Two ragged men stand at a busy intersection near Durban's central business district. The drivers in glossy cars speed past, taking little notice of them with their faded clothes, untamed hair and tattered cardboard signs asking for money.
If one of these drivers were to stop and ask, they would find out that these homeless men live a few metres from where they stand. Originally, one is from the nearby town of Hillcrest and the other from Hillbrow in Johannesburg.
Jack Coss* (39) and Kurt de Villiers* (32) have more than begging in common. They are addicts, and every day they inject the illicit drug heroin into their veins, bought with coins given to them through car windows. And they share needles even though they know that sharing used needles with other drug users has caused them to contract life-long infectious diseases.
Had the two men been in a different country, their stories may have been substantially different.
If they were heroin addicts in the United Kingdom, they could have been part of a needle-exchange programme where users are provided with clean syringes on a daily basis to prevent the spread of diseases. Introduced in 1987, this programme has expanded, helping more drug users lead healthier lives.
Harm reduction for injecting drug usersHIV prevalence among injecting drug users dropped from 12.8% in 1990 to 6.9% in 1993 solely because of the wide availability of clean syringes provided by the government, according to a 1995 study published in the journal AIDS.
The UK has prioritised a "harm reduction" approach to dealing with drug addiction and irreversible health consequences of this behaviour because, as noted in the study, "the risks of HIV transmission and other infectious diseases in this marginalised population are hampered by punitive law enforcement and social stigma towards this marginalised community".
De Villiers and Coss see needles as an expensive and limited resource. They share needles often because their earnings go almost exclusively to buy drugs.
When they do get clean needles, from the only syringe exchange programme in the city run by the TB HIV Care organisation, law enforcement confiscates them within days, they say.
Homeless, hooked on heroin and HIV positiveDe Villiers, who spent his childhood moving from one dilapidated area in Johannesburg to another, has HIV. His KwaZulu-Natal-born companion Coss, who was abused as a child by his adopted parents from the UK, found out he has hepatitis C during a free screening campaign four years ago.
Coss wipes his mouth with the back of his sleeve, looking at the congested road in front of him.
Before he steps off the pavement to take up his position in the middle of the street he says: "We share needles. Of course I have something – I'm surprised it's only hepatitis."
De Villiers says: "I can never know exactly when or how I got HIV but I can tell you this much: I don't have much sex."
The two don't know how many others they may have infected by sharing their needles, but they do know that their own infections and those of others could have been prevented if they had been given help.
De Villiers has known of his illness for a year longer than Coss but that hasn't changed the outcome: both have tried and failed to get treatment. They say that being drug addicts denies them the option of treatment.
Harassed for being a heroin addictPolice officers have harassed them repeatedly, confiscating De Villiers's identification document in the process. Without it, health workers have refused to open a file for him – which would result in getting free antiretroviral treatment.
Coss has similarly been told by health workers he doesn't qualify for hepatitis C drugs because he is "untrustworthy" and wouldn't take his medication every day.
"Just because I use drugs doesn't mean I am not a South African. I have the right to go to the clinic and get help. But try tell a nurse or policeman that. The drug we take is illegal but we are not. We are people. I am a person."
Whereas Coss is impassioned with frustration, De Villers has lost hope: "I have no home, money, family, friends – no ID and no way to get one. I don't have medicine but who cares? Because I basically don't exist," he says.
Harm Reduction International and public healthHarm Reduction International, a global organisation affiliated to the United Nations, defines harm reduction in its 2015 Global State of Harm Reduction report as a movement which "works to reduce the negative health, social and human rights impacts of drug use and drug policy – such as the increased vulnerability to HIV and hepatitis infection among people who inject drugs – by promoting evidence-based public health policies and practices, and human rights based approaches to drug policy".
The two public health strategies that show the best results in reducing the spread of HIV among people who inject drugs are the needle exchange programmes and opioid substitution therapy, where users are given medicine that mimics heroin, helping with cravings and withdrawal symptoms.
Chris Beyrer, president of the International Aids Society, says that despite overwhelming evidence that these two policies result in less infections, and help individual users to function better in society, few countries in the developing world have such programmes.
Andrew Scheibe, public health consultant and a specialist in injecting drug use, says that although most South African HIV infections happen through sexual contact, "the role substance abuse plays hasn't been given any attention – and it's not a small problem".
HIV prevalence among injecting drug usersThere are an estimated 67 000 injecting drug users in the country and about one in five are HIV-infected, according to research conducted by the South African Medical Research Council.
The latest data from the Joint United Nations Programme on HIV and Aids (UNAids) estimates that this mirrors the prevalence in the general population, where just under 20% of adults between the ages of 15 and 49 are living with the virus.
"The problem is the general HIV estimates are based on ubiquitous reliable research [but] the research for anything to do with substance abuse is so limited, it often ends up as a guessing game," explains Scheibe.
But the figure is still higher than the global estimate: the 2015 UN World Drug Report says that 13% of the 12.7-million people who inject drugs are HIV-infected and that higher rates of injecting heroin in a community is followed by "an exponential increase in HIV transmission".
Scheibe says that although there isn't credible evidence to show the "true nature of South Africa's injecting drug problem", reports from rehabilitation centres and nonprofit organisations "indicate heroin use is going up – slowly – but it is increasing. A bigger issue is that the proportion of people injecting the drug, as opposed to smoking it for example, is going up at a much faster rate."
