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The Opioid Epidemic in Africa And Its Impact

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Official websites use. Share sensitive information only on official, secure websites. AEK wrote the first draft, RC conducted the literature review, and all authors contributed to writing, editing, and responsibility for the final manuscript. Corresponding Author: Ann E. Opioid use disorder OUD is a global phenomenon and is on the rise in Africa, denoting a shift from historical patterns of drug transport to internal consumption. In contrast, opioids for clinical pain management in Africa remain among the least available globally. This region also has the highest HIV and HCV disease burden, and the greatest shortages of health workers and addiction treatment. We undertook a systematic review of the literature to describe opioid use in Africa and how it is being addressed. A total of 84 articles from to were identified. Descriptions of country-specific populations and patterns of opioid misuse were common. A smaller number of articles described interventions to address OUD. OUD occurs in sub-Saharan Africa, with attendant clinical and social costs. Evidence-based policies and health system resources are needed to promote OUD prevention and management, and infectious disease transmission reduction. Opioids can be consumed as part of a clinically indicated pain regimen or non-clinically as part of the growing global problem of opioid use disorder OUD. As opioid trafficking routes have changed globally to increasingly utilize African trading routes, opioid consumption for non-clinical indications has increased in this region. While consumption often started among people who smoke cannabis \[ 2 \] in areas proximate to where opioids were imported e. The original push of opioids into the African market was to smuggle opioids to higher paying markets, namely Europe. This availability created opportunities for local sales and, as a result, a burgeoning opioid market in sub-Sahara Africa, facilitated by more transport infrastructure as opposed to having to transverse high mountains in Central Asia and the promise of wealth \[ 4 \]. Opioid antagonists such as naloxone can be administered in the community for acute overdose reversal. Evidence-based interventions to reduce the acquisition of blood borne pathogens also exist, including needle and syringe programs NSPs. Unfortunately, these programs to address opioid misuse, and substance use in general, are in limited supply in Africa \[ 5 \]. Likewise, availability of mental health and addiction health professionals is under resourced \[ 6 \] compared with high-income settings Some estimates place the African continent at the highest HCV prevalence 5. We undertook a literature review to document the extent of the opioid epidemic in Africa, its management, resulting intervention needs, and to generate future recommendations. We chose to extend the timeframe of the search beyond the most recent five years of publications, given the relative dearth of articles. All search terms were used in all databases, except for Google Scholar which yielded limited new results. We excluded titles that dealt with opioids in palliative care, or therapeutic opioid use for pain management; studies of substance use in Africa that were not opioid-specific, and studies focused only on epidemiologic estimations methodology as they were not opioid specific. Finally, we excluded multinational surveys and systematic reviews, in favor of original research publications. We also reviewed bibliographies of recent articles — to ensure capture of all recent literature. We identified 84 articles describing original research related to substance use disorders, including OUD, in Africa. Table 1 summarizes key elements of the recent literature of the last 18 years — Most of the studies are observational, with only a handful of treatment trials or interventions described; and almost no implementation science framing or work. Additionally, it is important to point out the lack of available epidemiologic or clinical data about opioid overdose in the literature examined; there is practically no information known about overdose mortality rates in Africa. Opioid and other substance use continues to grow throughout multiple African jurisdictions. Most of the published studies and articles that we found were from the east African region see Figure 1. Many describe patterns of drug use. Heroin trafficking and use in Kenya and Tanzania, for example, have been noted to have escalated \[ 94 \]. Mental health disorders are prevalent among people who use drugs and successful treatment for OUD requires a recognition of co-occurring mental illness and evidence-based treatments for these disorders. A common theme was the lack of targeted interventions for women who use drugs who often did not self-identify to researchers; most populations sampled in the papers published were primarily male. For many persons in Africa with OUD, challenges occur around stigma, persecution by police, incarceration, condemnation from religious and community leaders, and barriers to MOUD. It is important to point out specific subpopulation issues in OUD in Africa. Women who have OUD often are at a distinct disadvantage in terms of barriers to accessing services, differential gender and power norms in society, child care, a high prevalence of violence \[ 32 \], and poverty. When services such as methadone treatment exist, they are often dominated by men, making it uncomfortable or unsafe for women who may be victims of violence to wait in line. People who inject drugs PWID are an additional subpopulation of note that is growing in some countries in Africa. Comprising a growing proportion of HIV transmissions in the region, they have been a politically powerless group that has lacked access to addiction treatment and HIV prevention and often faces persecution from police and communities \[ 98 \]. Additional literature has pointed out that use of tramadol