Although longitudinal studies are lacking, the evidence from secondary data sources suggests a growing problem of drug misuse in many sub-Saharan African countries. Many cities are trafficking routes for cannabis, heroin, cocaine, and other psychotropic substances (Day 1992). The spill-over effects are reflected in the reported increase in the misuse of heroin and cocaine in many countries, with anecdotal reports of the injecting of these substances from some of these countries (United Nations Drug Control Programme [UNDCP] 1994). Trends in drug misuse in sub-Saharan Africa indicate the potential diffusion of injecting drug use with major and severe implications for the future transmission of HIV and other blood-borne diseases. To date, drug policy control efforts have focused on supply reduction (reducing the availability of drugs) and demand reduction (reducing the use of drugs). Harm reduction interventions, which focus on reducing harmful consequences of drug use, have become established in many developed countries but have yet to be developed systematically in sub-Saharan Africa.  

In recent years cannabis use has increased extensively with the typical cannabis user being young (age 10 to 30 years) and male. Use has been reported among students, farmers, soldiers, street children, and civil servants (Ohaeri and Odejide 1991; Ekpo et al. 1995). Substances such as stimulants are obtained from licit and illicit sources, are widely used in sub-Saharan Africa (Baasher 1989) and have been reported from Burkina Faso, Chad, Gabon, Ghana, Mali, Senegal, and South Africa (United Nations Economic and Social Council 1994). The stimulants are usually smuggled into African countries where they are consumed mainly by adolescents (predominantly students) and unskilled labourers, such as drivers and farmers, for the purpose of keeping awake or alert to study or work.

The misuse of barbiturates is more limited, having been reported from Cote D'Ivoire, Mali, Mauritius, and Tanzania (United Nations Economic and Social Council 1994). Ineffective pharmacy control systems, as well as poor prescribing protocols for health professionals, have been partly blamed for the latter (Asuni and Pela 1986). There is widespread use of khat (catha edulis) in the eastern countries of Somalia, Kenya, and Ethiopia where its use is legal and in Eritrea and Tanzania where it is an illegal substance. Khat is reported to be used by students to improve their academic performance, by truck drivers to keep themselves awake, and by labourers to supply the extra vigor and energy they need to work. The trafficking in, and the use of, Mandrax (methaqualone) is a major concern in the southern and eastern countries of Zambia, South Africa, Swaziland, Namibia, Mauritius, Kenya, Uganda, and Tanzania (UNDCP 1994). Synthetic narcotic analgesics (e.g. Wellcanol) are well-known misused substances in South Africa, Sudan, and Tanzania. The sniffing of glues and petrol is found among street children and juveniles in Kenya, Tanzania, Sudan, Somalia, Swaziland, and Zambia (UNDCP 1994).

In the early 1980s, West Africa became an important trans-shipment route for heroin from south-east Asia en route to Europe and North America, and for cocaine from South America, initially involving Nigeria and then Cote D'Ivoire, Mali, Ghana, and Senegal. Since then, the use of heroin has been increasing in almost all of the countries in the continent, particularly those hitherto recognized as drug trafficking transit zones (e.g., Nigeria, Liberia, Cote D'Ivoire, Senegal, Chad, Ghana, Kenya, South Africa, and Mauritius) (Day 1992). Similarly, cocaine use is reported as a problem in Nigeria, Ghana, Mali, South Africa, Tanzania, and Uganda and as a limited but growing problem in Cote D'Ivoire, Gabon, Kenya, Mauritius, and Senegal (United Nations Economic and Social Council 1994).

A recent multisource review in 1995 indicated that drug injecting had been reported in Cote D'Ivoire, Nigeria, Gabon, Ghana, Mauritius, Senegal, South Africa, Tanzania, Uganda, and Zambia (Stimson and Adelekan 1996). Wellcanol is reported to be injected in South Africa, Tanzania and Uganda.

The increasing presence of drug trafficking routes, the ineffective supply control strategies, the increased availability of heroin and cocaine, and the reduction in prices of heroin and cocaine (Olukoya 1995) in many sub-Saharan African countries indicate a real potential for the rapid diffusion of injecting practices in this region. Given the current profile of HIV infection in Africa, the introduction of high-risk injecting practices would bring further huge personal, community, and national costs.