Smoking street drugs containing heroin, such as nyaope – where the drug is mixed with cannabis and other substances – "has been given enough media attention to show it's a rapidly growing epidemic but what people don't know is that many of these users will transition from smoking to injecting", says Scheibe.
A 2006 study published in the Journal of Acquired Immune Deficiency Syndrome reported that up to 64% of noninjecting heroin users, who usually smoke or snort the drug, move to using syringes.
The amount of time it takes to shift from one way of using the drug to another hasn't been researched in South Africa, but in Tanzania research has shown that most users start injecting within two years of starting to use heroin.
"Hence, interventions looking to prevent the transition to injecting drugs, and consequences thereof, would need to be provided within a year or two after the initiation of heroin use in order to be useful," notes the study.
A strategy to stop needle transmission of HIVIn the context of the country's "massive" HIV epidemic, he says "it would be a mistake to ignore this population – in a decade we could come to regret it", says Scheibe.
According to a 2013 study published in the Journal of the Association of Nurses in Aids Care, "HIV transmission through blood exposure is up to 100 times higher than from sexual contact" – sharing needles exponentially increases one's risk of contracting the virus.
UNAids published its global HIV strategy last year, which aims to drive progress in ending the HIV epidemic: by 2020, 90% of people living with HIV should know their status, 90% of those diagnosed should be on antiretroviral treatment and 90% of the people on treatment should be virally suppressed (when the drugs bring the amount of virus in the blood down enough to significantly decrease the risk of transmission).
According to the 90-90-90 report, this cannot be achieved without "renewed and sustained focus" on injecting drug use, which accounts for 30% of new infections outside of sub-Saharan Africa.
But, because of growing heroin use across Africa, the report predicts that injecting drug use will soon become a similarly significant local problem.
It states that although, globally, people who inject drugs are 28 more times likely to have HIV than the general population, "treatment access is substantially lower" for these drug-users because of a combination of social stigma and human rights violations.
"Drug users are a marginalised group in any society. They are seen as morally bankrupt and basically bad people to the point where health workers may refuse to treat them or do so only when compelled," says Scheibe, who has conducted research about injecting drug use in five South African cities.
"Law enforcement has also been a barrier – in any country – as they [drug users] are beaten and arrested, with possession of a small amount of an illegal substance often as their only crime."
Scheibe's research has found that these arrests seldom result in positive results: most drug users spend a few days in prison without being charged.
"This has little impact on law enforcement – there aren't less drugs on the black market or fewer users of these drugs – but the individuals who are needlessly locked up are the ones who feel it, losing time and money and experiencing even more trauma than they need to," says Scheibe.
Criminalisation of drug useDavid Bayever, from the University of the Witwatersrand's pharmacy faculty, says the criminalisation of drug use globally has led to a situation where individuals are persecuted for using drugs, "but that does not make a person a delinquent or a criminal ... No person sets out with an ambition to become an addict. It may be the consequence of number of circumstances that one finds themselves in."
He says that youth are encouraged to have "enquiring minds on the one hand and then [we] condemn them when they experiment".
UNAids estimates that up to 90% of people who inject drugs will be incarcerated at some point in their lives and that this "hinders the HIV response, as fear of arrest impedes people's access to and uptake of HIV services".
Harm reduction in AfricaIn sub-Saharan Africa only one country has harm reduction legislation, Mauritius.
A further seven have at least one needle exchange or substitution therapy programme: Kenya, Madagascar, Nigeria, Seychelles, South Africa, Tanzania and Zanzibar, according to a 2016 article in the International Journal of Drug Policy. This is despite injecting drug use being reported in "28 African countries, with increasing evidence of linked HIV epidemics".
In South Africa Bayever says there are four harm reduction programmes in the Western Cape, two in Gauteng and one in KwaZulu-Natal but "we are lagging far behind other countries".
He says "we need to beef-up our medical and social system" because this "must become a priority in the country".
Scheibe says one of the issues locally is that programmes often focus on specific groups leaving many drug users "without access". For example one needle exchange programme in the Western Cape only focuses on men who have sex with men.
"We shouldn't delay. We know harm reduction works and if we're serious about getting a hold on HIV we need to take action," he says.
"We're a leader on the continent for our action around HIV. Why should this be any different?"
Begging to get money for heroinAs the late afternoon traffic dissipates, with Durban's workforce having made their way home, Coss and De Villiers too head home. It's the end of their work day.
Coss empties a pocket and counts the coins. It comes to R135 – enough to buy heroin "and cooldrink".
"We don't need much money for food because you don't really have an appetite from the heroin," he says, putting the money carefully into another pocket.
De Villiers does the same, smiling at Coss as he waves a R50 note in the air.
"I'm lucky today," he says. He's made R160.
But his smile fades as he carefully packs his money into a pocket.
He says the word and pauses, standing motionlessly in a driveway of a run-down street. He spits on the concrete slab where he will return to sleep tonight.
"You know, when I was clean for three years and I took my first hit after the divorce … after not using for so long I took too much and nearly overdosed."
He mumbles something inaudible and Coss asks: "Huh?"
De Villiers clicks his tongue before repeating himself loudly.
"I said, if I was lucky I would have died then. I think about killing myself every day but I'm a Christian so I can't do it. But this is no life."
* Names have been changed
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