which is not listed as a controlled substance regulated by the International Narcotics Control Board is increasing; codeine misuse has also been noted in South Africa \[ 23 \] as well as other countries in Africa. The UNODC pointed out in that tramadol trafficking from Asia to central and west African countries through militant groups including Boko Harem has both increased dramatically yearly seizures from kg to more than 3 tons and is contributing to political destabilization in the region \[ \]. While tramadol is a relatively safe analgesic when used at therapeutic doses, misuse can result in dependence, withdrawal, overdose \[ \], and intoxication when co-ingested with other drugs or alcohol. It is encouraging that at least some OUD-specific prevention and treatment services are growing in Africa. Csete et al. However, these services are not yet the norm in many countries. A handful of papers in our review discussed addiction treatment models, such as the Matrix model in South Africa, but these have not focused specifically on evidence-based models of care for people who use opioids. Starting in , Tanzania \[ \], and thereafter Kenya \[ 14 , 52 , \], launched opioid treatment programs to address the opioid epidemic. With the successes of these programs, many additional countries have started to discuss opioid treatment as a way to address the opioid epidemic in Africa, including Mozambique, Senegal, and Nigeria. Douglas Bruce, personal communication, June Opioid use contributes to HIV and HCV transmission, particularly when parenteral methods are used for drug consumption, and with tuberculosis transmission. In Kenya it is estimated that Gupta et al. The control and management of infectious diseases including TB also is critical in this region of the world; a growing TB epidemic among people who use drugs with high HIV and HCV rates could cause serious issues. For example, TB rates are higher among people with HIV and many of the drugs can cause hepatic injury, complicating what are already-limited treatment options. A focus on TB prevention can be supported through directly observed therapy approaches integrated into methadone programs \[ \]. Meanwhile, availability of opioids for appropriate clinical management including palliative care also is often unavailable in this substantial region of the world. Although opioids are on the WHO list of essential drugs, it has been noted that there is a lack of opioids for pain management in many formularies in Africa \[ 1 \]. Uganda has been an example of one country that has increased access to morphine for palliative care and chronic pain management, using local production of liquid morphine and dispensing by nurses, demonstrating one of several viable models \[ \]. Expanded access will need to balance availability of clinically-indicated opioid prescriptions with strategies to address diversion and misuse. Opioids are increasingly being used in African countries by populations at risk for addiction and infectious diseases transmission. Treatment is outpaced by illicit distribution and consumption; something that will continue to fuel infectious diseases such as HIV, HCV and TB that are prevalent among people who use drugs. The time is now. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute On Drug Abuse or the National Institutes of Health. This article does not contain any studies with human or animal subjects performed by any of the authors. Papers that have been published recently that are of particular interest have been highlighted as:. As a library, NLM provides access to scientific literature. Curr Addict Rep. Published in final edited form as: Curr Addict Rep. Find articles by Ann E Kurth. Find articles by Peter Cherutich. Find articles by Rosabelle Conover. Find articles by Nok Chhun. Find articles by R Douglas Bruce. Find articles by Barrot H Lambdin. Issue date Dec. PMC Copyright notice. The publisher's version of this article is available at Curr Addict Rep. Overview of opioid access, use and problems in African jurisdictions. Peer educators in this study were predominantly older men; should be more diversified to reflect the spectrum of people who use drugs, i. Broader structural and system changes need to occur in order for peer-led outreach to achieve the potential to play a central role in harm reduction interventions. Three fourths of people who use drugs, primarily male, one fourth secondary informants, such as police officers or health-care workers Illicit drug use increasing in all regions. Most people who use drugs work in the cash economy. Cannabis most common drug, then heroin. Women using drugs increasing, though less visible. With high levels of genetic diversity, harm reduction strategies and monitoring for effective patient management should be implemented. Who has ever loved a drug addict? It is a lie. HIV and harm reduction programs should address these different forms of stigma, which requires a combination of interventions. This suggests targeted, preventive measures for people who use drugs. Perspectives on biomedical HIV prevention options among women who inject drugs in Kenya. Results demonstrate the importance of countering codeine misuse and dependence. Hepatitis C: a South African literature review and results from a burden of disease study among a cohort of drug-using men who have sex with men in Cape Town, South Africa. HIV status extracted from case notes. Drug and sexual risk behavior captured with survey. High burden of HCV exposure or infection. MSM especially those who report drug use should be actively screened for HCV, and referral networks developed for treatment access. Treatment included psychosocial interventions, detoxifications, and pharmacotherapy. Most common profession was social work, and then psychiatry. Demonstrates possibility of providing HIV risk-reduction services to a population of individuals who use substances. Behavioral and biological risk factors must be addressed to reduce HIV incidence. The OAT group had increased retention rates, increased