Supporting safer sex and drug use: practical guidance for healthcare workers
CAPE TOWN, 10 OCTOBER 2025: Authors, in a recently published set of South African harm reduction guidelines for chemsex in the Southern African Journal of HIV Medicine, highlighted critical gaps in the country’s health response to drug use in sexual contexts. Chemsex typically involves the use of substances such as methamphetamine, cocaine, GHB/GBL, mandrax, and methcathinone to facilitate or enhance sexual activity. South Africa faces one of the world’s highest HIV burdens, with 7.8 million people living with HIV. Drug use and chemsex have been linked to higher rates of HIV and STI transmission, sexual violence, stigma in healthcare settings, and barriers to accessing services.
“Harm reduction is an essential evidenced-based intervention that when prioritised in all parts of the public health system is an opportunity to curb new HIV and TB infections, reduce health inequities, and advance South Africa’s public health goals,” says Dr Andrew Scheibe, lead author and Technical Advisor at TB HIV Care.
In the publication, authors articulate that people who practice chemsex face heightened vulnerability to HIV and other sexually transmitted infections, compounded by limited access to essential prevention tools such as Pre-Exposure Prophylaxis (PrEP), condoms, and regular testing. Beyond infectious disease risks, they experience significant psychological and physical health challenges, including overdose, dependency, mental health distress, and sexual assault. Access to care is further undermined by stigma, discrimination, and limited provider knowledge about chemsex-related health issues. However, evidence shows that non-judgmental, harm reduction-oriented approaches improve outcomes, supporting better treatment adherence, reducing overdose risk, and increasing uptake of HIV prevention and care services.
Until now, there has been no tailored, evidence-based framework for clinicians and community health workers to address these intersecting health needs. The harm reduction guidelines underscore the need for evidence-based harm reduction interventions within the health system to address the intersecting risks of HIV, tuberculosis, and other infectious diseases. The evidence is clear that harm-reduction interventions such as needle and syringe programs have been shown to reduce HIV transmission by approximately 50%(3), while opioid agonist therapy is associated with lower incidence of both HIV and tuberculosis(4). When integrated with HIV services, harm reduction interventions further enhance outcomes by improving adherence to antiretroviral therapy and reducing high-risk practices(5). Similarly, the World Health Organization identifies harm reduction as a critical component of effective HIV and TB responses, emphasising integration into primary health care.
“Chemsex is a reality in South Africa. With stigma-free, evidence-based care, we can improve the health outcomes and dignity of people who use drugs and are involved in sexualised drug use,” says Yolaan Andrews, Programme Manager: NACOSA.
The new guideline offers practical guidance for healthcare providers to better support patients who use drugs in sexual contexts. It emphasises a harm reduction approach that prioritises safety, dignity, and trust, while integrating sexual health and harm reduction services, including HIV testing, PrEP, STI screening, hepatitis care, and overdose prevention.
“These guidelines serve a dual purpose, empowering healthcare workers to provide dignified care, while ensuring people who use drugs receive the Constitutionally guaranteed care they deserve, says Professor Harry Hausler, Chief Executive Officer at TB HIV Care.
Providers are encouraged to deliver trauma-informed, stigma-free care that acknowledges the intersections of substance use, sexuality, and mental health, and to collaborate closely with community-led services to ensure continuous, patient-centred support. By adopting these recommendations, healthcare workers can reduce HIV and STI transmission, improve adherence to HIV treatment and PrEP, prevent drug-related harms, and strengthen patients’ mental health and overall wellbeing. This represents a pivotal step forward in advancing rights-based, inclusive healthcare in South Africa.
References:
1. UNAIDS (2023) Global AIDS Update 2023. Geneva: UNAIDS. Available at: https://www.unaids.org/en/resources/documents/2023/global-aids-update-2023 UNAIDS+1
2. World Health Organization (2022) Global Tuberculosis Report 2022. Geneva: WHO.
3. Stone, J., et al. (2021) ‘Effectiveness of harm reduction in reducing HIV among people who inject drugs: systematic review’, The Lancet HIV.
4. Degenhardt, L., et al. (2019) ‘The impact of opioid substitution therapy on HIV and TB outcomes’, The Lancet Infectious Diseases.
5. World Health Organization (2019) Consolidated guidelines on HIV, viral hepatitis and sexually transmitted infections. Geneva: WHO. Available at: https://iris.who.int/bitstream/handle/10665/360425/9789240053274-eng.pdf
Issued by:
| Aziel Gangerdine TB HIV Care, Spokesperson E-mail: aziel@tbhivcare.org Cell: +27 (0) 66 545 6053 |
Sophie Hobbs Head of Communications & Advocacy E-mail: sophie@nacosa.org.za Cell: +27 (0) 72 145 2813 |
ENDS.
TB HIV Care
TB HIV Care is a registered non-profit company (NPC) that puts integrated care at the heart of responding to TB, HIV, and other major diseases. We work to prevent, find and treat TB and HIV in South Africa as well as targeting our interventions to address the needs of populations most at risk, including communities in the Eastern Cape and Western Cape, adolescent girls and young women in KwaZulu-Natal, inmates in correctional centres, sex workers and people who inject drugs.
