Risky sex on drugs a challenge for HIV prevention

South Africa's status as the country with the highest number of HIV infections in the world is well known; its rapidly emerging roles as a major transit route for trafficking illegal drugs and the leading consumer in the region is less well documented.

Injecting drug users are an established sub-culture in South Africa but the rising consumption of cheap drugs that tend to increase the likelihood of unprotected sex is causing growing concern. Experts agree that risky sex while under the influence of narcotics is now the country's biggest drug-related HIV problem.

Changing trends

Drug-use trends vary widely from one province and even one town or district to the next, but users are getting younger and more racially diverse. As organised drug syndicates spread their reach beyond inner cities, users are as likely to be small-town schoolgirls as inner-city sex workers or gay clubbers. A few years ago, whether you smoked crack cocaine, swallowed club drugs like ecstasy or injected heroin depended largely on your race.

"Tik Monsters"

CAPE TOWN, In Cape Town, the Women's Health Co-op, which works with women in the US and South Africa to reduce drug abuse and other high-risk behaviours, has conducted one of the few surveys exploring the links between drug abuse and HIV risk. The findings confirmed that the use of mephamphetamines (locally known as "tik") has reached epidemic levels among the city's coloured, or mixed-race, population. Of the 280 young coloured women surveyed, 89 percent had used tik, and of those only 46 percent had used a condom at last sex - significantly lower than non-tik users. The tik-using women were also more likely to have had multiple partners, and less likely to have talked to their partner about condoms. Dr Wendee Wechsberg, the study's principal investigator, said participants reported that trading sex for tik was common, and girls who did tik were especially vulnerable to sexual abuse and violence. "They call the girls who do tik, 'tik monsters' - men pool their money to buy them enough drugs to make them unconscious, then they gang rape them," she said. The next stage of the project, funded by the US National Institute on Drug Abuse (NIDA), will introduce some interventions aimed at addressing the intersection between substance abuse, sexual risk and violence. In Wechsberg's view, such an approach is overdue: "Everyone is operating in a silo, no one is looking at the links between drugs, sex and violence."

"It used to be mostly white people using heroin, whereas dagga [cannabis] and mandrax [a blend of the pharmaceutical drugs methaqualone and antihistamine, originally sold as sleeping tablets] was more for blacks, but not any more," said Captain Francois Reuts of the South African Police Service's Crime and Intelligence Unit in Witbank, a town in Mpumalanga Province, northeast of Johannesburg.

People's choice of drug and mode of consumption now often depends on where they live. "It varies from one spot to another, even within a township you'd hear that one group is smoking and one injecting," said Modi Marishani, of the Pretoria office of the United Nations Office on Drugs and Crime (UNODC).

"It used to be generally that only white people injected, but trends have changed - it's cross-racial. Now it depends more on who introduced it and how many people follow; it's about peer pressure."

East of central Johannesburg in one of the city's oldest suburbs, tree-lined streets and Victorian houses are mixed with low-cost housing. Most residents are working-class; a few, including the recent influx of Mozambican immigrants, are slipping into poverty.

Black, white and mixed-race, they come to John [not his real name] for everything from cocaine to methcathinone (locally known as 'cat') to crack - which he makes himself and sells for R50 (US$7) a half-gram.

"In [Johannesburg's inner-city suburb of] Hillbrow you'll get the same for R20 (US$3) but it's not nice - they mix it with too much other stuff," said John, who is not a drug user but personally tastes every batch he makes.

At night he works behind the bar of his own tavern, an establishment that the local community forum has fought to close down. Knife fights frequently spill out into the street and young girls perform impromptu strip teases on the stage while customers drift in and out with orders. Everything but heroin is on the menu. "That stuff is dangerous," John said. "You get caught with that and things will go bad. You won't find many selling that."

According to the South African Community Epidemiology Network on Drug Use (SACENDU), which monitors drug-use trends, heroin is now reaching Johannesburg and Pretoria via the "Maputo Corridor", the main trucking route from Maputo, capital of Mozambique.

As a result, Mpumalanga, a largely rural province that the drug route cuts through, is experiencing an expanding heroin problem. Even within Mpumalanga, trends vary: in Witbank it is more likely to be mixed with cannabis and smoked by black users; in Nelspruit, a town closer to the Mozambique border, mostly white users tend to inject it; in the small town of Piet Retief, in the south of the province, it is hardly available at all, and cannabis and mandrax are the main problem.

