This summary provides an overview of the key points in the scientific paper scoring guide document: 1) The scoring guide evaluates the scientific merit of research articles based on how well the research advances scientific knowledge, contributes to theories and the field of study, and analyzes scientific methods. 2) Articles are also analyzed based on the validity and reliability of the research study design and how it contributes to scientific merit. 3) Ethical concerns in research study design are also evaluated, as well as the professionalism and quality of writing and formatting of the article.

1. Scientific Merit Paper Scoring Guide
Evaluates the scientific merit of the article by analyzing how
the research advances the scientific knowledge base. Evaluates
the scientific merit of the article by analyzing how the research
contributes to research theory and the field of study. Evaluates
the scientific merit of the article by analyzing the scientific
methods. Analyzes the validity and reliability of a selected
research study and elaborates on how it contributes to scientific
merit. Analyzes the effectiveness of strategies selected for
addressing ethical concerns in the design of a research study.
Communicates in a manner that is completely scholarly,
professional, and consistent with expectations for members of
the identified field of study, and uses APA style and formatting
with few or no errors.
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International Journal of Drug Policy 21 (2010) 289–295
Contents lists available at ScienceDirect
International Journal of Drug Policy
j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c

3. a t e / d r u g p o
esearch paper
pportunities for enhancing and integrating HIV and drug
services for
rug using vulnerable populations in South Africa
harles D.H. Parry a,b,∗ , Petal Petersen a, Tara Carney a,
Richard Needle c
Alcohol & drug Abuse Research Unit, Medical Research
Council, South Africa
Department of Psychiatry, Stellenbosch University, South
Africa
Pangaea Global AIDS Foundation, USA
r t i c l e i n f o
rticle history:
eceived 25 July 2009
eceived in revised form
0 November 2009
ccepted 24 November 2009
eywords:
apid assessment
llicit drugs
ex risk
IV
ntegrated services
outh Africa
a b s t r a c t

4. Background: Little has been done to improve the integration of
drug use and HIV services in sub-Saharan
Africa where substance use and HIV epidemics often co-exist.
Methods: Data were collected using rapid assessment methods
in two phases in Cape Town, Durban
and Pretoria, South Africa. Phase I (2005) comprised 140 key
informant and focus group drug using
interviewees and 19 service providers (SPs), and Phase 2 (2007)
comprised 69 drug using focus group
interviewees and 11 SPs.
Results: Drug users put themselves at risk for HIV transmission
through various drug-related sexual
practices as well as through needle sharing. Drug users in both
phases had limited knowledge of the
availability of drug treatment services, and those that had
accessed treatment identified a number of
barriers, including affordability, stigma and a lack of aftercare
and reintegration services. SPs identified
similar barriers. Drug users displayed a general awareness of
both HIV transmission routes and prevention
strategies, but the findings also indicated a number of
misperceptions, and problematic access to materials
such as condoms and safe injection equipment. Knowledge
around HIV treatment was low, and VCT
experiences were mixed. SPs recognized the importance of
integrating HIV and substance use services,
but barriers such as funding issues, networking/referral gaps
and additional burden on staff were reported
in Phase 2.
Conclusion: A comprehensive, accessible, multi-component
intervention strategy to prevent HIV risk in
drug users needs to be developed including community
outreach, risk reduction counselling, VCT and

5. substance use treatment.
ntroduction
There is growing evidence for the effectiveness of a multi-
omponent approach to HIV/AIDS prevention for drug users
ncluding community-based outreach; HIV risk reduction coun-
elling that addresses both drug and sexual risk behaviours; HIV
ounselling and testing; access to sterile injection equipment;
ccess to treatment for drug dependence; and for HIV positive
rug users, access to HIV/AIDS care and treatment (Des Jarlais
t al., 2004; National Institute on drug use, 2002; Weinhardt,
arey, Johnson, & Bickham, 1999). However, in reality services
are
ften fragmented with little integration of drug treatment and
IV programmes (World Health Organization, 2005). Numerous
∗ Corresponding author at: Alcohol & drug use Research Unit,
Medical Research
ouncil, PO Box 19070, Tygerberg, 7505, South Africa. Tel.: +27
21 938 0419;
ax: +27 21 938 0342.
E-mail address: [email protected] (C.D.H. Parry).
955-3959/$ – see front matter © 2009 Elsevier B.V. All rights
reserved.
oi:10.1016/j.drugpo.2009.11.008
© 2009 Elsevier B.V. All rights reserved.
barriers exist, including limited capacity and training for drug
treat-