response to treatment, but low abstinence from illicit opiates. Future programs should consider extending treatment duration. However, abstinence by treatment exit were equal between both groups, and barriers to treatment engagement for those with opioid use are unclear. Older age and longer duration of injection drug use were independently associated with HCV infection. HCV infection among people who inject drugs is lower in Zanzibar than in other countries but could rise without proper interventions. Integrating HIV care into the OTP clinic setting will reduce stigma and discrimination but must also maintain confidentiality about HIV status and not overburden providers. Sample included women not enrolled in methadone as controls and 93 women enrolled in methadone as cases. Violence and discrimination are significant barriers to methadone treatment for females, as intimate partner violence IPV was associated with not enrolling in methadone. Women enrolled in OAT had a higher proportion of risky sexual behaviors. It is important to develop and implement interventions targeted towards reducing gender-based violence to facilitate participation in methadone. Data thematically analyzed. Results showed mistrust and discrimination against PWID, especially women who inject drugs. Student t tests and backward stepwise regression analysis clients of the clients enrolled in methadone program at Muhimbilli National Hospital in Dar es Salaam, Tanzania, from February — April Significant improvements noted in physical and mental health composite scores. Methadone treatment has positive short-term effects on health-related quality of life. Expanded drug surveillance, education, and programming responsive to local conditions is important. There is a need for increased access to sterile injecting equipment, education around safer injecting practices, and access to sexual and reproductive health services for people who inject drugs. PWID have poor access to health care, and the majority of participants do not seek health care. Interventions targeting PWID must be implemented to improve their health-seeking behavior; this should include providing health education and increasing ability to generate income. PWID practice high-risk behaviors but have poor utilization of screening services. There was increased risk of morbidity, mortality, and disenfranchisement at social and structural levels. Themes include: the hardship of addiction, silencing of HIV in the community, and discrimination and support in the clinic. These create barriers to care, and clinic-based care may be fundamentally difficult to access for some PWID. Rates of initiation and engagement with the Matrix substance use treatment model were comparable with substance use treatment in industrialized nations. Motivation was a key psychological factor that predicted treatment outcomes and engagement in treatment. Buprenorphine withdrawal in a detoxification regimen had a mild intensity and delayed onset and was more severe in females as compared to males, though the sample size was severely limited. Of the patients with Opioid Use Disorder due to tramadol, approximately three-fourths used other substances, one-third had drug-related problems, and they were twice as likely to have psychiatric and personality disorders. HIV infection associated with being female, having injected drugs 5 or more years ago, and having practiced receptive syringe sharing. Harm reduction program must be implemented as HIV prevention in Kenya. Used multivariable Cox proportional hazards regression to examine factors associated with linkage to care. Individuals with history of arrest were less likely to obtain a CD4 count and be linked to care. Multivariate statistical analysis was used participants in Mwanza, Tanzania, recruited between June and August More than a tenth considered themselves homeless. Unstable housing and cohabitation status were only characteristics significantly associated with heroin injection. More than half of heroin injections left syringes in common locations, and half reported sharing needles and syringes. Other risk behaviors such as no condom use during sex and use of drugs during sex was also reported. It is important to diversify drug treatments and combine them with social interventions enabling their access. Also drew on in-depth qualitative interviews and identified core thematic categories. HIV-1 prevalence was Most were sexually active and had more than 1 partner in the last 6 months, few reported condom use. Several had no knowledge of HIV transmission through injecting. Participants had used methamphetamine for 7 years on average, and Majority met ICD criteria for use disorder and had experienced severe consequences for their substance use. In qualitative analysis, barriers to treatment include beliefs that it is ineffective and relapse is inevitable, though they also expressed desire to be drug free and improve family functioning. HIV prevalence and indicators of risk and preventive behavior among PWID were more favorable in than ; prevention programs for this population were also scaled up at this time. Behavioral data and blood samples were gathered, and data was analyzed using the RDS analysis tool, and logistic regression. Population predominantly male with mean age of Estimated as size of people who use drugs population in Dakar area. Women more at risk for being HIV infected. Women need targeted interventions for decreasing HIV exposure. PWID link transitions to injecting to a range of social and behavioral factors, including the local drug supply and economy. Structural and social factors interact in the transition to injection; harm reduction programs must respond to these varied transitional experiences. Students screened for tramadol use using Drug Use Disorders Identification Test and urine screen for Tramadol school students age 13—18 in 6 schools in Zagazig, Sharkia governorate, Egypt. Total target population was 86, Prevalence of tramadol use among school students was 8. Significant associations