Anova Health Institute’s harm reduction initiatives for people who use drugs

Chemsex is the colloquial term used for a specific pattern of drug use that is increasingly common globally among men who have sex with men (MSM). In a recent UK study, 22% of HIV negative men attending a sexual health clinic had used a drug associated with chemsex within the last 3 months,¹ while the prevalence of chemsex is unknown in South Africa.² The practice, also known as ‘party and play’ (PnP), has been associated with high-risk sexual practices and increased transmission of HIV and sexually transmissible infections (STIs).¹ Chemsex differs from other patterns of drug use because the recreational substances employed are used specifically in a sexualized context.³ Drugs used for chemsex vary widely, but the most commonly used drugs are: crystal methamphetamine, methadrone, gamma-hydroxybutyrate (GHB) and gamma-butyrolactone (GBL).^1,4,5 Chemsex drugs are often used in combination with each other and may also include alcohol, cannabis, nitrates (poppers) and sometimes heroin.^2,6

The reasons for chemsex among MSM are complex. MSM experience stigma and discrimination in their daily lives in many settings, which negatively affects their lived experiences and their health access and outcomes.^7,8,9 This can result in internalised homophobia and higher levels of depression, anxiety and substance abuse compared to heterosexual people.¹⁰ Other reasons for drug use include sensation seeking, increasing and prolonging sexual pleasure, overcoming inhibitions and coping with isolation and loneliness.^3,7

There are multiple possible harms associated with chemsex and, particularly, with slamming. Psychosocial harms include criminal arrest, addiction and decreased functionality regarding daily activities. Biomedical harms associated with drug use include risks of overdose or death, transmission of blood-borne viruses (hepatitis and HIV) as well as a range of other sexually transmitted diseases.^6,11

The World Health Organization (WHO) has provided health guidance to address drug use among key populations such as MSM.^12,13 Despite this, little implementation has occurred in South Africa, and harm-reduction projects remain unfortunately rare. Anova Health Institute (Anova) explored harm-reduction services at their Ivan Toms Centre for Men’s Health (ITCMH) clinic in Cape Town, South Africa.

This project, known as Tikking the Boxes (Tik is a local South African word for crystal methamphetamine), was funded by the Dutch organisation, Aids Fonds, together with the technical assistance of Mainline, another Dutch organisation with expertise in programs addressing recreational drug use. The objectives were two-fold; first to provide direct harm-reduction services to drug-using MSM in Cape Town, South Africa, and second, to reduce HIV and hepatitis B and C transmission among this population. This was done by identifying drug-using behaviour among MSM and linking them to harm-reduction services. Drug-using MSM were supplied with safe injecting and/or non-injecting drug use packs, risk-reduction counselling, screening for HIV, viral hepatitis, and STIs and were linked to general health, psychiatric or rehabilitation services as needed.

The project started in August 2013 and ran through to October 2014. Staff included sensitised general Health4Men peer educators and clinical staff already providing a range of health services to MSM. Four additional outreach workers who were active drug users with current access to networks of other drug users, and who were regularly invited to private MSM sex parties where crystal methamphetamine-injecting behaviour was practised, were also employed for the program. Employing people who were currently using drugs was a novel aspect of this program, which was very successful in facilitating access to drug-using networks.

Program staff, including sensitised healthcare workers, four outreach workers and 20 peer educators received formalised and extensive in-house training from Anova and Mainline about values clarification, stigma and prejudice, harm-reduction concepts, providing education and support, overdose management, linkage to care, safe injection practices and a range of health issues that pertain to MSM who use drugs. These staff members were deployed into the community (including venues such as gay saunas). Table 1 explains in more detail the roles of the different staff members.