6. ment providers, drug prevention workers, harm reduction
outreach
workers and other service providers who work with drug users
or
with sub-populations of commercial sex workers (CSW) or men
who have sex with men (MSM) who use drugs; and stigma, dis-
crimination or policy barriers that impede access to HIV
treatment
for active drug users (Niang et al., 2003; Reif, Golin, & Smith,
2005).
While there has been a move towards improving the integration
of
drug use and HIV services in some countries (Cook & Kanaef,
2008),
in sub-Saharan Africa efforts in this regard have been minimal
apart
from one or two small scale efforts (Deveau, Levine, &
Beckerleg,
2006).
South Africa is currently experiencing one of the world’s most
devastating HIV epidemics and was estimated to have 5.3 mil-
lion people living with HIV in 2007 (Department of Health,
2008).
Since 1994 there has been a rapid increase in local consumption
of a broad range of drugs including cocaine, heroin, Ecstasy,
and
more recently methamphetamine (Parry & Pithey, 2006; Parry,
Plüddemann, & Myers, 2007; Plüddemann, Myers, & Parry,
2008).
http://www.sciencedirect.com/science/journal/09553959
http://www.elsevier.com/locate/drugpo
mailto:[email protected]

7. dx.doi.org/10.1016/j.drugpo.2009.11.008
2 urnal
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90 C.D.H. Parry et al. / International Jo
ost drugs are smoked, but there is evidence of increasing injec-
ion use of heroin in some parts of the country (Parry,

9. Plüddemann,
Myers, 2005). There is now also emerging evidence from a
grow-
ng number of local research studies of the link between
substance
se and HIV/AIDS, mostly through substances’ effect on sexual
risk
ehaviour (Morojele et al., 2006; Morojele et al., 2004; Simbayi
et
l., 2006; Simbayi et al., 2004).
The need for a comprehensive HIV/AIDS prevention plan that
ncludes drug users has been articulated in two recently released
olicy documents: South Africa’s Second National Drug Master
lan (Department of Social Development, 2007) and South
Africa’s
ational AIDS Strategy (Department of Health, 2007). There is,
owever, a need to go beyond rhetoric and have information that
ill facilitate the roll-out of comprehensive service delivery
mech-
nisms for drug users. The aim of this study was to understand
he risk behaviours of drug users, both injection drug users
(IDUs)
nd non-injection drug users (NIDU), the barriers and facilitators
o HIV and drug treatment services, their willingness to be tested
or HIV, their opinions on drug use as a coping mechanism for
HIV
ositive drug users, and to use this understanding to inform the
evelopment of programs and services to reach vulnerable drug
sing populations at risk for HIV infection.
ethods
Two cross-sectional qualitative studies were undertaken in

10. 005 (Phase 1) and 2007 (Phase 2), with the second phase being
o determine if there were any newly emerging trends in drug use
nd to ask more refined questions about service delivery issues
that
ould be useful in informing the intervention phase that began in
007.
articipants
In Phase 1 information was gained from drug using partici-
ants in known hotspots for drug use and risky sexual behaviour
y undertaking 131 key informant interviews (45 in Durban, 50
in
ape Town and 36 in Pretoria) and 21 focus group interviews
con-
tituting 109 participants (34 in Durban, 40 in Cape Town and 35
n Pretoria). The final sample of drug users comprised 78 MSM,
115
SWs, 96 IDUs as some drug users fit into more than one
category,
nd 45 NIDUs who were also not CSWs or MSM. Further data on
hese sub-populations are provided in published articles that
focus
n drug-related HIV risk behaviour among these sub-populations
nd that do not include service provider data or go into detail of
ser-
ices related issues (Needle, Kroeger, Belani, Achrekar, &
Dewing,
008; Parry, Dewing et al., 2009; Parry, Petersen et al., 2008).
n addition, nineteen service providers (SPs) were interviewed
rom public, private and civil society (NGO/CBO) organizations
hat target the general population and at-risk groups, including
irectors of drug treatment agencies (3), social workers in the
ubstance dependence field (2), HIV/AIDS trainers/counsellors
(5),
irectors/managers of various NGOs providing HIV and other

11. risk
eduction services (3), VCT nurses (3), shelter
caretakers/managers
2) and a policeman. Street intercepts and snowball sampling
tech-
iques were used to identify the drug using populations, and the
Ps were identified as a result of prior contacts members of the
esearch team had and through referrals from SPs.
In Phase 2, key informant interviews were conducted with 11
Ps chosen from the substance dependence fields (6) and other
GOs (5) that currently work with vulnerable populations. They
lso recruited study participants. Thirteen focus groups with drug
sers were conducted in Cape Town, Durban and Pretoria. Five
focus
roups (n = 28 drug users) were conducted with MSM, 3 in Cape
own and 2 in Pretoria. Two focus groups (n = 13 drug users)
were
of Drug Policy 21 (2010) 289–295
conducted with CSWs in Durban, and 6 focus groups (n = 28)
were
conducted with drug users who were neither MSM nor CSWs, 3
in
Cape Town and 3 in Durban.
Procedures
Data for the first phase of the study was collected over six
weeks
in late 2005. In Phase 1 key informant interviewees were
offered
free voluntary counselling and testing (VCT) for HIV by
certified

