that a person with these types of issues will not get custody of their children, but there can be hurdles that are set up that the affected person will have to “jump over” to show that the children are safe in his or her care.

The current conditions in South African prisons fail to meet the minimum standards established in national and international legislation and declarations. Further, South African prison conditions represent serious breaches of rights enshrined in the South African Constitution. The only right that inmates should be deprived of is liberty. Prisoners’ rights to dignity, bodily integrity, and the right to be protected from any cruel, inhuman and degrading treatment, must be upheld in a constitutional democracy.

Currently, South Africa is experiencing an influx of cases of police brutality. More than 5 500 cases of police criminal offences are reported every year. Of these numbers, according to the 2019/2020 Independent Police Investigative Directorate (IPID) Annual Report Statistics, more than 3 500 cases of torture and assault (police brutality) were reported. This equates to more than 60% of reported cases of police brutality (torture and assault) with an average of 65% for the past four financial years. These statistics indicate that South Africa did not only inherit the culture of police brutality as the legacy of the past but has inherited the acceptance of such criminal behaviour by failure to hold the police accountable for their criminal acts of police brutality. 

Armed community members and vigilante groups have stepped in ‘to tackle unrest’ in South Africa, taking matters into their own hands and sometimes stoking violence as security forces struggle to restore order. These groups often target people who use drugs or small-scale dealers and turn their frustration and aggression against them. 

Soldiers from the South African National Defence Force have moved into various suburbs in what’s known as the Cape Flats – an area of Cape Town racked by gang violence.

South Africa has 243 correctional centres (or ‘prisons’), with a total inmate population of approximately 141.000 in early 2022. Of these, 34% are in pre-trial detention. The vast majority of sentenced and unsentenced inmates are male – 2.4% of prisoners is female. Prison conditions in South Africa are particularly dire. Inmates and remand detainees experience extreme overcrowding – prisons are at 127% of their capacity - and inhumane living conditions, including: poor ventilation; inadequate ablution facilities; lack of sanitation and privacy; a shortage of beds and bedding; insufficient supervision and oversight; and poor healthcare provision. Consequent of these conditions, prisons can be hotbeds for sexual violence and disease transmission, including human immunodeficiency virus (HIV) and Tuberculosis (TB). 

It is unclear what percentage of inmates in imprisoned for drug-related offenses. 

The NDMP accepts the notion that sending drug users to prison could have negative consequences in particular if there are few behavioural or biological interventions in prison that aid drug users. Exposure to the prison environment often facilitates involvement with older criminals, criminal gangs, and organisations. It also increases stigma and the formation of a criminal identity. The prison environment often increases social exclusion, worsens health conditions, and reduces social skills. Besides, incarceration and serving penalties for drug use is expensive, whereas humane treatment in the community encourages voluntary uptake of treatment

Diversion entails voluntarily attending a life skills course and counselling. You must take responsibility for your actions and avoid re-offending. You may be required to do some form of community service. If our diversion application is successful, you will not have a criminal record. 

Aside from a recent, small-scale pilot in Durban for female prisoners, there is no access to Opiate Agonist Therapy (OAT), overdose prevention or other harm reduction commodities. Women in South African prisons have reported dehumanizing and punitive attitudes, including hindered access to basic health care based on discriminatory attitudes of prison staff against drug use. 

There is no access to clean needles and syringes while in prison.

The Department of Correctional Services has primary health facilities and programmes for HIV, TB, sexually transmitted infections (STIs) and primary health conditions (Department of Correctional Services, 2018). In principle, people should be able to continue with medical treatment (including ART) while in prison. 

The prevalence of TB and HIV among incarcerated adult males is notably higher than among males in the general population, with higher levels probable among incarcerated people who use drugs (South African National AIDS Council, 2017; Human Sciences Research Council, 2018). HIV prevalence in prison populations is estimated at 15.6%, which is more than three times higher than the general population. According to the correctional services, 97% of HIV positive inmates in South Africa’s correctional centres are on HIV treatment and there is an 84% TB cure rate at these centres., but anecdotal evidence suggests that this claim is exaggerated and in practice access to health screening and health care is very poor. Most prisoners have to rely on family members to get access to their prescribed medication. 

Among the 75,000 people who inject drugs in South Africa, it is estimated that between 16% and 23% of these are women. Previous studies in the country have called attention to the difficulties of health systems in responding to women who use drug’s needs. Women who use drugs are ‘not on the agenda’ of health policy and planning, and services end up being unresponsive to the multiple needs of the population. 

A few assessments with women who use drugs called attention to some of their unmet needs and barriers to access health care. A 2021 in-depth study called ‘Sister Spaces’, bundled the available information and included the perspective of service providers who (could potentially) work with women who use drugs. 

The ‘Sister Spaces: Needs, Challenges and Services for Women who Use Drugs’ documents the needs and challenges of women under the following categories:

1.  Discrimination when accessing public health care

2. Legal barriers and law enforcement harassment

3. Gender-based violence

4. Intimate partner violence

5. Lack of privacy and condidentiality

6. Family relations and stigma

7. Parental rights and motherhood

8. Self-stigma

9. Lack of hygiene, clothing and nutrition

10. Lack of shelter

11. Unemployment and lack of (formal) skills

12. Centralised services and lack of transport

13. Lack of programmes for non-injecting drug use

Most harm reduction services in South Africa are gender-neutral, with the exception of some female-only activities and in a few cases female-only opening hours. Activities that were mentioned were SRHR services, distribution of dignity packs, support groups, psycho-social support and individual counselling and skills development activities. The Sister Spaces report offers 26 practical recommendations to improve the service offer for women who use drugs in South Africa and is an important source for further advocacy.