between tramadol use and older age, male gender, higher education, and smoking. However, all three strategies reached a large proportion of first time testers. These offer useful laboratory markers for screening injection heroin users in initiating and monitoring anti-retroviral treatment. Anti-social personality disorder Used Kaplan-Meier survival curves to assess retention probability, and proportional hazards regression model to evaluate association of characteristics with attrition from methadone program PWID enrolled in methadone treatment from February to January at Muhimbili National Hospital in Dar es Salaam, Tanzania. Clients who were younger, male, had a history of risky sexual behavior, or history of sexual abuse had higher rates of attrition from program. Patients receiving higher doses of methadone had lower risks of attrition. Female clients had a lower likelihood of attrition. None had achieved more than three weeks abstinence on methadone. Sustained-release naltrexone implant treatment may be an option for patients with OUD due to buprenorphine. This is 23 times that of the general Tanzanian TB prevalence of. Service requirements and disease prevalence estimates for and were also calculated, as well as treatment coverage targets and care packages for the priority disorders, staffing ratios, and full time equivalent FTE staffing estimates by service type. There will be a one and half fold increased in disability burden associated with non-communicable compared to communicable diseases. There is a large gap between estimated minimum FTE staffing requirements in the health sector for and the actual FTE staffing numbers. Reaching FTE targets for service requirements requires a shift from current practice in most African countries. Multivariate logistic regression compared classes on demographics, sexual risk behavior, and disease status. The Crack class was 6. Patterns of drug use differ in sexual risk behaviors. New evidence on the HIV epidemic in Libya: why countries must implement prevention programs among people who inject drugs. Binomial regression estimated adjusted relative risk estimates comparing females to males. Also people enrolled in the methadone program at Muhimbili National Hospital. Female PWID were more likely to report multiple sex partners, anal sex, commercial sex work, and struggle under a higher burden of addiction, mental disorders, and abuse. A profile on HIV prevalence and risk behaviors among injecting drug users in Nigeria: Should we be alarmed? Recruited from 6 urban centers. For injecting risk behavior, only receptive sharing was associated with HIV in Oyo and Kaduna states respectively. There is a need for targeted HIV interventions for females, and community-based opioid agonist treatment and needle exchange programs should be implemented. Average of 33 staff per unit. The 16 residential units provided no medication treatment. Suggests a shortage of substance abuse treatment units in Nigeria, with under-funding and inadequate government attention. Recommend organization and centralization of substance abuse treatment centers with increased governmental role. Utilized purposive and snowball sampling, and thematic analysis. Heroin availability was increasing and the most problematic. Sites randomly sampled and individuals interviewed at each location, using univariate, bivariate, and multivariate logistic regression for data analysis. Most could inconsistently get new syringes. Multiple sexual partnerships and risky behaviors are likely facilitating HIV transmission. Statistical analysis utilized independent-samples t-tests and chi square tests. There is an unmet need for heroin treatment, and efforts to help women transition away from survival sex may be warranted. More than half reported injecting with used needles, and Use of condom during sex was low. This demonstrates relatively low HIV infection prevalence compared to global estimates, with high incidence of risky injection practices and unprotected sex. In Phase 1 , key informant interviews with drug users and 21 focus interviews with participants who were drug users in Durban, Cape Town, and Pretoria. In Phase 2 , 69 drug users were interviewed in focus groups and 11 service providers. People who used drugs had various risk factors for HIV transmission, and limited knowledge of drug treatment availability. Those who accessed treatment identified many barriers, as did service providers. There are several misperceptions about HIV and limited access to preventive materials. Service providers reported barriers to integrating HIV and substance use services. A comprehensive and accessible intervention to prevent HIV risk in drug users must be developed. Statistical analysis utilized t-tests and chi square tests. Out of female injecting drug users who were interviewed, 28 reported ever using flashblood in Dar es Salaam, Tanzania. Those who practiced flashblood were more likely to be married, lived in their current housing situation for a shorter time period, forced as a child to have sex by a family member, inject heroin more in the last 30 days, smoke marijuana at an earlier age, use contaminated rinse-water, pool money for drugs and share drugs. Those who did not engage in flashblood practice were more likely to live with their parents. Practice of flashblood spreading from the inner city to the suburbs. Heroin use disorder interventions and programmes have begun to be implemented within the South African context; however, comorbidity factors such as psychiatric illness and HIV needs to be further addressed. Additionally, evidence-based public health policies to reduce the harmful consequences of heroin use still needs to be implemented. Blood specimens and self-reported socioeconomic status and behavioral data were collected. Data were analyzed using univariate odds ratios and multivariate logistic regression. The high rate of HIV infection suggests that injecting drug use may be a contributing factor in the continuing epidemic in sub-Saharan Africa. Risky