12. VCT nurses using the Smart Check Rapid HIV-1 Antibody Test
(fin-
ger prick) and confirmatory tests for those testing positive were
performed using the Acon Rapid HIV-1/2 Antibody Test.
Data for Phase 2 were also collected using rapid assessment
methods and included focus group interviews with drug users
(IDUs and NIDUs), including female CSWs and MSM, and key
infor-
mant interviews with SPs. Data collection was conducted over a
one week period in each site (Cape Town, Durban and Pretoria)
in
mid 2007.
All interviews and focus groups were facilitated by a team of
two trained field workers. Interviewees gave written, informed
consent at the beginning of the interview and were assured of
anonymity. Ethical approval for conducting the study was
granted
by the University of Stellenbosch. Interviews were conducted in
English, however interviewers with local level language
capacity
were employed.
Measures
In Phase 1 key informant interviews were conducted using a
semi-structured interview guide to elicit descriptions of the
context
of drug use, identify drug use and other risk factors for HIV
infec-
tion, and explore issues around drug and HIV service needs and
past
experiences. Focus groups were conducted to expand on,
confirm
and validate risk-related themes described in earlier interviews.

13. In
Phase 2 data were again collected using a semi-structured
question-
naire sheet for interviewing key informant SPs and an open-
ended
question guideline sheet for conducting focus groups with drug
users. The questions were similar to those asked in Phase 1, but
with less items overall and some additional items to probe
around
service delivery issues, with service delivery being broadly
defined
to include prevention and harm reduction activities.
Coding of the transcripts and analysis of textual data was per-
formed using AnSWR® (Strotman et al., 2002) to aid in
qualitative
data analysis. In Phase 2 data analysis utilized summary tables
in which responses were manually coded for each site and sub-
population for issues raised in the focus group and individual
interviews. Coders who were involved in Phase 1 independently
read all of the transcripts and noted down similarities with
findings
recorded in Phase 1, and differences in types of drugs used and
their
availability, mode of drug use, links to drug use and
engagement in
sex and issues related to drug use and HIV services.
Results
Drug user HIV risk
The most commonly used drugs across all groups were
cannabis, cocaine hydrochloride (HCl), crack cocaine and
heroin.
Methaqualone, otherwise known as Mandrax, (a barbiturate

14. com-
monly smoked with cannabis) was also widely used. There were
some inter-site differences, for example, crystal
methamphetamine
was widely used in Cape Town while dipipanone hydrochloride
(an analgesic known as Wellconal) was popular among persons
who injected in Durban (Parry, Petersen, Carney, Dewing, &
Needle,
2008). The majority of drug using interviewees across both
phases
of the study reported that drugs such as crystal
methamphetamine,
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C.D.H. Parry et al. / International Jo
rack cocaine and Ecstasy increased their sexual desire by
increas-
ng energy which often prolonged the sexual act, heightening
their
enses and generally improving both foreplay and sexual inter-
ourse.
In addition, most drug users reported not thinking about con-
oms and safe sex or being happy to forgo condom use when
hey were ‘high’. This was also the case for some CSWs if they
ere offered more money for condomless sex with a client. It
as common for the drug using interviewees to have riskier sex
with multiple partners/strangers, group sex and/or anal sex)
while
ntoxicated.
Both drug users and SPs agreed that long term heroin users
enerally reported that this drug diminished their desire for sex.
owever, long term heroin was often associated with injection
use,
nd IDUs’ injection practices were often riskier than their sexual
ehaviour. A number of heroin using interviewees were unaware
of
heir needles’ origin. Most reported sharing equipment with
regu-
ar partners, using blunt needles or sharing with others if
desperate
or a fix. Some also reported discarding needles in public places