Though South Africa is considered an upper-middle-income country, with a gross domestic product of USD 368 billion, it has one of the highest levels of socio-economic inequality in the world: half the population lives in poverty and a third of adults are unemployed (Statistics South Africa, 2019b; World Bank, 2019). Massive disparities in socio-economic status continue to play out along racial lines. Many people face considerable challenges in exercising their constitutional rights and—as we show in what follows—the context with regard to inequality has a significant impact on health outcomes (Ataguba, Akazili and McIntyre, 2011).

The high prevalence of childhood adversity among South African youth increases the likelihood of developing substance use problems and mental illness, as well as HIV infection (Jewkes et al., 2010). Recent research has identified high levels of violence and trauma among women who use drugs (UNODC, 2019a).

Violence in South Africa is ubiquitous: 40 per cent of children are exposed to or have been victims of violence, a quarter of women have been raped, and the homicide rate is 33 per 100,000 people (Day, Gray and Ndlovu, 2018).

The nexus between gangsterism and drug distribution persists. The increase in the number of gangs and gangsterism across the country continues to increase youth access to drugs and heightens competition for the illicit drug markets. The illicit drug markets are facilitated by sophisticated networks within the industry necessitating law-enforcement approaches (supply reduction) to focus mainly on the manufacturers, distributors, and traffickers of drugs as opposed to the people who use drugs. Currently, arrests of people who use drugs constitute more than 80% of drug related cases.

Media reports on drugs and drug-related crime are often very subjective and intend to arouse fear. Examples are the reports of Nyaope as a pandemic and assumption that substance abuse is the key cause of endemic crime rates in South Africa. 

The South African health system is sharply divided between a highly sophisticated private healthcare system, supported by the extensive use of private medical insurance (covering less than a quarter of the population), and a public healthcare system that provides care and treatment (including HIV and TB treatment) free of charge or on an income-based scale to the majority of the population (Health Policy Project, 2016). Overall, public health resources largely remain distributed along previous apartheid-informed lines, with historically advantaged white areas, which are often physically and practically inaccessible to the economically excluded black majority, hosting the most comprehensive, quality services (Harris et al., 2011; Coovadia et al., 2009). A substantial portion of healthcare, particularly for marginalised populations and as part of the HIV response, is now provided by civil society organisations (South African National AIDS Council, 2017). 

Health expenditure in South Africa comes from three primary sources. The government finances approximately half of all expenditure (in 2017/18 this was approximately USD 12.8 billion). In the 2017 Medium Term Budget Policy Statement, USD 0.3 billion was allocated to National Health Insurance over three years to establish a national health insurance fund and to enhance health technology assessment capacity, with additional investments planned (Day, Gray and Ndlovu, 2018). 

Donor investments account for a small proportion (2.4 per cent) of overall health spending, and the remaining financing is from the private sector (Day, Gray and Ndlovu, 2018). In 2016/17, approximately half of the government’s total health budget was allocated to the HIV/TB response, and 5 per cent to mental health (Docrat et al., 2019), of which services for people who use drugs form a small part.

In 2018, South Africa’s score for Universal Health Care coverage1 was 66 (of a maximum of 100) (Day, Gray and Ndlovu, 2018) in comparison with a global average of 65 (range 22–86) (Hogan et al., 2018).

 Based on data gathered via desk research and key informants, and on the validation meeting with Love Alliance grantees and other key stakeholders from South Africa, we propose the following recommendations:

Advocacy & policy reform

●       Advocate for the decriminalisation of people who use drugs

●      Advocate for alternatives to arrest in case of drug related crimes (pre-arrest diversion)

●      Advocate for domestic funding for harm reduction services, including NSP and OAT

●      Advocate for OAT to be covered by medical aid

●      Advocate for access to Healthcare and Sexual Reproductive Health Rights for people who use drugs

●      Foster CSOs participation in public hearings in Parliament

●      Foster CSOs engagement with government to discuss Policies and Strategic plans as well as implementation gaps and practical solutions.

Awareness raising

●     Promote awareness-raising among police force regarding violence and discrimination of people who use drugs, specially people who are experiencing homelessness

●      Addressing Stigma and Discrimination through various Community Engagements

●      Identifying areas where communities have least access/support.

Community-based research and assessments

●      Update population size estimates

●      Build up on the Department of Health plans of implementing mental health screening that includes substance use screening in households and community health centres

●      Implement the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) from the World Health Organisation (WHO) in community health care centres, as a way of collecting accurate and updated data on substance use at the com

●      Investigate the extent of harm reduction implementation at the community level

Harm Reduction services

●      Develop broader harm reduction approaches around poly drug use in current services

●      Upscale services and specific interventions for people using stimulant drugs

●      Set up harm reduction services in rural communities

●      Provide harm reduction in prison settings

●      Provide peer-distribution of Naloxone

Learning needs

●       Educate health departments ion successful models for national harm reduction implementation

●       Sensitise media on how to report on Harm Reduction