injecting behaviors among PWID were common, most engaged in sex when on drugs, some without condoms. Views about drug- and HIV-intervention services, accessibility, and their efficacy were mixed. Findings suggest risk-reduction strategies should be made more accessible, and that greater synergy is needed between drug- and HIV-intervention areas. First drugs reported for males and females were marijuana, alcohol, and heroin. Females had shorter drug careers than males, and time from first use of heroin to first injection also shorter for females. Years injecting was a mean of 5 years for males and 3 years for females. Findings confirm that heroin injecting is well established in large cities in east Africa and that HIV prevention will need to include focus on this population. Condom use was irregular. Heroin use has become a major concern in Cape Town and may still be increasing. Injecting heroin use still appears to be limited, but this has the potential to change. Key informants tested for HIV. Mean age was Some people who used drugs fit into more than one category. Drug users reported selling sex for money to buy drugs. CSWs used drugs before, during and after sex. PWID reported needle sharing behavior. There was a widespread lack of awareness about where to access HIV prevention and treatment services. Numerous barriers to accessing HIV and drug intervention services reported. Targeted interventions are needed to reach this vulnerable population and limit the spread of HIV. Thirty-three were without injection 15 men and 18 women ; 19 were PWID 12 men and 7 women. Average age for females was 28 years, 31 years for males. Findings indicate that in this population, drugs play an organizing role in patterns of daily activities, with sex work closely linked to the buying, selling, and using of drugs. Participants reported using multiple drugs. Organization of sex work and patterns of drug use differed by gender, with males having more control over their daily routines and drug and sexual transactions than females. Mixing patterns across drug and sexual risk networks have the potential to accelerate HIV spread. Multivariate logistic regression estimated risk of needle sharing. Average age of men were 28 years and women were Men were significantly older, more likely to inject only white heroin, share needles, and give or lend used needles to other injectors. Women were more likely to be living on the streets, inject brown heroin, have had sex, have had a higher number of sexual partners, traded sex for money and drugs, diagnosed with an STI in the last 12 months, and have used a condom with the most recent sex partner. Semistructured interviews were also conducted and qualitatively analyzed. Used syringes collected from 73 heroin injection drug users. Semistructured interviews with confirmed that syringes were shared widely. Findings suggest that HIV is being transmitted by needle- and syringe-sharing practices, thereby creating the possibility of a new wave of HIV transmission in Dar es Salaam, if not Tanzania. Most injectors reported using a syringe for 1—3 days. Majority reported injecting in a group of three or more and described risk behaviors for HIV transmission. Results highlight the need for a range of services, including needle exchange, counseling, and referral to residential treatment programs. Treatment indicators point to a substantial increase in heroin use over time. Most who used heroin in treatment tend to be white, male, between the ages of 21 and 24 years and tend to smoke rather than inject the substance. However, emerging trends point to changes in heroin use patterns, demonstrating the need for continued monitoring of the situation. Emergent themes around hangout places, initiation of heroin use, and progression to injecting were qualitatively analyzed. Injecting is a recent practice in Africa and coincides with Tanzania transitioning to a heroin consuming community, importance of youth culture, innovation of injecting practices, intro and ease of use of white heroin, and perceived need to escalate use to a more effective form of heroin ingestion. Specialist substance use treatment centers to describe substance use treatment demand and patters of service utilization in Cape Town, South Africa. Treatment demand for alcohol related problems remain high. Treatment demand for other substances not related to alcohol has increased over time. Increased use of treatment service utilization by adolescents, while patterns suggest that women and black South Africans remain underserved. Recommendations are to improve access to substance use treatment services. Networks were established in five sentinel sites Cape Town, Durban, Port Elizabeth, Gauteng, Mpumalanga to facilitate the collection, interpretation and dissemination of data. Alcohol reported as the most common substance of abuse across sites. Most frequently reported illicit drugs of abuse were cannabis and mandrax methaqualone either alone or in combination. Use and burden of illicit substances is on the rise. There was an increase in the use of ecstasy MDMA , either alone or in combination with other substances, reported among young people. Possible solutions include increasing the number of AOD treatment options, especially among marginalized groups; providing specific treatment protocols for specific drugs for substance use practitioners; developing protocols for the identification, management and treatment of patients in general hospitals, primary health-care settings, trauma units, etc. Substances most commonly used were alcohol, tobacco, khat, and cannabis. Rates of substance use was generally low except for alcohol and tobacco. The differences between the rural and urban samples were not statistically significant. More males than females had significantly used alcohol Open in a new tab. Competing interests The authors declare that they have no competing interests. Human and Animal rights and Informed Consent This article does not contain any studies with human or animal subjects performed by