17. or
n garbage bins.
In Phase 2, drug using interviewees had contradictory opinions
bout injection drug use as a risk. Some agreed that the increase
in
eroin use had led to an increase in injection use, and risks asso-
iated with reuse and sharing of needles. MSM generally agreed
hat IDUs shared equipment. In Cape Town needle sharing was
ssociated with pushing boundaries by ‘looking for the next
high’.
owever, some MSM felt that injection use was not glamorous
nough for the ‘gay scene’.
nowledge and experiences with drug services
While many drug users have received drug treatment of some
ind, a large proportion has not. Reasons included not knowing
here to access services or what they offer, not wanting to go or
ot seeing the reason for treatment, or because they held the gen-
ral belief that they were in control of their drug use. Drug users
in
hase 1 recommended that better education should be provided
on
he dangers of drug use, especially to hidden, vulnerable popula-
ions. This was further elaborated upon by interviewees in Phase
2,
ho stated that issues that put drug users at increased risk for
HIV,
uch as sharing both injection and non-injection equipment as
well
s sexual risk, are not traditionally addressed by drug treatment
roviders.
Others, however, reported that they were not interested in the

18. essation of drug use. Some SPs stated that patients’ ‘difficult
atti-
ude’ or ‘lack of motivation’ hinders treatment. A number of
IDUs
nd a few MSM reported that they had been treated for their
addic-
ion ineffectively with prescription medication. Only one SP,
based
t a hospital, indicated that they provided methadone substitution
herapy for heroin addiction, and one IDU specifically spoke
about
eing on methadone to stop his heroin use:
Methadone. Yes, which is actually. . . It brings you off heroin. .
.
You buy it at the chemist but it’s a Schedule 7 drug. You have
to
get it from a prescription. It’s actually - it takes the craving and
the sore and the sickness away. It’s about R100 [about US$ 12]
a bottle. (33 year old male IDU, Durban Phase 1)
In Phase 2, NIDUs/IDUs and SPs in Durban and Cape Town
were
ware of the successful provision of more than one kind of med-
cation (methadone and buprenorphine in Durban) to assist with
ymptoms associated with heroin withdrawal. However, drug
users
entioned a number of difficulties associated with drug
treatment.
ntry into public treatment was described as a lengthy process
hile the alternative, private drug treatment, was not affordable.
hey felt that it was necessary for the government to provide

19. of Drug Policy 21 (2010) 289–295 291
free treatment, and for more community outreach programs to
be implemented, especially those that deal with issues pertain-
ing to specific sub-populations of drug users (such as MSM).
SPs
expanded on this issue, viewing state subsidized centres as
over-
crowded often with limited services, with private treatment
being
unaffordable for many.
Another barrier to receiving services for drug use was that
drugs
were reported to be widely available in rehabilitation centres by
a
few SPs but mainly by drug users who have used the services:
I have been in rehabilitation once, the first time I overdosed
of heroin, and Ecstasy, then I went to rehabilitation in [Centre
X]. I was there for three months and when I came out there, I
felt more drugged than I have ever felt in my whole entire life.
Really, because inside rehabilitation there’s even more drugs
than there is, than there is outside. (24 year old male IDU, Cape
Town Phase 1)
NIDUs in Durban especially spoke of the use of physical pun-
ishment as treatment and the lack of foci on drug use or the
risks
related to HIV. Ongoing treatment was also seen as problematic,
and
almost all drug service users reported that they relapsed after
reha-
bilitation because they returned to their previous environment.
While a few SPs explained that they provided support groups
and

20. meetings with patients and family after formal treatment, most
agreed that there was a need to address reintegration into func-
tional society:
And a lot of times that is what is going to save the patient, if
someone will just trust them and give them a job. Even if it’s
just wiping floors or whatever. . . No one looks at re-integration
into the community. That’s still a big problem for me, ja [yes].
Because no one wants to employ someone that’s had a heroin
problem. (Substance dependence social worker, Pretoria Phase
1)
Knowledge and experiences with HIV intervention services
Drug using interviewees had general knowledge of HIV trans-
mission routes and prevention strategies. Many IDUs and MSM
in
Phase 1 were particularly aware of the importance of not
sharing
needles and other drug equipment. In addition, substitution ther-
apy was recommended by SPs and IDUs in Phase 2 as a
necessary
prevention measure. However, one IDU and the majority of
CSWs
mentioned that sexual and other risks were more likely risk
factors
for drug users than injection drug use.
A number of misperceptions around HIV transmission and the
prevention thereof also existed among drug users. One IDU in
Phase
1 described cleaning his genitals after sex and a few CSWs in
Cape
Town reported eating shellfish (arikreukal) to prevent HIV, as
well
as cleaning needles with ineffective materials such as tap water.

