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Injecting drug use is an increasing cause of HIV transmission, the number of countries in which injection of drugs has been reported has increased over the last decade. The high prevalence of HIV among many populations of injecting drug users represents a substantial global health challenge. Extrapolated estimates suggest that 15.9 million people might inject drugs worldwide. However, existing data are far from adequate, in both quality and quantity, particularity in view of the increasing importance of injecting drug use as a mode of HIV transmission in many regions such as South Africa [8]. Although injection drug use is low in South Africa in comparison with many other countries, with the increase over time in the use of substances such as heroin, the potential exists for this to change rapidly [9]. The rapid assessment undertaken with drug using commercial sex workers in Cape Town, Durban and Pretoria by Parry et al. in 2009 recognises the need for prioritising interventions recognising the role of drug abuse in HIV transmission, the issues of access to services, stigma and power relations [3]. Furthermore, a study by Dos Santos, Rataemane, Fourie and Trathen (2010) notes that limited strategic public health care policies that address substance use disorder syndromes complexities have been implemented within the South African context [10]. The study further emphasises the need for pragmatic and evidence-based public health care policies that are designed to reduce the harmful consequences associated with heroin use in particular, still needs to be implemented. According to Weich, Perkel, Van Zyl, Rataemane, and Naidoo (2008), medical practitioners in South Africa are increasingly confronted with requests to treat patients with heroin use disorders for example, but many do not posses the required skills to deal with these patients effectively [11]. The study by Dos Santos et al (2010) further discerns the need be make HIV testing and treatment services available in places accessed by vulnerable people as fear of stigma and discrimination often keep injecting users away from public health facilities [10]. According to Parry et al (2008) there is also a widespread lack of awareness about where to access HIV treatment and preventative services, and numerous barriers to accessing appropriate HIV and drug-intervention services such as long waits and appointments being cancelled without notice [4]. These authors further reiterate that multiple risk behaviours of vulnerable populations and lack of access to HIV prevention services could accelerate the diffusion of HIV.

The findings and recommendations from the assessment of the current drug/HIV situation in Pretoria, South Africa, are presented in this article. It forms part of the project 'Developing HIV prevention services among drug using populations and among prisoners in South Africa' of the Trimbos Institute - the Netherlands Institute of Mental Health and Addiction, in cooperation with local South African partners. The project was implemented from September 2009 until October 2010 and was funded by the Dutch AIDS Fonds. The project of three assessments on the nature and extent of health problems among (injecting) drug users in Cape Town, Johannesburg and Pretoria. In Pretoria the assessment was undertaken by the Foundation for Professional Development (FPD)2 with support from the Trimbos Institute. FPD is a South African Private Institution of Higher Education established in October 1997 by the South African Medical Association (SAMA) with support from the Trimbos Institute. Pretoria is the executive capital of South Africa with over two million inhabitants. The Pretoria drug scene can be described as emerging, with relatively large numbers (several hundred) of drug users, mainly black people, visiting and loitering in the inner city. Pretoria has a regional retail function for the large surrounding townships of Atteridgevile, Soshanguve, Mamelodi and the wider region.

The focus of RAR is on adequacy rather than scientific perfection. For adequate interventions in the field of health promotion the need to know the absolute number of people involved in certain risk behaviour is not necessary. It is sufficient to have cognisance that a substantial number of people are involved in this risk behaviour. Through cross-checking information from various data sources, RAR enables the establishment of reliable information about the occurrence and the nature of certain forms of risk behaviour. RAR is therefore used in cases where the focus is not on knowledge as such, but on knowledge which makes a quick response possible. Relevance to interventions and pragmatism are key features of RAR [17].

The following steps were included in the RAR: viewing existing information, access (to relevant stakeholders and target groups) and sampling (KI participants for interviews), semi-structured interviews, and FGs (to verify collected information and to agree on appropriate and feasible interventions).

The direct risk of health/organ damage from substance use was overwhelming cited by all KI participants. Health and organ damage related to a range of problematic, including drain, liver and kidney damage, as well as skin lesions and abscesses. Affluence appears to play a prominent role in terms of accessibility to needed medical intervention. Overall HIV protection measures seems to be insufficient, and that more protective measures should be adopted, such as condom use, clean needle accessibility, and to stop using needles altogether. It appears as though both KI users and a number of KI service provider participants are also not fully aware of the real, concrete health risks involved in drug use, and the vague ideas that many participants hold does not allow for concrete measures to protect themselves (apart from ceasing drug use). This is underlined by some of the user participants citing multivitamin usage as an effective means of preventative intervention. This finding has important implications for responses on multiple levels: thorough information is urgently needed for users and professionals alike, such as information programmes and brochures (for users and service providers), training (for professionals), counseling, and peer support and education.

The mention of the development of mental disorders such as depression and psychosis highlights the need for integrated mental health services for those afflicted by the dual diagnosis of psychiatric disorders. Epidemiological studies have shown that between 30% and 60% of all substance dependents have a concurrent or co-morbid mental health diagnoses, including major depression, schizophrenia, bipolar disorder, anxiety disorders, PTSD and personality disorders [23-25]. A concurrent mental disorder can complicate substance use disorder treatment in a multitude of ways, for example, clinically depressed individuals have an exceptionally hard time resisting environmental cues to relapse. People with heroin dependence and mental illness co-morbidity, for example, are more likely to engage in behaviours that increase the risk of HIV/AIDS, and injecting heroin dependents with antisocial personality disorder more frequently share needles [26].

State sponsored interventions are also needed, especially residential care, as well as drug awareness campaigns in schools and correctional services, outreach programmes, legal enforcement and police intervention. It was also felt that the target group might not accept all interventions due to the denial of their problem, and due to the reality that they do not want to get caught by anyone. Evangelical religious rehabilitation centre interventions were also cited as not being accepted due to their fundamentalist and extremist strategies as well as rehabilitation centres in general as the target group may not prepared to go, some of these centers remain unregisterd in South Africa and various human rights violations have been reported [27]. The cost of residential treatment was regarded to be too high, and accessibility was regarded to be problematic. Similarly, in the study by Parry et al (2009), drug user interviewees felt that there was a shortage of drug rehabilitation centres, and suggested the opening of more drug treatment facilities in nearby areas as well as making more outreach programmes available [3]. The concern was further raised that rehabilitation centres would not be accepted by politicians and policy makers due to a lack of information and unwillingness to provide funding. The view was held that politicians and policy makers might not be trained extensively enough in the field to make informed decisions. 041b061a72


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