Harm reduction

With so many different drug "cultures", each with its associated HIV risks, developing targeted prevention programmes is a challenge. Other countries, particularly in Asia, have adopted harm-reduction strategies such as needle exchange and drug substitution programmes to combat HIV epidemics that are highly concentrated among injecting drug users.

"Ke Moja"

PIET RETIEF, With support from UNODC, a drug prevention programme called Ke Moja - meaning No thanks, is being run at schools all over the country. At an after-school session, Ke Moja peer educators at Amadlelo Aluhlaza Secondary School in Piet Retief reflected on their past experiences with drugs and alcohol. "I was an alcoholic. When school closed, I started drinking," said Zandihle*. "I also got involved in love, I had many boyfriends. It was peer pressure, it was a fashion." "I was smoking mandrax and dagga," said Beauty*. "I was buying it from people at school. I felt nice, like I can love everyone." "I learned boys are like bees, visiting different flowers; after that the flower just dies," said another peer educator. Barry Van Rensberg, director of an inpatient SANCA clinic in Piet Retief, said there had been a marked drop in the average age of his clients. "We discuss risky sex with our outpatients and I haven't had one who didn't admit to having risky sex," he said. "And, lately, I've had a lot of young girls." *Not their real names

South Africa's recently adopted National Strategic Plan for HIV and AIDS recommends the incorporation of "HIV harm reduction measures" into new legislation aimed at preventing and treating substance abuse, but Carol du Toit, head of the Durban office of the South African National Council on Alcoholism and Drug Dependence (SANCA), pointed out that the government has yet to define what it means by the term.

Harm reduction can be broadly interpreted to mean anything from safer sex counselling to condom distribution. For now, she added, the low levels of injecting drug use in South Africa have not warranted needle exchange or drug substitution treatment programmes.

Such efforts in South Africa are mainly limited to outpatient drug-treatment facilities that rely on individual counselling to motivate clients to stop using, but because there are very few state-funded facilities, drug users in lower income groups have tended to fall through the cracks.

The partially government-funded clinics run by SANCA, a non-governmental organisation with a network of drug treatment facilities, offer some of their services on a sliding scale, depending on the client's income. But Captain Reuts said few of Witbank's poor black users, many of whom live on the streets and wash cars to pay for their habit, find their way to the local SANCA clinic.

Need for more integration

Measuring the incidence of risky sex resulting from drug use is very difficult, so relatively little is known about the extent of the problem and, given the overwhelming scale and generalised nature of South Africa's HIV epidemic, it received little attention until recently.

A 2006 review of the existing studies on drug-related HIV risk, published by Prof Charles Parry and Anne Pithey of the Medical Research Council's (MRC) Alcohol and Drug Abuse Research Unit, found very few programmes in South Africa that focus specifically on the prevention of HIV among drug-using populations. Instead, the government has mainly relied on law enforcement to reduce the supply of drugs, and awareness campaigns aimed at reducing demand.

As part of a programme being piloted by the MRC, the Triangle Project, a Cape Town-based service organisation for the lesbian, gay, bisexual and transgender community is now linking up with the Cape Town Drug Counselling Centre to share knowledge and swap skills.

"We're very clued up on substance abuse and they're very clued up on HIV," Grant Jardine, director of the Cape Town Drug Counselling Centre told IRIN/PlusNews. "For a long time we've wanted to address HIV among our client base because, anecdotally, we know a large number of them are HIV positive."

Previously, clients wanting to know their HIV status had to be referred elsewhere, but through the MRC project, the centre will soon be able to offer in-house counselling and testing (VCT) services, condoms and advice on how to minimise HIV risk.

Meanwhile, volunteers from the Triangle Project will soon be targeting men in gay clubs and bars with information on the increased risks of HIV infection associated with drug use.

"We're sitting on two epidemics in the MSM [men who have sex with men] community: one is HIV, and one is recreational drugs," said Glenn de Swardt, head of health services and research at the Triangle Project. "A lot of our [HIV-positive] clients say drugs played a role in their infection."

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See new indepth: Deadly cocktail: HIV and drug use