Urban Futures Centre, Steve Biko Campus, Durban University of Technology, Durban, South Africa.
TB HIV Care, 7th Floor, 11 Adderley Street, Cape Town, South Africa.
Harm Reduct J. 2020 Apr 15;17(1):25. doi: 10.1186/s12954-020-00368-1.
Moral conservatism within government and communities has resulted in a reluctance to support the provision of opioid agonist therapy for people with opioid use disorders in South Africa. In April 2017, South Africa's first low-threshold opioid agonist therapy demonstration project was launched in Durban. The project provided 54 low-income people with heroin use disorders methadone and voluntary access to psychosocial services for 18 months. At 12 months, retention was 74%, notably higher than the global average. In this paper, we aim to make sense of this outcome.
Thirty semi-structured interviews, two focus groups, ten oral histories and ethnographic observations were done at various project time points. These activities explored participants' pathways into drug use and the project, their meaning attributed to methadone, the factors contributing to project success and changes they experienced. Recordings, transcripts, notes and feedback were reviewed and triangulated. Key factors contributing to retention were identified and analysed in light of the existing literature.
The philosophy and architecture of the project, and social cohesion were identified as the main factors contributing to retention. The use of a harm reduction approach enabled participants to set and be supported to achieve their treatment goals, and was shown to be important for the development of trusting therapeutic relationships. The employment of a restorative justice paradigm provided a sense of acceptance of humanity and flaws as well as an imperative to act responsibly towards others, fostering a culture of respect. Social cohesion was fostered through the facilitation of group sessions, a peace committee and group sport (soccer). In concert, these activities provided opportunities for participants to demonstrate care and interest in one another's life, leading to interdependence and care, contributing to them remaining in the project.
We believe that the high retention was achieved through attraction. We argue that opioid agonist therapy programmes should take the principles of harm reduction and restorative justice into consideration when designing low-threshold opioid agonist therapy services. Additionally, ways to support cohesion amongst people receiving agonist therapy should be explored to support their effective scale-up, both in low-middle income countries and in high-income countries.
政府和社区内部的道德保守主义导致南非不愿意为患有阿片类药物使用障碍的人提供阿片类激动剂治疗。2017 年 4 月，南非首个低门槛阿片类激动剂治疗示范项目在德班启动。该项目为 54 名低收入海洛因使用者提供美沙酮，并在 18 个月内自愿获得心理社会服务。在 12 个月时，保留率为 74%，显著高于全球平均水平。在本文中，我们旨在理解这一结果。
在项目的不同时间点进行了 30 次半结构式访谈、2 次焦点小组、10 次口述历史和民族志观察。这些活动探讨了参与者进入毒品使用和项目的途径、他们对美沙酮的意义、促成项目成功的因素以及他们经历的变化。对记录、记录、笔记和反馈进行了审查和三角分析。根据现有文献，确定并分析了保留的关键因素。
项目的理念和架构以及社会凝聚力被确定为保留的主要因素。采用减少伤害的方法使参与者能够设定并得到支持以实现他们的治疗目标，这对于建立信任的治疗关系非常重要。采用恢复性司法范式提供了一种接受人性和缺陷的感觉，以及对他人负责的必要性，培养了尊重的文化。通过促进小组会议、和平委员会和团体运动（足球），促进了社会凝聚力。这些活动共同为参与者提供了相互关心生活的机会，导致相互依赖和关心，促使他们留在项目中。
我们认为，高保留率是通过吸引力实现的。我们认为，阿片类激动剂治疗方案在设计低门槛阿片类激动剂治疗服务时，应考虑减少伤害和恢复性司法的原则。此外，应探索支持接受激动剂治疗的人之间凝聚力的方法，以支持它们在中低收入国家和高收入国家的有效扩大规模。