any of the authors. Similar articles. Add to Collections. Create a new collection. Add to an existing collection. Choose a collection Unable to load your collection due to an error Please try again. Add Cancel. Peer-led outreach initiatives play a role in harm reduction activities among people who use drugs. Context and characteristics of illicit drug use in coastal and interior Tanzania. Rapid assessment, triangulating in-depth interviews of key informants, secondary informants, and ethnographic mapping. Three fourths of people who use drugs, primarily male, one fourth secondary informants, such as police officers or health-care workers. Illicit drug use increasing in all regions. Methadone is an object of recovery potential, which produces an affective flow through social interactions. Human immunodeficiency virus infection predictors and genetic diversity of hepatitis B virus and hepatitis C virus co-infections among drug users in three major Kenyan cities. Substance abuse treatment engagement, completion and short-term outcomes in the Western Cape province, South Africa: Findings from the Service Quality Measures Initiative. Includes data from adult patients. Women who inject drugs experience multiple stigmas. Socio-demographic and sexual practices associated with HIV infection in Kenyan injection and non-injection drug users. Predictors of HIV infection include sex for police protection and history of sexually transmitted infections in people who inject drugs, and divorced, separated, or widowed marital status in those who do not inject. Among the 3 biomedical HIV prevention methods that were tested or under development at the time antiretroviral oral pre-exposure prophylaxis PrEP , intravaginal rings, and topical microbicide gels , only 1 woman had ever heard of PrEP, and 1 of microbicides gels. Barriers and facilitators of access to HIV, harm reduction and sexual and reproductive health services by women who inject drugs: role of community-based outreach and drop-in centers. In-depth interviews conducted and analyzed using empirical phenomenological psychological 5-step method. Primary themes included: participant profile and product preferences, motives for codeine use, transitioning from use to dependence, purchasing from pharmacy, alternative sourcing, codeine effect and withdrawal experiences, help-seeking and treatment, and strategies for prevention. Descriptive study to describe HCV burden among drug users. Codeine misuse and dependence in South Africa: Perspectives of addiction treatment providers. Cross-sectional semi-structured interview on provider experience of clients analyzed using descriptive statistics and thematic analysis for qualitative and quantitative data. Reducing substance use and risky sexual behaviour among drug users in Durban, South Africa: Assessing the impact of community-level risk-reduction interventions. Quantitative analysis at baseline and post-agency implemented behavioral intervention and harm reduction strategies. No decrease in drug use practices, though reduction in alcohol use. Rural realities in service provision for substance abuse: a qualitative study in uMkhanyakude district, KwaZulu-Natal, South Africa. Mental health service delivery in this rural area is challenging; a district, provincial, and national standard for substance use treatment services is needed, as well as response to the gaps in such under-resourced areas. Prevalence and predictors of human immunodeficiency virus and selected sexually transmitted infections among people who inject drugs in Dar es Salaam, Tanzania: a new focus to get to zero. Report on the first government-funded opioid substitution programme for heroin users in the Western Cape Province, South Africa. Naturalistic retrospective study reviewing records between standard care only and opioid agonist treatment OAT group. More participants in the OAT group Beyond methamphetamine: documenting the implementation of the Matrix model of substance use treatment for opioid users in a South African setting. Comparison via chart review of people with primary opioid and primary methamphetamine use undergoing treatment at Matrix model substance use treatment site. Descriptive statistics and multivariable logistic regression. Multivariable Poisson regression with hepatitis C virus HCV serostatus as variable of interest based on review of programmatic data. Convenience without disclosure: a formative research study of a proposed integrated methadone and antiretroviral therapy service delivery model in Dar es Salaam Tanzania. In-depth semi-structured interviews with providers and HIV-positive patients to examine patient and provider perspectives; thematic content analysis. First report of gender-based violence as a deterrent to methadone access among females who use heroin in Dar es Salaam, Tanzania. Case control study to examine factors associated with non-enrollment in methadone treatment; logistic regression and multivariable statistical analysis. Females who use drugs identified by snowball sampling in neighborhoods in Dar es Salaam, Tanzania. Generating trust: programmatic strategies to reach women who inject drugs with harm reduction services in Dar es Salaam, Tanzania. Improvements in health-related quality of life among methadone maintenance clients in Dar es Salaam, Tanzania. Routine data on clients enrolling in methadone focusing on changes in physical and mental health composite scores. Student t tests and backward stepwise regression analysis. An ethnographic exploration of drug markets in Kisumu, Kenya. Ethnographic fieldwork, surveys, and qualitative interviews. Surveys conducted with injecting drug users in Kisumu, Kenya, 29 participants in qualitative interviews. Drug availability is increasingly important, and there are widespread perceptions of cocaine availability and injection. HIV prevalence and risk among people who inject drugs in 5 South African cities. Consider our plight: A cry for help from nyaope users. This exploratory study demonstrates that the drug is very strong, easy