21. SPs confirmed that there was a lack of education around HIV
among
drug users, and one SP stated that preconceptions were also
present
among certain sub-populations of drug users:
. . .lots of people think because, people think it comes from the
gay community, Los Angeles, so many years ago, 1982, that
the gay people know how to practice safe sex. They don’t need
information. . .and then all focus on the heterosexual. . .I think
wrongly, yes, because, I think wrongly. Because the younger
gay person [who] is now out of the closet won’t know what
happened in 1982 for instance. (AIDS counsellor, Pretoria Phase
2)
Drug users that were interviewed listed community health
centres and clinics, various health care professionals, the media
and personal experience as their sources of information around
2 urnal
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a
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lengthen counselling sessions and that, in general, they were not

23. 92 C.D.H. Parry et al. / International Jo
IV/AIDS. IDUs also referred to the lack of information provided
y HIV services for this specific sub-population of drug users.
Many
nterviewees were aware that condom use could prevent HIV
trans-
ission, but access to free condoms was problematic. In Phase 2,
DUs in Cape Town suggested that injection equipment is only
avail-
ble through pharmacists that often do not provide the necessary
quipment to customers who are suspected of being drug users.
Dif-
culties in getting access to clean needles and syringes after
hours
ere similarly raised by drug users as well as SPs:
At night time, there’s no needles. Then people start sharing
needles. There’s no condoms, because the chemists [pharma-
cies] are closed. They should always be available, needles and
syringes, and condoms; there should always be a visibility of
them, a presence where they can go and get them for free. (34
year old MSM, Cape Town Phase 1)
SPs generally agreed that needle exchange programs (NEPs) had
een effective in other countries to prevent HIV risk behaviour
such
s sharing needles. Furthermore, NEPs could also be a place for
etting into contact with and providing education to IDUs:
. . .Australia for example, you have places where people can go
and shoot heroin safely. And get a clean needle and get counsel-
ing at the same facility, get education, get pamphlets, get
spoken

24. to about their drugging. (Drug service director, Phase 1)
Many SPs recognized that improved service delivery was
needed
ecause HIV prevention was not a priority for drug users. In
Phase
, NIDUs and IDUs themselves agreed that HIV prevention was
not
priority for drug users due to their lack of finances as money
as spent primarily on drugs. In Phase 1, it was established that
rug using sub-populations were interested in VCT if it was
avail-
ble and accessible and that certain sub-populations had higher
IV prevalence than others (Parry et al., 2008). Ninety-two
(70%)
f 131 drug using key informants agreed to be tested for HIV as
art of the study and received their test results: 37 (80%) MSM,
50
74%) CSW, and 15 (71%) NIDUs (Parry et al., 2008). While a
smaller
roportion of IDUs (63%) agreed to testing, several reported
having
een tested in the past and already knew their status. Several
indi-
iduals partook in the study because they wanted to be tested for
IV.
For those drug users who had been tested before, reasons for
esting included concern about their high risk sexual and/or drug
sing behaviours, having an HIV positive friend or partner and
being
reated for other STIs. A number of drug using interviewees that
ad been tested for HIV previously had either positive or
negative
xperiences. A common experience was feeling stigmatized due
o being a member of a vulnerable sub-population of drug users

25. nd/or being HIV positive:
We tend to have this attitude towards testing you know because
fearing that when we get there, they are going to see that you
are
gay. . . There is a belief that the nursing sisters at the clinic,
they
laugh about gay people and stuff. (MSM focus group
participant,
Pretoria Phase 2)
In Phase 1, drug users (including IDUs) indicated that VCT ser-
ices did not seem to be accessible to people like them. Some
CSWs
pecifically felt that SPs and mobile clinic staff are often scared
to
o into the areas that they frequent. Improving accessibility was
herefore indicated as an urgent need. SPs also noted that the
loca-
ion and cost of HIV testing needed to be changed to promote
use.
CT was generally only provided by those employed at
HIV/AIDS
gencies, although the director of a general drug counseling
organi-
ation reported that their centre had a VCT site on the premises.
In
of Drug Policy 21 (2010) 289–295
Phase 2, drug users and SPs alike argued that VCT should be
offered
routinely at drug treatment centres.
However, MSM had mixed opinions about whether VCT

26. services
should educate drug users about the possibility of their
behaviour
putting them at risk for HIV. While some felt that the two issues
were related, due to injection and sexual risk, a few perceived
drug
use and HIV as two separate issues:
Listen here, if I chose, if I’m doing drugs or I am addicted that
is
not really, okay I’m coming in for an HIV test. I want to know
if
I’ve got HIV. That’s what I want to know about. . . Pushing the
whole drug guilt down my throat I think that will actually make
me less comfortable to come for an HIV test. (MSM Focus
group
participant, Pretoria Phase 2)
Knowledge about the availability and role of ARV treatment
was minimal among drug using interviewees, but in Phase 2
CSWs
demonstrated an understanding of how ARVs function. A few
MSM
correctly identified potential side effects of ARVs and some
IDUs
acknowledged drug interaction and adherence issues. Both SPs
and
drug using interviewees expanded on these two subjects in
Phase
2. Drug using interviewees had mixed opinions about the
function
of drug use as a coping mechanism for HIV positive drug users.
While the majority of interviewees felt that they would continue
drug use as justification and an excuse, others believed that
drug
users could cease drug use depending on their perception of

