Antiretrovirals in South African drug cocktail

23 Oct Antiretrovirals in South African drug cocktail

South Africa has a long history of unique drug cocktails. The latest (although having been on the market for years already) is whoonga and can contain heroine, cocaine, cannabis and antiretroviral drugs. The mixture is extremely addictive and several experts have warned that the spread of the drug may affect the country’s effort to battle hiv/aids.

This article was published in Swedish magazine Alkohol & Narkotika (Alcohol & Narcotics) on October 23rd 2015. This is a translated version protected by Swedish copyright law. 

“In the end it wasn’t about the high anymore, just about getting rid of the pain. When the high faded the cramps started. Sometimes it felt like someone stabbed me in the back and twisted the knife.”

That is how Mohamed Firdos describes his whoonga addiction to me. The drug, which is also known as nyaope or sugars, is a heroine-based drug mixture with shifting composition; among the most common ingredients are cocaine, morphine, rat poison, detergent and – sometimes – antiretroviral drugs used against hiv/aids. The ingredients are mixed in a joint and smoked.

The drug is extremely addictive and has spread rapidly through the already so exposed townships of Durban. South Africa’s president Jacob Zuma has highlighted whoonga as a drug with particularly severe consequences for the society. And as often the underlying problem is poverty, unemployment and other social ills.

Mohamed is eloquent, but behind the shy smile and the small, black ear rings is a darker side – a drug addiction with almost mythical overtones in Durban. Whoonga users, some still in their younger teenage years, can be found unconscious on the city streets, often with running noses and a zombie-like gaze.

The withdrawals are known to be extremely painful, which make whoonga users desperate to find their next hit. According to medical experts it is the strychnine, a substance found in rat poison, that causes the infamous stomach cramps. The chemical combination is merciless – a new hit and the pain once again dissipates into another heroine and morphine high.

“You can leave reality for a while and forget all of your problems”, Mohammed says. “Before the cramps start it is a nice high.”

Because of the social stigma that surrounds whoonga, and the relatively low street price, the drug primarily affects already vulnerable communities and populations. The street price is below 20 SEK per dose, but the addiction quickly makes it expensive. When Mohameds addiction escalated his economic situation became unbearable. He sold his company, all his possessions and became involved in crime. In total he estimates that his addiction has cost him around half a million SEK.

“I used to say that stuff was broken and that I was going to get them repaired”, he tells me. “Then I sold them. One time I even cut the cord to the tv.”

Mohamed’s addiction wasn’t revealed until he sold all his parents possessions when they were abroad and a family acquaintance saw him take them to the pawnbrokers.

“I completely emptied their house, took all their jewellery and all their money. Thereafter I broke all the house’s windows to make it look like a burglary. That was the first time I was exposed.”

Sam Pillay

The whoonga epidemic started to gain attention around 2010. But according to Sam Pillay, director of the Anti Drug Forum Centre in Chatsworth in Durban, the problem is not new.

“The name whoonga is relatively new”, he explains. “But the drug in itself isn’t.”

According to Sam whoonga is a new example of an older drug cocktail known as sugars and which has plagued the slums of Chatsworth since 2005. It only gained national attention when it spread to the rest of Durban and to Johannesburg. Whoonga users are often accused of boosting the city’s crime rates. In a country where the rate of violent crime is already sky-rocketing the social stigma around people with addiction problems becomes extra intense. As a result the police often employs violence in order to chase whoonga users of the city’s streets. Local activists have testified how the police at several occasions have violated the human rights of users in so-called “clean-ups”. But despite the growing problem, Durban lacks adequate rehabilitation facilities and the social safety nets for people with addiction problems are almost non-existent.

South African, and sometimes international, media has often reported that whoonga contains antiretroviral drugs. In a country where around 18 % of the population between 15 and 49 years lives with hiv, recreative use of antiretrovirals is of huge concern and exaggerated and horrifying media stories are common.

Available scientific evidence provides a more nuanced picture. Several studies have described how antiretroviral drugs, mainly Efavirenz, are crushed and mixed with illegal drugs in South Africa.[1] These studies are, however, based on interviews with persons addicted to whoonga and which do not necessarily know the exact composition of the drug. In a chemical test performed at the University of KwaZulu-Natal in Durban, only one of the samples was shown to contain traces of antiretrovirals. The sample selection was, however, limited and given that the exact composition is said to shift frequently this result can just as well be random. As more thorough chemical testing is still required, one should not lightly ignore all those reports in the media that do describe how whoonga contains antiretrovirals.

“We have encountered antiretrovirals in whoonga“, Sam Pillay testifies. “But it is used in order to dilute the mixture. Antiretrovirals are very easy to get in South Africa.”

The recreational use of antiretrovirals is not unique to South Africa – similar observations have been made in Miami. Even though the exact effects of antiretrovirals in combination with other drugs are still unclear, studies speculate that Ritonavir and Efavirenz might enhance or affect the effect of cannabis, oxikodone, methadone, MDMA, ketamine and PCP. Efavirenz might potentially also have an independent psycho-active effect. But the idea that whoonga contains antiretrovirals is dangerous in itself, since it may increase the risk that patients and doctors with access to antiretrovirals are robbed. Sam Pillay has warned of this.

“When the rumour spred that whoonga contains antiretrovirals people started selling their medicine. Patients have even been robbed outside aids-clinics. The media attention has made it worse.”

Simphiwe Myeza

Simphiwe Myeza, in charge of distribution and medication of antiretroviral drugs in the urban slum of Bhambayi outside Durban, agrees.

“I have noted how drugs disappear in Bhambayi”, he says. “We know exactly who is selling and using drugs, but we cannot do anything.”

Apart from the horrific stomach cramps associated with whoonga it has also been reported that addicts suffer from paranoia and aggressions. For Mohamed, his eight year long addiction and constant rehabilitation efforts affected both him, his wife and his twin daughters.

“When I came home from rehab the first time I was no longer welcome”, he tells. “My wife was scared of me, of what I’ve become. When I was using whoonga I was aggressive. I often broke things, one time I even hit my wife. I used to be shy and silent, but the drugs changed me. Whoonga turned me into a monster.”

Today Mohamed is clean since eight months and he has been reunited with his family, much thanks to Sam Pillay and his co-workers. Throughout the years Sam Pillay has handled hundreds of cases, often successfully. But as long as the relevant state institutions fail to address the problem it will continue to spread.

Mohamed still has to fight to stay away from drugs; when he leaves home he doesn’t dare bringing his cell phone or any money since it would enable him to buy whoonga.

“The only time I gave my twin girls attention was when I was high”, he tells me shamefully. But now that I’m clean I tend to them all the time. Everyone wants to be near me and everyone wants to talk to me.”

Mohamed smiles for the first time during the interview and reveals a front tooth made of gold. He knows he’s been lucky. The majority of South Africa’s whoonga users don’t get a second chance.

[1] See for example K. Rough et. al., 2014, Whoonga and the Abuse and Diversion of Antiretrovirals in Soweto, South Africa. AIDS Behaviour, 18, 1378-1380; D.J. Grelotti et. al., 2014, Whoonga: Potential Recreational Use of HIV Antiretroviral Medication in South Africa. AIDS Behaviour, 18, 511-518.