to access, and difficult to quit. Users express a desire to find help to overcome current circumstances. Correlates of health care seeking behaviour among people who inject drugs in Dar es Salaam, Tanzania. Baseline cross-sectional study as part of prospective cohort study involving PWID with aim of examining role of integrated MOUD program on reducing high-risk injecting, sexual behaviours, and criminal activities, while increasing access to care. A mismatch between high-risk behaviors and screening of infectious diseases among people who inject drugs in Dar es Salaam, Tanzania. Baseline cross-sectional study as part of prospective cohort study. Themes involved desperation and uncertainty, with sub-themes of withdrawal, unpredictable drug availability, changes in drug use patterns, modifications in relationship dynamics among people who use drugs, family and community response, and new challenges with the heroin market resurgence. Access to HIV treatment and care for people who inject drugs in Kenya: a short report. Implementation of cognitive-behavioral substance abuse treatment in Sub-Saharan Africa: Treatment engagement and abstinence at treatment exit. Retrospective chart review to assess treatment readiness and substance use severity at treatment entry as compared with treatment exit. Opiate withdrawal syndrome in buprenorphine abusers admitted to a rehabilitation center in Tunisia. Assessed buprenorphine withdrawal syndrome in subjects who sought treatment for dependence. RDS, using questionnaire, blood samples, and sputum samples. PWUD in this area are at high risk of HIV, especially in women, sex workers, and men who have sexual relationships with other men. Psychiatric comorbidity among Egyptian patients with opioid use disorders attributed to tramadol. Patients interviewed using a semi-structured questionnaire, addiction severity index, and a urine drug screening was performed to investigate psychiatric comorbidities associated with tramadol. HIV and STI prevalence and injection behaviors among people who inject drugs in Nairobi: results from a bio-behavioral study using respondent-driven sampling. PWID were predominantly male, Examined linkage to care for HIV positive individuals by measuring days between HIV-positive test and CD4 result at methadone maintenance treatment clinic. Stabilization through higher methadone doses, self-perceived poor health, and primary education or lower, increased probability of obtaining a CD4 count. Epidemiology of drug use and HIV-related risk behaviors among people who inject drugs in Mwanza, Tanzania. Used targeted sampling and participant referral to recruit and interview participants about their substance use and associated risk behaviors. Multivariate statistical analysis was used. Quantitative data using descriptive statistics and logistic regression. Woman had greater than 4 times higher likelihood of being HIV positive. The efficacy of a blended motivational interviewing and problem-solving therapy intervention to reduce substance use among patients presenting for emergency services in South Africa: A randomized controlled trial. Navigating the poverty of heroin addiction treatment and recovery opportunity in Kenya: access work, self-care and rationed expectations. Qualitative interview analysis with field observation. In the drug treatment experience, rehab is used as a primary means of respite and harm reduction rather than recovery. A mixed-method mathematical modelling and qualitative study. Combined mathematical modelling with qualitative data analysis to explore effects of implementing methadone in Kenya and project HIV transmission impact. The modelled impact of opioid agonist treatment shows slight reductions in HIV incidence over 5 years at coverage levels anticipated in planned roll-out, but there is higher impact with increased coverage. Co-infection burden of hepatitis C virus and human immunodeficiency virus among injecting heroin users at the Kenyan coast. Drug use and sexual behavior: the multiple HIV vulnerabilities of men and women who inject drugs in Kumasi, Ghana. In-depth qualitative interviews coded and analyzed by theme. Addiction and treatment experiences among active methamphetamine users recruited from a township community in Cape Town, South Africa: A mixed-methods study. Structured clinical interviews, computerized surveys, and in-depth interviews to assess substance abuse and treatment history, drug-related risks, and experiences with methamphetamine use and drug treatment. Individuals with active methamphetamine use men and women ranging in age form 18 — 66 years from Delft, near Cape Town, South Africa. HIV prevalence and risk behaviors among people who inject drugs in two serial cross-sectional respondent-driven sampling surveys, Zanzibar and Behavior and biological surveillance using RDS. Duration of injection drug use for 5 years or more was associated with higher odds of HIV infection. Capture-recapture estimated size of population using drugs. HIV prevalence, estimated incidence, and risk behaviors among people who inject drugs in Kenya. Respondent-driven sampling for HIV-1 prevalence and viral load determination and survey data. A qualitative analysis of transitions to heroin injection in Kenya: implications for HIV prevention and harm reduction. Qualitative study of HIV care access and ethnographic study of heroin trade in Kenya. Cross-sectional study with systematic random sampling method. Evaluating the effect of HIV prevention strategies on uptake of HIV counselling and testing among male most-at-risk-populations in Nigeria; a cross-sectional analysis. Cross-sectional study. Clinical chemistry profiles in injection heroin users from Coastal Region, Kenya. Cross sectional clinical laboratory study. The association between psychopathology and substance use: adolescent and young adult substance users in inpatient treatment in Cape Town, South Africa. Heroin Methadone treatment for HIV prevention—feasibility, retention, and predictors of attrition in Dar es Salaam, Tanzania: