SOUTH AFRICAN BIO-BEHAVIOURAL SURVEY AND POPULATION SIZE ESTIMATION AMONG PEOPLE WHO INJECT DRUGS, 2023

​Conducted in South Africa at four sites in 2023 between May and September, TB HIV Care’s BioBehavioural Survey (BBS) showed high prevalence rates of HIV and Hepatitis C in people who inject drugs (PWID). The Survey found that HIV prevalence among PWID was as high as 72.1% in Tshwane, 49.3% in eThekwini, 45.4% in Mashishing, and 30.3% in Mbombela. Anti-hepatitis C prevalence was highest in Mbombela (90.5%), followed by Tshwane (89.0%), eThekwini (75.2%), and Mashishing (40.8%). The Survey also measured the prevalence of drug-susceptible tuberculosis (TB) in the study population, generating the first such data in South Africa. Across the sites statistics pointed to a notable burden and the need for intensified TB diagnosis and treatment by highlighting prevalence of 7.2% in eThekwini, 2% in Tshwane and less than 1% in both the Mashishing and Mbombela sites. ​

​“Hepatitis C is often called the silent killer because many people remain completely asymptomatic until the infection progresses, causing serious liver damage and life-threatening health issues,” explains Andrew Scheibe, Technical Advisor at TB HIV Care. “Today’s treatment with direct-acting antivirals (DAAs) are highly effective, but cost and access are an issue in South Africa. We need to continue to advocate for easier, cost-effective access to generic DAAs, especially for populations at risk”, says Scheibe.   Despite having the world’s largest antiretroviral therapy (ART) program, this survey illuminates significant gaps in access to care and health service utilization by PWID and underscores the imperative to integrate viral hepatitis services into primary healthcare. In Tshwane, people in the study population living with HIV, who were aware of their status and adherent to their ART treatment showed encouraging viral suppression1 at 92.2%. The other sites, eThekwini (63.3%), Mbombela (59.9%), and Mashishing (42.3%) could make significant strides towards 95% viral suppression – the ambitious UNAIDS 95-95-95 targets aimed at closing the gap in HIV treatment coverage and outcomes. To prevent and reduce the burden of disease requires efforts on the part of the healthcare system and PWID. The Survey shows safe injecting practices among PWID across the four sites. In eThekwini, 71.3% used a sterile needle the last time they injected drugs and 66.6% used a condom the last time they had sex. In Mashishing (65.0%), in Mbombela (87.9%), and in Tshwane (76.3%) of the study population used a sterile needle the last time they injected drugs. In Mashishing, Mbombela, and Tshwane above 50% rates were reported by study populations who used a condom when they last had sex.   “This biobehavioural survey has given us a deeper understanding of the challenges faced by people who inject drugs,” says CDC Country Director, Dr John Blandford. “We know, for example, that the prevalence of physical or sexual violence across all the sites was more than 30%. We also know that a third of PWID have not accessed healthcare in the last year due to fear of stigma or discrimination. This information allows CDC partners to include post-violence care in their programmes and sensitisation training for healthcare workers. The high HIV and anti-HCV prevalence means we need to focus on harm reduction efforts – and continue to advocate for the rights of key populations”, Blandford concluded.  1 Opioid agonist therapy (OAT) is an effective treatment to help people addicted to drugs stabilize their lives and to reduce the harms related to their drug use. Respectively in eThekwini and Mashishing, the Survey showed that 20.3% and 17.5% of the study populations at these sites have ever been on OAT and that 1.0% of both populations were on OAT. In Mbombela, 10.0% of PWID have ever been on OAT, and 8.0% were on OAT. In Tshwane, 10.0% of they site study population have ever been on OAT and 2.2% were currently on OAT.  “Considering the high HIV and Hepatitis C prevalence, there is an urgent need to scale up access to  needle and syringe services and OAT by government and donor-funded civil society organizations to prevent exposure and new HIV and Hepatitis C infections in PWID”, says Prof Harry Hausler, Chief Executive Officer at TB HIV Care. For PWID, access to dignified care is a necessary imperative. The UNAIDS 10-10-10 targets aim to remove social and legal impediments to accessing or using HIV services. Findings from the Survey necessitate interventions to remove barriers which obstruct access to care by key populations such as PWID. In eThekwini, 52.7% of the study population avoided healthcare due to stigma and/or discrimination because of drug use compared to 34% in Mashishing, 36.8% in Mbombela, and 47.5% in Tshwane.  “Biobehavioural surveys are critical because they allow us to estimate the population size of marginalised groups like PWID in sites across South Africa, estimate the prevalence of infections like HIV and viral hepatitis, assess health-seeking behaviour, gauge injecting practices and other risk factors, and examine the intersectionality between injecting drug use with behavioural, social and structural factors – including the ability to access healthcare services,” says Joel Steingo, Strategic Information and Business Development Director at TB HIV Care.       The South African Bio-Behavioural Survey highlighted the extremely high prevalence of HIV and Hepatitis C in PWID, and significant gaps in progress towards the 95-95-95 treatment targets and the 10-10-10 social enabler targets. A high percentage of PWID across all sites – Mashishing (66.8%), Tshwane (57.4%), eThekwini (51.6%), and Mbombela (48.9%) - indicated their willingness to take pre-exposure prophylaxis (PrEP) signalling optimism towards achieving the 95-95-95 goals in the study population.  The BBS survey was implemented by TB HIV Care and made possible with funding from the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and technical assistance from the U.S. Centers for Disease Control and Prevention (CDC).