South Africa has taken a significant step toward reshaping its response to substance use, following the launch of a three-year national initiative led by TB HIV Care (THC) and funded by the Elton John AIDS Foundation.
The programme, launched in June, brings together public health experts, legal specialists, civil society, policymakers, and people with lived experience to develop evidence-based legal and policy models on harm reduction tailored to South Africa’s realities. The initiative aims to shift the national approach to drug use away from punishment and toward public health.
A System Under Pressure
South Africa faces an escalating crisis at the intersection of health and justice. Peer-reviewed estimates suggest that around 67 000 people inject drugs across the country, with women making up nearly a quarter of this population. Drug-related offences still account for more than 25 percent of all arrests, according to 2023 SAPS data.
This heavy reliance on criminalisation has overwhelmed courts, prisons, and policing structures. Thousands of people are arrested each year for the possession of drugs intended for personal use, diverting resources from serious crimes and reinforcing cycles of poverty, stigma, and incarceration.
Evidence continues to show that punitive drug laws fail to curb use or harm and often deepen both.
Strengthening a Public Health Response
The national programme builds on TB HIV Care’s long-standing harm reduction work and forms part of the organisation’s capacity-building agenda for the People Who Use Drugs (PWUD) sector. It aligns with the National Drug Master Plan (2019–2024) and the draft Prevention and Treatment for Substance Use Disorders Policy.
The initiative seeks to empower communities, strengthen local networks, and support the development of a coordinated national strategy rooted in dignity, inclusion, and health-based alternatives to punishment.
“It is encouraging that our country’s policies relating to health issues and drugs are increasingly informed by local evidence and practice,” said Dr Andrew Scheibe, Technical Advisor at TB HIV Care. “This aligns with best practice and global norms.”
Learning From Global Success
International evidence shows the impact of decriminalisation when paired with strong health systems. Portugal’s 2001 reforms resulted in a 93 percent drop in new HIV infections among people who use drugs and a significant decline in overdose deaths. Ghana’s 2020 Narcotics Control Commission Act shifted the national focus to treatment, increasing the uptake of health services and lowering reoffending rates.
“Whereas other countries’ reforms have often been top-down, South Africa’s opportunity is rooted in grassroots understanding,” said Mfezi Mcingana, Programme Director for Key Populations at TB HIV Care. “Those most affected are also those leading the call for change.”
Urgent Gaps in Care
People who inject drugs (PWID) face some of the highest rates of HIV, hepatitis C, and tuberculosis in South Africa, driven by unsafe injecting conditions, social exclusion, and barriers to healthcare.
Only seven of South Africa’s 52 districts currently provide comprehensive harm reduction services. HIV prevalence among PWID reaches 72.1 percent in Tshwane, 49.3 percent in eThekwini, and 45.4 percent in Mashishing.
Studies also show hepatitis C prevalence as high as 90.5 percent in Mbombela, while TB rates among PWID in eThekwini reach 7.2 percent.
More than half avoid care due to stigma, and fewer than half of those living with HIV know their status. Access to opioid agonist therapy (OAT) remains extremely limited, with uptake at just 1 percent in key districts such as eThekwini and Mashishing.
A Turning Point for South Africa
Recent legislative shifts signal growing momentum for reform. The Cannabis for Private Purposes Act, 2024 legalised private adult use and cultivation and expunged past convictions. The Act set a precedent that drug use for personal purposes need not be treated as a criminal offence.
This new TB HIV Care-led initiative aims to build on successful harm reduction projects in Cape Town, Gauteng, and KwaZulu-Natal, expand access to dignified services, and empower people who use drugs to help shape national policy.
A Pivotal Moment
“This grant allows us to align with local and global evidence that treating substance use as a health issue, not a crime, saves lives and strengthens communities,” said Professor Harry Hausler, CEO of TB HIV Care.
The initiative was reinforced by scientific discussions showcased at the 13th International Conference on Health and Hepatitis in Substance Users (INHSU 2025), hosted in South Africa for the first time in October. The conference highlighted innovation in harm reduction and integrated care across the continent.
A Rights-Based Future
A rights-based approach would require acknowledging drug dependence as a health condition, not a moral failing. It would shift the state’s response from punishment to prevention and care, aligned with South Africa’s constitutional commitment to dignity, equality, and the right to healthcare.
As the country confronts rising substance use alongside the ongoing challenges of TB, HIV, and mental illness, this initiative marks a critical investment in evidence-based reform that prioritises the health and humanity of every person.