Table 1.  Staff responsibilities in Anova Health’s harm reduction initiative, “Tikking the Boxes”
HTS, HIV Testing Services; HBV, hepatitis B virus; STI, sexually transmissible infection; IDU, intravenous drug use

During the grant period, ~45 000 MSM were reached with harm reduction through various methods including media platforms, Information, Education and Communication (IEC) materials, radio interviews and community events undertaken by outreach workers. In the same time period, 2260 injecting harm-reduction packs and 1119 non-injecting harm-reduction packs were distributed, which translated to ~45 200 clean needles and syringes and other drug-use paraphernalia. A total of 1260 contacts with clients were recorded by outreach workers during this period.

At the launch of the project in South Africa, the concept of harm reduction was mostly an alien one and easily misunderstood. There was a high level of denial among drug users, and an equally high level of denial in society in general about the extent of use and abuse of recreational drugs among MSM, and how certain drugs have serious health implications. The project was perceived by some quarters within the gay community as harmful, as they felt that it re-enforced public perceptions about risky behaviours among MSM and it implied that all gay men were drug addicts. Many of the same people felt that the program was enabling users. The reaction in many cases was similar to the reaction of a simple and effective harm-reduction tool, the condom, at the beginning of the AIDS crisis. If it is acknowledged that MSM will have sex and take drugs despite the potential risks, then it is logical that they should be offered the information to make informed decisions and the tools to reduce potential harm to themselves and others.

Another challenge was that the harm-reduction service, encompassing needle exchange, was not comprehensive enough and did not encompass all components of care recommended by the WHO. For example, the program lacked access to opioid substitution therapy (OST), and had limited in-house psychiatric services, rehabilitation services or access to shelters and food supplies. The program could have been substantially more impactful if OST had been available.^12,13

People who use drugs were employed as outreach workers, creating some novel challenges that meant that the project needed to be very flexible to adapt to sometimes complex lives and difficult-to-reach peers. This required a commitment of time, resources and flexibility. The benefits, however, outweighed any challenges, as these four staff members were successful in reaching previously difficult-to-reach networked MSM who use drugs and attended sex parties. They were less successful in reaching occasional users who were not part of any established networks but remain equally vulnerable to drug-related harms (e.g. young MSM who purchase drugs on the street from ‘car guards’ on an ad hoc basis when intending to party).

Although the focus was to specifically target MSM who used drugs, people who did not identify as MSM were also included in the program if they presented for services.

JAB SMART is Anova’s new harm-reduction initiative, in partnership with the Department of Health, that builds on lessons learnt from our earlier ‘Tikking the Boxes’ harm-reduction project in Cape Town, South Africa. JAB SMART started in May 2017, with support from the City of Johannesburg Health Department, and is the first project of its kind in the city to provide harm-reduction services to people who inject drugs (PWID) and their sexual partners. The project is supported by the Global Fund, through its implementing partner Right to Care, and similar harm-reduction projects are currently operating in four other cities in South Africa.

The Project supports the 90–90–90 ethos aimed at reducing HIV prevalence among PWID and their sexual partners who experience many barriers to accessing care. The majority of the PWID that the project is working with are from the most vulnerable groups, including homeless people, women and young people, as well as from overlapping key populations (PWID who are also sex workers, transgender people and MSM). Unlike Anova’s earlier project, JAB SMART is not focused particularly on MSM and transgender PWID.

JAB SMART follows the WHO recommendations for a comprehensive package of care for HIV and PWID in providing harm-reduction services. These services are delivered through deployment of a mobile clinic unit in Johannesburg and two fixed sites at government health facilities. Key to the success of the project is the use of peer educator-based outreach services, led by current and former PWID that allow for access to hard-to-reach networks. The peer educators are also part of a referral system that trains them to link PWID to appropriate health services, including anti-retroviral therapy and to track lost-to-follow-up clients. In conjunction with these activities, the project will also be providing access to free OST as part of a structured intervention.

It is imperative to include harm-reduction services in our package of care for MSM and to create spaces where drug use can be comfortably discussed.

The authors declare no conflicts of interest.