Towards an inclusive health agenda: people who inject drugs and the COVID-19 response in Africa.

Coronavirus disease 2019 (COVID-19) is a major global public health threat of the 21st century and African countries have not been spared of its impact, particularly on healthcare systems, and social and economic activities.1, 2, 3 The pandemic has led to various government-led interventions and response activities to curb the spread of COVID-19. However, it has been reported that Africa's COVID-19 responses have excluded some vulnerable populations, including people who use drugs. In Africa, drug use is not uncommon and people who inject drugs are highly stigmatised, marginalized, criminalised and, of course, are disproportionately affected by the pandemic. These problems and the COVID-19 pandemic impose additional burdens on this vulnerable group. Interestingly, COVID-19 response interventions by African governments focus primarily on the general population and frontline medical personnel. COVID-19 has highlighted the need for an inclusive health approach in response to pandemics. This inclusive health approach should be based on two main principles: (1) equitable access to healthcare services for the whole population, including marginalized communities, and (2) full participation and meaningful engagement in all health programmes and services, without discrimination.

The key population of HIV (Human Immunodeficiency Virus), including people who inject drugs, face the same risk of COVID-19, if not higher, compared with the general population. This situation remains a threat to possible transmission of COVID-19 by acting as a transmission bridge to the general population. The prevalence of HIV among people who use drugs can also be expected to increase, as access to treatment and harm reduction services in Africa have been significantly disrupted by the COVID-19 pandemic. According to the World Health Organization, as of 8 July 2020, disruption in HIV health services were reported as follows: HIV testing (38 countries, including some African countries); key population of HIV services (17 countries); condom provision (12 countries) and pre-exposure prophylaxis (7 countries). In 2014, the Joint United Nations Programme on HIV/AIDS (UNAIDS) and partners launched ambitious targets geared towards putting an end to the HIV epidemic. The objective of this resolution, commonly known as ‘90-90-90’, is to ensure that 90% of all people living with HIV will know their status, 90% of people diagnosed will receive sustained antiretroviral therapy (ART) and 90% of people receiving ART will have viral suppression, all by 2020. The COVID-19 pandemic will have a significant impact on the 90-90-90 target and all those living with HIV, including people who inject drugs will be significantly impacted as a result of disruption to healthcare services.

In Africa, before the COVID-19 pandemic, it was reported that harm reduction services, such as needle exchange programmes and opioid substitution therapy, for people who use drugs were limited. With the emergence of COVID-19, the supply chain of many essential and life-saving commodities has been disrupted; , this is not any different for injecting drugs and their associated tools. With limited supply, this could lead to risky injecting practices, such as the sharing of needles and syringes, among this vulnerable group. In addition, with the need to prevent withdrawal symptoms, the disruption in drug supply may result in people who inject drugs switching to more dangerous forms of drug use, thus further significantly impacting their health and increasing the risk of death due to overdose.

As a result of stigma and other sociocultural issues associated with drug use, the estimate of the number of people who inject drugs in Africa is unknown and this remains a major threat to ending the HIV epidemic. Regional HIV prevalence rates are high in people who inject drugs in all parts of the world (up to 15.5% in East and Southern Africa). Apart from the high rates of HIV among people who inject drugs in Africa, additional major concerns include high-risk behaviours, inadequate HIV knowledge and low HIV testing uptake. , High prevalence of other diseases, such as hepatitis C, has been well documented among people who inject drugs. On 11 March 2020, the International Network of People who Use Drugs published recommendations that included advice on well-being and health, which aims to limit the impact of COVID-19 on the substance use community. It has also been reported that the UNAIDS supported women who use drugs in Tanzania by providing health promotion messages on COVID-19, stigma and discrimination, basic hygiene supplies (buckets, soaps and sanitisers) and basic food rations. Despite the fundamental efforts by some organisations to limit the impact of the pandemic on vulnerable populations, people who inject drugs are excluded from the African government safety net and their health needs are significantly neglected.

To avoid law enforcement, injecting drug users often locate themselves in the slums, where physical distancing is impossible and good ventilation is not guaranteed. In addition, people who inject drugs frequently relocate, meeting and mixing with other drug users. These communal behaviours can aid the transmission of COVID-19 and may pose a major threat to COVID-19 response in Africa by creating opportunities for community transmission of the virus. In densely populated areas and informal settlements, where many of the urban dwellers who use drugs reside, running water and sanitation infrastructures are limited. People who inject drugs are also likely to be immunocompromised, increasing their risk of having severe COVID-19, thus further contributing to the burden of the pandemic on the African continent. A history of stigmatization and discrimination in many of Africa's healthcare settings and fear of prosecution and referral to law enforcement make it less likely for people who inject drugs to seek medical attention for COVID-19 symptoms. This can lead to further community transmission of COVID-19, with the additional challenge of tracing contacts. It is also important to note that, when caught, people who inject drugs are often jailed by the law enforcement agency, and prisons are often in poor condition, thus facilitating the spread of COVID-19 and further confounding HIV response in the region.

As African countries continue to fight COVID-19, governments need to engage drug use advocacy groups to design inclusive health responses to the COVID-19 pandemic. With the adoption of the 2030 Agenda for the United Nations Development Program, it is essential that no one is left behind and that the most disadvantaged populations are the first to receive the help required. This could not be more important than it is today, as people who use drugs are already being neglected in the African COVID-19 response. Nobody is safe, until everyone is safe.

Author contributions

Y.A.A. conceptualized and wrote the first draft of the manuscript with an important contribution from D.E.-L.P. All the authors read and approved the final manuscript.