27. HIV.
SPs on the other hand, generally stated the assumption that a
sig-
nificant proportion of drug users use drugs to cope with being
HIV
positive. In Phase 2, some drug using participants also reported
knowing of individuals using ARVs in combination with other
sub-
stances such as alcohol and cannabis, a finding that did not
emerge
during the earlier phase. While CSWs believed that the purpose
of
this was for enjoyment, one MSM spoke of his experience of the
use of cannabis in curbing side effects of ARVs, such as
drowsiness.
SPs furthermore expressed the belief that drug use interferes
with
HIV positive individuals’ compliance with medication.
Current and perceived need for integration between services
SPs recognized the need for addressing HIV and drug use
together, as well as the possibility of integrating the two
vertical
programs:
What I have realized is that people, they only focus on what
they
are there to do. . .So what I am saying is that the first contact,
either the sister or nurse whoever has the first contact with the
patient, should be able to diagnose or access whether this
person
is a drug user. (CSW service provider, Phase 2)
A number of potential barriers to this integration were identi-
fied. While the primary strategy of training and capacity

28. building
was viewed as critical to strengthen and develop links among a
variety of service-providing organizations and agencies, SPs
iden-
tified that activities such as building networks or cross-training
are
rarely funded. In Phase 2, SPs therefore suggested networking
with
local action committees, forums and advisory boards as well as
with organizations outside of their area of expertise such as law
enforcement agencies.
Some HIV service providers said that they currently do coun-
sel clients on drug and alcohol use in relation to HIV and
ARVs. In
Phase 1, VCT nurses however, argued that drug counselling
would
trained to deal with drug users who are often in denial.
Similarly in
Phase 2, a potential obstacle identified was the increase in
work-
load if HIV services were to be included into drug treatment, or
drug-related risk into HIV services.
urnal of Drug Policy 21 (2010) 289–295 293
d
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O
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30. 2
p
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Table 1
Operational and training objectives to facilitate more efficient
and integrated deliv-
ery of drug and HIV services.
Structural issues
• Move away from the approach to delivering services in drug
and HIV silos
• Provide a government subsidy for those NGOs/CBOs that
address drug
and HIV risks in a comprehensive and integrated manner
Operational issues
• Tailor community-based outreach to drug users that addresses
HIV/AIDS

31. risk
• Explore risks related to safe injection use and disposal
practices
• Integrate education, information, and communication of HIV
drug-related risks into current HIV prevention efforts and vice
versa
• Provide confidential, routine HIV counselling and testing in
substance
abuse programs
• Adapt VCT to be more localized, mobile, and population
specific
• Include risk reduction counselling in counselling and testing
that focuses
on HIV and drugs
• Decrease stigma of SPs against vulnerable drug using
populations (CSWs,
MSM, IDUs, etc.)
• Provide cross-training for persons delivering drug and HIV
services
• Encourage and support high-quality evaluations to provide
evidence for
programs that achieve behaviour change
• Develop capacity to provide access and referral to substance
abuse, HIV,
and other health services and treatment to vulnerable
populations
engaged in high risk behaviours
Capacity building and training

32. • Scale up outreach efforts to targeted groups in high risk areas
• Provide more resources to NGOs/CBOs to address both drug
and HIV risks
•
C.D.H. Parry et al. / International Jo
SPs discussed the difficulty experienced with drug users who
o not want to know their HIV status and thought that HIV
preven-
ion and testing was not considered of vital importance to many
rug users. They therefore recommended that HIV-related
preven-
ion efforts should be free and drug user friendly. They reported
hat additional burdens faced in coordinating services with other
ectors were fears about loss of confidentiality and restrictions
on
he kind of information that can be shared across organizations.
ther issues mentioned were staff burnout and frustration with
lients who may have difficulty complying with counseling mes-
ages and treatment regimens due to their drug use. The need for
dditional training in how to access hidden and vulnerable
popula-
ions and how to handle the sensitive and potentially stigmatized
ssues of drug use, sex work and MSM sexual behaviours was
widely
cknowledged.
iscussion
This study found similarities and differences between drug
sers’ views of services and those who provided services. SPs
were
oncerned about drug users’ risky behaviour, and drug users
them-
elves reported engaging in a number of risky injecting and
sexual