A retrospective cohort study. Used Kaplan-Meier survival curves to assess retention probability, and proportional hazards regression model to evaluate association of characteristics with attrition from methadone program. Naltrexone implant treatment for buprenorphine dependence—Mauritian case series. Observational case series on patients who received double naltrexone implant treatment. Age 19—28 years and injecting buprenorphine tablets daily in Mauritius. Active case finding for tuberculosis among people who inject drugs on methadone treatment in Dar es Salaam, Tanzania. Administered questionnaire to determine prevalence of tuberculosis among PWID on methadone. Mental and substance use disorders in Sub-Saharan Africa: Predictions of epidemiological changes and mental health workforce requirements for the next 40 Years. Based on the Global Burden of Disease study, burden of disease estimates were produced for 20 mental and substance use disorders. From to , it is estimated the population will double in size and age. Latent class analysis of polysubstance use, sexual risk behaviors, and infectious disease among South African drug users. Cross sectional survey using respondent driven sampling. Identifying programmatic gaps: Inequities in harm reduction service utilization among male and female drug users in Dar es Salaam, Tanzania. Utilized routine outreach data and baseline data on clients enrolled in methadone to assess gender inequities in utilization of outreach and MOUD services and evaluate differences in HIV risk behaviors between female and male PWID. Cross-sectional design using respondent driven sampling conducted in six states to investigate prevalence and correlates of HIV among injecting drug users in Nigeria. An urgent need to scale-up injecting drug harm reduction services in Tanzania: prevalence of blood-borne viruses among drug users in Temeke District, Dar-es-Salaam, Among PWID, A descriptive survey of types, spread and characteristics of substance abuse treatment centers in Nigeria. Cross sectional online survey of substance use treatment centers, analyzed using descriptive statistical analysis. Rapid assessment response using observation, reviewing existing information, mapping of service providers, key informant interviews, and focus groups. Key informants felt that black communities, especially men, were most affected by substance use in Pretoria, and poverty made access to treatment harder. HIV risk behaviours, perceived severity of drug use problems, and prior treatment experience in a sample of young heroin injectors in Dar es Salaam, Tanzania. Computer assisted survey interview, with participants recruited through targeted sampling, modified snowball sampling, and RDS. Sexually active females had a mean of HIV prevalence and risk behaviors of male injection drug users in Cairo, Egypt. Opportunities for enhancing and integrating HIV and drug services for drug using vulnerable populations in South Africa. Rapid assessment using key informants and focus groups interviews with drug users and service providers, analyzed qualitatively. Flashblood: blood sharing among female injecting drug users in Tanzania. Cross-sectional design to examine association between flashblood practice and demographic factors, HIV status, and variables associated with risky sex and drug behaviors. HIV risk and the overlap of injecting drug use and high-risk sexual behaviours among men who have sex with men in Zanzibar Unguja , Tanzania. An approach to heroin use disorder intervention within the South African context: a content analysis study. HIV seroprevalence in a sample of Tanzanian intravenous drug users. Participants were recruited using a combination of targeted sampling by an outreach worker or participant referral from a larger condom use study among sexually active PWID to assess factors associated with HIV acquisition risk. Rapid assessment using key informants and focus groups FG interviews with injection and non-injection drug users, analyzed qualitatively. Drug use careers and blood-borne pathogen risk behavior in male and female Tanzanian heroin injectors. Snowball or chain referral sampling to investigate HIV-related risk behaviors among heroin users. Rapid assessment using key informants and focus groups interviews with commercial sex workers CSWs , MSM and injection and non-injection drug users, and service providers analyzed qualitatively to examine link between drug use, risky sexual practices and HIV. Rapid assessment using key informants and focus groups interviews conducted to learn more about patterns of drug use and HIV risk behaviors among drug-using, street-based sex workers. Differences in HIV risk behaviors by gender in a sample of Tanzanian injection drug users. Data were collected using the Peer Outreach Questionnaire to examine drug use and sexual behaviors. A rapid assessment of heroin use in Mombasa, Kenya. Rapid assessment using key informant interviews, questionnaires, informal interviews and feedback from local agencies working with PWID. Heroin treatment demand in South Africa: trends from two large metropolitan sites January December Surveillance data were collected to provide information on nature and extent of heroin use. Semi-structured interviews were conducted to ascertain practice of those who use heroin, interactions and narratives for insights into appropriate HIV prevention interventions. Indicators of substance abuse treatment demand in Cape Town, South Africa — Descriptive epidemiological information about patterns of alcohol and other drug AOD treatment services utilization for purpose of informing policies and practice related to substance use interventions in the region. Descriptive epidemiological study of AOD indicators. Substance abuse in outpatients attending rural and urban health centres in Kenya. Descriptive cross-sectional survey to estimate prevalence and pattern of substance use among patients at primary health centers in urban and rural settings.

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