The development of harm reduction programmes are difficult due to logistic problems such as access to populations, both physically because of poor access to the media, poor transport and communications, and because of low educational levels (Stimson and Adelekan 1996; Wodak et al.1993).

The healthcare system in many countries is generally characterized by an insufficient allocation of resources for service development, a lack of qualified personnel, and poorly developed information gathering systems. As a result the majority of African people do not have easy and ready access to good quality and affordable health services.

Drug misuse is still highly criminalized, and users can receive a lengthy prison sentence for the possession or use of a small quantity of illegal substances. The emphasis on criminalization further prevents accessibility of the already marginalized drug-dependent individuals to the limited services available. Needle exchanges for drug users can also be difficult to set up when some medical centres still do not have access to regular clean needles.

A recent study which looked at 63 female sex workers who are heroin injectors in Dar es Salaam, Tanzania have found evidence of a new needle sharing practice they call 'flashblood', which is the term used to describe drawing blood back in a syringe until the barrel is full, and then passing the syringe to a female companion who injects the blood. By injecting the syringe about 4 cc's of blood, women believe that they can avert symptoms associated with heroin withdrawal because the first injector's blood is thought to have ‘some heroin in it.' Female sex workers began the flashblood practice amongst themselves in the last couple of months in an altruistic attempt to help their impoverished and more desperate associates. Male injectors interviewed are still unaware of this practice (McCurdy, 2005).

During 2003, one kete of high quality, mostly pure white heroin cost US$0.50. One kete was all many injectors needed to get high. Now the price of heroin has increased to US$1 per kete, and the heroin is reportedly adulterated. By the summer of 2005, most injectors claimed they need two kete to get high.

Women most affected by the increase in cost and decline in quality of heroin are those who are in poor health as the result of chronic heroin abuse. Because of their appearance and obvious poor health, these women are unable to attract enough clients to support their habits.

Female sex workers in Dar es Salaam will agree to forgo the condom at the clients' request if they are desperate for money. Many Tanzanian men prefer not to use condoms and routinely ask female sex workers not to use them. Female heroin injectors who are desperate, like the women who accept ‘flashblood', are the most likely to agree to forgo condoms. The practice of flashblood is an exaggeration of the practice of needle sharing which magnifies HIV transmission risk. If the first injector is HIV or HCV infected, the amount of virus directly transmitted into the bloodstream by the second injector could be quite large.

Injection drug use has emerged in East Africa in the last five to six years, and it is spreading rapidly throughout the region (Beckerleg 2004; Beckerleg & Hundt 2004; McCurdy 2005). If the practice of ‘flashblood' spreads from Dar es Salaam to other cities in East Africa, its impact on the rate of HIV and HCV transmission could be substantial. Heroin injection now appears to be occurring in most large towns of Kenya and Tanzania. A study of 336 heroin users in Nairobi, Kenya found that 44.9% were, or had been, injectors [UNIDCP, 1997]. Of 101 current injectors, 52.5% were HIV- positive. This compares with a 13.5% prevalence rate among heroin users who had never injected.

South Africa is by far the largest market for illicit drugs entering Southern Africa. Its relative affluence within the region makes it a tempting ‘emerging market’ in its own right. The country’s geography, porous borders and international trade links with Asia, Latin America, Western Europe and North America have made it an attractive drug transit country. Drug trafficking and abuse have escalated in recent years, with the point of escalation traceable to the liberalization of most aspects of society in the years immediately surrounding the country’s first democratic elections in 1994. South Africa is a society in transition. Drug use correlates strongly with the pressures placed upon social capital by rapid modernization and the decline in traditional social relationships and forms of family structure.

Among the non-White population, social injustice and the weakened family bonds which resulted from decades of apartheid policies have created an environment in which temporary escape from the harsh reality of everyday life is often sought through the consumption of psychoactive substances. Among the White population, anecdotal evidence also supports a connection between increased substance abuse and both increased availability of drugs and the psychological consequences of adjusting to life in the “new” South Africa. The use of “club drugs” (principally ecstasy and LSD, but including a wide range of substances) has grown dramatically in this community since the early 1990s, in part due to active interaction with the youth cultures of industrialized nations. While amphetamine-type stimulants, notably ecstasy, are mainly imported from Europe to satisfy domestic demand in the club scene, there is also evidence of local manufacturing of these substances.