33. ehaviours that put them at risk of HIV, although they were not
lways aware of these risks. Drug users generally reported neg-
tive experiences of drug treatment, mixed experiences of HIV
ervices and several had no previous interaction with such
services.
hile drug users faced a number of barriers to accessing services,
Ps additionally mentioned a number of constraints that affected
heir service delivery. While a few SPs reported that the services
hey worked for made concerted efforts to coordinate their
efforts
hrough referrals and other mechanisms, HIV and drug services
ere generally seen as very fragmented by both SPs and drug
users.
ther studies have likewise demonstrated that few programs have
ttempted to integrate HIV and drug services (Ball, Rana, &
Dehne,
998; Kellerman, Drake, Lansky, & Klevens, 2006).
In developing a more comprehensive, multi-component
pproach, based on findings from the current study and
specifically
oming out of a workshop held in August 2006 to review the
find-
ngs of the first phase in relation to international best practice,
we
ropose a number of important structural, operational and train-
ng objectives to facilitate better integration and delivery of drug
nd HIV services to vulnerable drug using populations as well as
mprove referrals and networking to establish better links
between
rganizations (Table 1). Firstly, we recommend that there needs
to
e a move away from the common approach of delivering
services

34. n drug and HIV vertical programs (National Institute on drug
use,
002).
A number of agencies attributed their failure to provide a com-
rehensive array of services to a lack of time, staff and money.
herefore we propose that an increased subsidy be provided by
gov-
rnment to those NGOs/CBOs that address both drug and HIV
risks
n a comprehensive and integrated manner. Such funding could
be
sed for training, possibly hiring and accommodating new staff,
to
upport the building and maintenance of referral networks, and
ncreased costs related to management and supervision of staff
ith enlarged job descriptions or new specialists with skills dif-
erent from their current staff complement.
The core interventions in a comprehensive approach include
ommunity outreach (essentially peer education and outreach that
ncludes risk assessment and reduction counselling); supplies
pro-
ision (condoms/lubricant and access to safe injection equipment
nd referrals to services); risk reduction counselling that
addresses
oth injection and non-injection drug- and sexual risk taking;
safe
njection and disposal (needle cleaning skills, access to bleach,
otton, and needles); VCT; and substance dependence treatment
Incorporate HIV drug-related risks into tertiary training of

35. health
professionals
• Sensitize SPs to issues affecting “most at-risk groups”
(National Institute on drug use, 2008). A specific
recommendation
emerging from drug users interviewed in the study was for con-
fidential, routine HIV counselling and testing to be provided in
substance dependence treatment settings. Previous studies have
shown that it is possible to effectively bring HIV education
(Strauss,
Astone, Des Jarlais, & Hagan, 2005) and testing (Friedmann,
Lemon,
Durkin, & D’Aunno, 2003; Strauss, Des Jarlais, Astone, &
Vassilev,
2003) into drug treatment as part of a comprehensive plan.
We also propose an integration of education, information and
communication of HIV drug-related risks into current HIV
preven-
tion efforts, and vice versa. Drug users realized to some extent
that
injection and other drug use practices increase their risk of con-
tracting HIV, and several requested improved education to
inform
them about drug-related HIV risk behaviour and where to get
assistance. Most drug users acknowledged their risky
behaviours,
as some had HIV tests in the past, but others seemed relatively
ignorant about the dangers of their own behaviour. This also
demonstrates a need for basic awareness raising through peer-
and
other forms of education and outreach activities to draw in drug
users who might not be fully aware of the risks of their
behaviour

36. and where to access services. Specifically VCT should address
both
sexual and drug taking risks associated with HIV (Des Jarlais &
Semaan, 2005; Kellerman et al., 2006; Semaan, Des Jarlais, &
Malow,
2006).
The drug using interviewees’ risky injection practices identified
in this study included disposal of needles and syringes in ways
that
potentially place themselves and others at risk for getting
pricked.
There is now a growing recognition of the importance of
addressing
such practices and in the UK and elsewhere technologies have
been
developed to assist IDUs in safe disposal practices. These
should
be explored and made more available in South Africa where
such
technologies are almost unheard of.
Drug using interviewees pointed out that numerous barriers
prevent them from accessing existing VCT services. Previous
stud-
ies have shown similar barriers such as staff attitudes,
engagement
in risky behaviours and fear of testing HIV positive (Downing
et al.,
2 urnal
2
b
e

37. b
h
i
o
p
t
c
T
t
H
e
f
i
a
t
i
c
e
a
a
v
p
w
a
S
v
s
d
p
w
p
S
t
C

38. (
t
w
a
e
a
o
o
t
f
S
i
i
v
l
t
f
e
n
n
r
m
t
h
a
94 C.D.H. Parry et al. / International Jo
001; Kellerman et al., 2002). Accessibility to VCT in particular
has
een shown to be one of the more challenging barriers
(Kellerman
t al., 2002), and the relatively high rate of participants willing
to
e tested as part of this study indicates that persons engaged in

