High risk injection drug use and uptake of HIV prevention and treatment services among people who inject drugs in KwaZulu-Natal, South Africa

The use of injection drugs in South Africa is increasing. HIV prevention, treatment and addiction services for people who inject drugs (PWID) in South Africa are not well documented. We conducted a mixed-methods study to understand current drug use practices and access to HIV prevention and treatment services for PWID in KwaZulu-Natal, South Africa. We used respondent-driven sampling to recruit 45 people who reported injecting opiates within the past 6 months from Durban, KwaZulu-Natal, South Africa. We found high rates of practices that increase HIV/viral hepatitis risk including the use of shared needles (43%) and direct blood injections (bluetoothing) (18%). Despite 35% of participants living with HIV, only 40% accessed antiretroviral therapy within the past year, and one accessed PrEP. None of the participants reported ever testing for Hepatitis C.

27 and directly injected intravenously into another person, has been reported. (10,11) Called flash-28 blooding in other African countries, this practice is often performed in settings of poverty and 29 poor access to needles or needle exchange programs. (12)(13)(14) This practice, in addition to 30 needle sharing, has potential to increase the risk of HIV and viral hepatitis among PWID and 31 spill over into the general population through sexual networks. (15)(16)(17)(18) 32 33 Given the limited data on the population of individuals using injection drugs in KwaZulu-Natal, 34 South Africa, we conducted a mixed-methods, respondent-driven study to understand drug use 35 practices and current access to health care in preparation for targeted prevention and treatment 36 interventions.

38 Methods:
39 We used respondent driven sampling (RDS) to recruit individuals aged 18 years or older, with 40 self-described use of injection drugs within the last 6 months, and currently living in KwaZulu-41 Natal, South Africa. We excluded individuals who did not speak either English or isiZulu, who 42 were severely or visibly intoxicated, or those with severe mental or physical illness preventing 43 participation in informed consent procedures.

45
We recruited three initial seed individuals (who also reported injection drug use in the past 6 46 months) who were attending a harm reduction center in Durban, South Africa. These three seed 47 individuals were encouraged to recruit up to three other PWID from their individual social 48 network. Each additional participant was also asked to recruit up to three different individuals 49 from their own social network, until we reached a total sample of 45 participants. After providing 50 written informed consent, participants completed a facilitated questionnaire that collected 51 information on sociodemographics, drug use, sexual behavior and network characteristics, HIV . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted January 18, 2023. ; 52 testing practices, and use of HIV prevention or treatment services. Interviewers entered data 53 directly into a REDCap database as questions were answered. (19) 54 55 We assessed the frequency, type, and methods of drug use, information on needle 56 procurement, use, and sharing using the National HIV Behavior Surveillance System; (20) and

76
. CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted January 18, 2023. ; 77 The median reported starting age of injecting drug use was 22 years (IQR 19 -26). The 78 majority of participants did not use alcohol (64%; n=29) but reported use of other drugs (53%; 79 n=24). Most participants (93%; n=42) reported use of injection drugs within the last month, with 80 91% (n=41) reporting averaging more than one injection per day. All participants (100%)   99 In this study we found high rates of unsafe injection drug practices that included sharing and re-100 using needles and drug preparation materials, as well as the practice of directly injecting blood 101 from an individual who had recently injected (bluetoothing). These practices, if widespread 102 amongst PWID, coupled with the low uptake of treatment and preventative services described in . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted January 18, 2023. ; 103 this study, including HIV testing, PrEP and ART services, could negate some of the efforts 104 made in the HIV prevention and treatment continuum of care in South Africa. 125 the narrative of police as punitive to one of protectors and advocates of health services for 126 PWID. (26,27) Continued work is needed to reduce ongoing stigma towards PWID which limits 127 access to HIV prevention services and harm reduction programs. (28,29) 128 . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted January 18, 2023. ; 129 Without the availability of widespread interventions, injection drug use has continued to increase . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted January 18, 2023. ; 152 Nzwakie Mosery performed the data collection, contributed to the drafting of the manuscript, critically reviewed the manuscript and approved the final manuscript as submitted.
Michael Wilson assisted with the conceptualization and design of the study, contributed to the data collection, and critically reviewed the manuscript, and approved the final manuscript as submitted.
Shannon Bosman contributed to the data collection, and critically reviewed the manuscript, and approved the final manuscript as submitted.
Cecilia Milford assisted with the conceptualization and design of the study, contributed to the analysis plan, reviewed and revised the manuscript, and approved the final manuscript as submitted.
Jennifer Smit assisted with the conceptualization and design of the study, contributed to the analysis plan, reviewed and revised the manuscript, and approved the final manuscript as submitted.

Funding:
This work was supported via: Center for AIDS Research at Emory University (P30AI050409)