References

Abiodun OA, Adelekan ML et al. Pattern of substance abuse among secondary school students in ilorin, Northern Nigeria. West African Journal of Medicine 13(2): 91-97. 1994.

Adelekan ML. Self-reported drug use among secondary school students in the Nigerian. State of Ogun. Bulletin on Narcotics 41(1 and 2): 109-116. 1989.

Adelekan ML and Adeniran RA. Rehabilitation and follow-up issues in drug abusers managed at the Neuropsychiatric Hospital, Abeokuta, Nigeria. West African Journal of Medicine 10(1): 354-360. 1991.

Adelekan ML et al. Monitoring trends in substance use through a repeat cross-sectional survey in a Nigerian university. Drugs: Education, Prevention and Policy 3(3): 239-247, 1996.

Adelekan M and Stimson GV. Problems and prospects of implementing harm reduction for HIV and injecting drug use in high-risk sub-Saharan African countries. Forthcoming in Journal of Drug Issues, special issue on AIDS and Drug Use, 1996.

Asuni T and Pela OA. 1986 Drug abuse in Africa. Bulletin on Narcotics 38(1 and 2): 55-60.

Beckerleg S. How 'Cool' is heroin injection at the Kenya coast. Drugs: Education, Prevention & Policy (11)1, 67-78, 2004.

Beckerleg S and Hundt GL. The characteristics and recent growth of heroin injecting in a Kenyan coastal town. Addiction Research & Theory (12)1: 41-54, 2004.

Day G. 1992 Geographical, economical and political situation in West Africa: Significance of drug trafficking and abuse. In Drug control in Africa: Experiences from a seminar for West African countries, Padova: ARFI, 1992

Eide AH and Acuda SW. Drug use among secondary school students in Zimbabwe. Addiction 90(11): 1517-1527, 1995

Ekpo M et al. Lagos "area boys and girls" in rehabilitation: Their substance use and psychosocial profiles. East African Medical Journal 72(5): 311-316. European Centre for the Epidemiological Monitoring of AIDS, 1995

McCurdy SA et al. The emerging heroin epidemic in Dar es Salaam , Tanzania : Youth hangouts, maghetto and injecting practices. AIDS Care 17 (Supplement 1): S65-76, 2005.

McCurdy S et al. 'Flashblood' and HIV risk among IDUs in Tanzania.
afaids@eforums.healthdev.org. 2005.

Ohaeri JU and Odejide AO. Admissions for drug and alcohol-related problems in Nigerian psychiatric care facilities in one year. Drug and Alcohol Dependence 31: 101-109. 1991.

Olukoya SA. Worrisome development: Hard drug consumption is gaining ground in Nigeria. Newswatch 21-22, 1995

Stimson G & Choopanya K: Global Perspectives on Drug Injecting. Drug Injecting and HIV Infection, 1998.

Stimson GV and  Adelekan M L. The diffusion of drug injecting in developing countries. International Journal of Drug Policy 7(4): 246-256. 1996.

United Nations International Drug Control Programme (1997). World Drug Report. Oxford, Oxford University Press.Meursing, K., and N. Morojele. Use of alcohol among high school students in Lesotho. British Journal of Addiction 84(11): 1337-1342, 1989.

United Nations Drug Control Programme 1994 Report of the expert forum on demand reduction in east and southern Africa. Nairobi, Kenya, November 1-5, 1994.

United Nations International Drug Control Programme. United Nations Economic and Social Council 1994 Examination of the world situation with respect to drug abuse, including illicit demand, illicit trafficking and supply. Commission on Narcotic Drugs, E/CN.7/1994/4.

Wodak A et al. An evolving public health crisis: HIV infection among injecting drug users in developing countries. In Psychoactive Drugs and Harm Reduction: From Faith to Science, eds. N. Heather, A. Wodak, E. Nadelman, and P. O'Hare, 280-294, 1993.