39. igh risk behaviours may be willing to receive VCT if this
service
s available in an accessible venue. Therefore, an important rec-
mmendation is to adapt VCT to be more localized, mobile and
opulation specific.
The majority of drug users felt that they needed increased
access
o all services beyond just VCT, and that outreach efforts that
atered for hard-to-reach populations would best serve this need.
ailoring community-based outreach that address HIV/AIDS risks
o drug users has shown to be effective as part of a
comprehensive
IV model (Academy for Educational Development, 2000;
Needle
t al., 2005) and would systematically increase access to
services. A
urther recommendation, therefore, is that NGOs involved in
work-
ng with vulnerable drug using populations should be encouraged
nd, if possible, supported to conduct or increase outreach activi-
ies.
This study furthermore provided strong evidence of the need for
ncreased capacity building and training in order to implement
the
ore components of a comprehensive plan for drug users (Needle
t al., 2005). Community health workers need further training on
ccessing hidden populations, providing risk reduction
counselling
nd VCT that addresses both drug and sexual risk behaviours. If
ser-
ices are to communicate and collaborate across existing vertical
rograms, one of the key issues identified by the SPs themselves
as training. If health professionals are trained at the tertiary

40. level
bout HIV drug-related risks, services could be improved.
Current
Ps should also receive sensitivity-training to respond to issues
of
iolence, drug use, and HIV, including issues of confidentiality
and
tigma related to hidden and vulnerable populations (such as
MSM
rug users, CSWs and IDUs) which were identified as somewhat
roblematic in this study. A number of previous studies
conducted
ith members of vulnerable populations have also shown negative
erceptions of certain providers (Downing et al., 2001; Neale,
1998;
eal et al., 2000). Efforts need to be made to address stigma
reduc-
ion among service providers who work with high risk
populations.
ross-training of SPs working in different sectors is also needed
Sylla, Bruce, & Kamarulzaman, 2007), to increase sensitivity
and
he use of non-judgmental language when working with persons
ho engage in stigmatized drug using and sex work behaviours,
nd to carry out sexual risk assessments that do not assume het-
rosexuality. Furthermore, additional training should
demonstrate
ppropriate ways to facilitate interaction between drug, HIV and
ther service sectors.
The findings of this assessment are subject to the limitations
f the study design. Firstly, the findings may not be
generalizable
o all drug users or to particular subgroups of drug users as the

41. ocus of the study was only on populations in selected hotspots.
econd, the findings are based on small numbers of respondents
n certain subgroups in some sites and this limited the breadth of
nterview material obtained in these sites. With regards to the
ser-
ice providers, because of their various positions they had
different
evels of knowledge about the agencies that they worked for and
his might have impacted on their competence to comment on
dif-
erent issues. Although a comparison between drug users’ and
SPs’
xperiences and needs was made, the SPs interviewed were not
ecessarily the ones to whom the drug users had exposure.
Overall, findings pointed to the numerous barriers that vul-
erable drug using populations face in accessing and utilizing
isk reduction, substance dependence and HIV services.
Program-
atic implications of the findings included the identification of
he need to tailor community-based outreach to drug users in
igh risk areas that address HIV/AIDS risks; improve linkages
with
ppropriate drug and HIV/AIDS treatment, prevention and harm
of Drug Policy 21 (2010) 289–295
reduction services; ensuring provision of confidential, routine
HIV
counselling and testing in substance dependence programs; and
adapting VCT to be more localized, mobile, population specific
and
include risk reduction counselling that focuses on drug-related
risks; and addressing constraints in terms of the availability of

42. opiate substitution therapy and NEPS in South Africa.
Acknowledgements
The research was funded by the US President’s Emergency Fund
for AIDS Relief (PEPFAR) through the US Centers of Disease
Con-
trol and Prevention (CDC) (PO S-SF750-06-M-0781). Its
contents
are solely the responsibility of the authors and do not necessar-
ily represent the official views of the CDC or PEPFAR. The
authors
would also like to acknowledge the support of our field work
staff
and NGOs in Cape Town, Durban and Pretoria; Angeli Achrekar
and
Thelma Williams who assisted the project as part of the CDC
Inter-
national Experience and Technical Assistance (IETA) Program;
as
well as our colleagues at the CDC in Atlanta (Karen Kroeger)
and
in Pretoria (Latasha Treger) for their technical support and
encour-
agement throughout the project.
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