Opioid use disorders, including heroin use disorders, account for 70% of the global burden of drug-related disease [1] and disproportionately affect people who have unmet social, emotional, economic, health and other needs. [2,3] Heroin is widely available in South Africa (SA) [4,5] and there is an upward trend in numbers of people using heroin who access drug use treatment facilities registered with the South African Community Epidemiology Network on Drug Use. [6] In addition, there is increasing concern around the link between injecting heroin use, hepatitis C virus (HCV) and HIV and the impact this could have on SA communities and the healthcare system. [7] Opioid substitution therapy (OST), using an agonist or partial agonist, aims to alleviate the symptoms of opioid withdrawal, reduce cravings, and reduce the opioid response through receptor coverage. Over 40 years of research has shown that OST saves lives, [8-11] improves retention in healthcare and treatment, [12-17] reduces illicit heroin use, [12,13,17,18] reduces interactions with the criminal justice system, [11,18,19] reduces HIV risk [20-22] and improves health and quality of life. [23-27] Despite the increasing need and inclusion in the SA National Strategic Plan for HIV, TB and STIs (2017-2021), [7] none of the medications suitable for OST are listed on the Essential Drugs List (EDL) for maintenance prescribing. Methadone in SA is significantly more expensive than in other middle-income countries; for example, it costs up to 30 times more than the average cost in the Ukraine and Georgia. [28] The high cost of methadone makes it unattainable for the majority of South Africans who need it. The Sultan Bahu Centre in Cape Town was the first civil society organisation to provide OST, doing so for 3 months as part of an intensive outpatient offering. Since 2016, financed mainly by foreign donors, the Durban University of Technology, TB HIV Care and the Anova Health Institute have started providing OST to a small number of people who use heroin in Durban, Cape Town and Johannesburg. [29] Since 2017, the City of Tshwane has funded OST as part of the community-orientated substance use programme run by the University of Pretoria. [31] For the most part, however, people in SA who have a heroin use disorder view OST as an important service that is unaffordable and inaccessible. [30] In view of the need for OST and growing local experience, we facilitated a half-day workshop at the 2017 South African Drug Policy Week to develop an advocacy agenda for OST in SA. Participants included academics (n=6), OST prescribers (n=3), coordinators from ongoing OST projects (n=5), OST outreach staff (n=6), and representatives from the Western Cape Government (n=3), the pharmaceutical industry (n=3) and the people who use drugs (PWUD) community (n=2). Using the nominal group voting technique, research, policy, service delivery and collaborations were identified as OST advocacy priorities. Research. Conducting research and economic evaluations on OST in SA's service delivery ...

Background: Emerging data points to a potential heroin use epidemic in South Africa. Despite this, access to methadone maintenance therapy and other evidence-based treatment options remains negligible. We aimed to assess retention, changes in substance use and quality of life after 6 months on methadone maintenance therapy provided through a low-threshold service in Durban, South Africa. Methods:We enrolled a cohort of 54 people with an opioid use disorder into the study. We reviewed and described baseline socio-demographic characteristics. Baseline and 6-month substance use was assessed using the World Health Organization's Alcohol Smoking and Substance Use Involvement Screening Test (ASSIST) and quality of life, using the SF-12. We compared changes at 6 months on methadone to baseline using the Wilcoxon signed rank test and paired-tests for the ASSIST and SF-12 scores, respectively. McNemar's test was used for comparisons between paired results of categorical variables relating to injecting frequency. Results:The majority of the participants were young, Black African males, with a history of drug use spanning over 10 years. Retention after 6 months was 81%. After 6 months, the median heroin ASSIST score decreased from 37 to 9 (p < 0.0001) and the cannabis ASSIST score increased from 12.5 to 21 (p = 0.0003). The median mental health composite score of the SF-12 increased from 41.4 to 48.7 (p = 0.0254). Conclusions:Interim findings suggest high retention, significant reductions in heroin use and improvements in mental health among participants retained on methadone maintenance therapy for 6 months. Further research into longer term outcomes and the reasons contributing to these changes would strengthen recommendations for the scale-up of methadone maintenance therapy in South Africa.