Harm Reduction as a Complex Adaptive System: Results from a Qualitative Structural Analysis of Services Accessed by Young Heroin Users in Mauritius

Abstract

Harm Reduction (HR) was introduced in Mauritius in 2006 to mitigate the local Human Immunodeficiency Virus (HIV) epidemic mainly driven by injecting drug use. With an estimated population of 55,000 drug users and an estimated population of 6600 injecting drug users with an average of 21 years at first injection, the impact of drug use on the epidemic remains high. Those aged 15–24 years account for 20% of all new HIV cases detected annually since 2010, with known causes of incidence including both injecting drug use and unprotected sexual intercourse. Beginning with an exploration of access and barriers to needles and syringes, our study evolved to consider the dynamics between concurrent services and the effectiveness of the resulting system. Utilising snowball and purposive sampling, we conducted in-depth interviews with 27 participants, including service providers, identified by peer fieldworkers from various NGOs. Our analysis showed that HR services were connected via informal networks and displayed the same characteristics as Complex Adaptive Systems (CAS). We propose using qualitative structural analysis as a viable method to explore the complexity of HR. CAS and proper acknowledgement of peer support could guide current and future HR policy reforms.

1. Introduction

Sharing needles and syringes remains a key mode of transmission for the Human Immunodeficiency Virus (HIV) and Hepatitis C (HepC) as well as other infectious diseases (UNAIDS, 2024; UNODC, 2024). The decreasing age of initiation for injecting drug use, usually during adolescence and young adulthood, has been observed worldwide and is both a recurrent and complex challenge for the transmission of HIV and HepC as well as other infectious diseases (Degenhardt et al., 2017; Hines & Trickey, 2020). The number of people who inject drugs and are living with HIV is deemed to be higher in Eastern Europe, Southwest Asia and Southern Africa (UNODC, 2023).

Central and Eastern European countries were among the first to report the lower age of initiation into injecting drug use, starting in the late teens and at ages as low as 12–14 years (Harm Reduction International, 2013). Behavioural studies carried out in that region suggest that young men and teenagers’ first experience of injecting drugs was unplanned and usually occurred among friends following a mix of curiosity and peer pressure (Merkinaite et al., 2010). Furthermore, young people, in general, were more likely to mix drugs and inject not only opiates but amphetamines as well, showing the emergence of polydrug use quite early. The gender divide noted in the prevalence of drug use was much narrower among young people compared to adults, according to most surveys (UNODC, 2017).

Harm Reduction (HR) refers to strategies designed to minimise the negative consequences of health behaviours without necessarily eliminating those behaviours entirely or permanently (Hawk et al., 2017). Experts view HR as grounded in these key principles:

• Humanism: Care is provided without moral judgement, recognising that context influences choices.
• Pragmatism: Focus on reducing immediate risks.
• Individualism: Acknowledgment that individuals have unique needs and strengths.
• Autonomy: The right to make informed choices, even if they go against expert recommendations.
• Incrementalism: Any positive change is considered an improvement over the current situation.
• Accountability without Termination: Individuals have the right to make their own choices without losing access to services based on those decisions.

HR includes a variety of health and social services and practices related to both illicit and legal drugs. These services encompass, but are not limited to, drug consumption rooms, needle and syringe programmes, non-abstinence-based housing and employment initiatives, drug checking, overdose prevention and reversal, psychosocial support, and education on safer drug use.

A body of evidence has demonstrated that HR strategies provide important individual and public health benefits, including the prevention of common infections, HIV and deaths from overdoses among people who use drugs (Puzhko et al., 2022; Campbell et al., 2017). HR approaches were shown to reduce healthcare costs and to refer people using drugs to treatment and other healthcare services (Kim et al., 2014; Nassau et al., 2022).

Thus, such approaches are evidence-based, cost-effective, and positively influence both individual and community health (Scheibe et al., 2020). However, among 21 countries in East and Southern Africa, only 4 provide (1) explicit supportive references to HR in national policy documents, (2) at least one needle and syringe program, (3) at least one operational opioid agonist therapy program, and (4) opioid agonist therapy in at least one prison (Harm Reduction International, 2024a).

According to global estimates, fewer than 1 in 5 people injecting drugs were accessing opioid agonist therapy per 100, and 35 needles and syringes were distributed per person who injects drugs per year (Colledge-Frisby et al., 2024). Worldwide challenges in accessing and utilising HR services for young people who inject drugs have been recognised for several years. Despite a declining age of initiation into injecting drug use, young people face various barriers to accessing HR services in many countries (Krug et al., 2015).

These barriers, whether actual or perceived, are often linked to the stigma and self-stigma associated with injecting drug use, which heightens users’ vulnerability to issues like HIV, HepC, sexually transmitted infections, and needle sharing (Fletcher & Krug, 2013). Such circumstances appear deeply rooted in existing control mechanisms prioritising judgement, punishment, and exclusion. Such mechanisms are often attributed to the “war on drugs”, a global campaign initiated by the United States in the 70s to disrupt the production, distribution and consumption of illicit substances through repressive measures, foreign aid and military intervention (Farber, 2022). This approach is believed to have failed at the global level more than a decade ago and even to have impeded public health initiatives to mitigate the spread of HIV and the occurrence of lethal overdoses among other harmful consequences of problematic drug use (The Global Commission on Drug Policy, 2011). Yet, the war on drugs continues in countries such as the Philippines, Colombia and Mexico where it is often linked to violence by law enforcement agencies and contractors against drug producers, distributors and consumers themselves (Cooper, 2015; Mattingly et al., 2022; Harm Reduction International, 2024b). Studies conducted in North America and the Philippines note with concern that young drug users are more likely to experience police targeting, interactions and brutality compared to their older peers (Greer et al., 2022; Gray et al., 2017). In Australia, contact with the police appeared to have a more positive effect mostly before young people started using hard drugs (Leslie et al., 2018).

1.1. Injecting Drug Use and Infectious Diseases in Mauritius

The HIV and HepC epidemics in Mauritius, a small island state located off the coast of Madagascar, are concurrent phenomena that follow similar modes of transmission. Transmission of both viruses is concentrated among socially, economically, and culturally marginalised populations engaging in high-risk behaviours, including needle sharing and unprotected sexual intercourse. The national HIV prevalence is currently estimated at 1% and 21.2% among people who inject drugs (UNAIDS, 2023). The national prevalence of HepC was estimated at 0.55% in 2022, and 89.2% of people who injected drugs were living with HepC in 2020 (Ministry of Health & Wellness, 2020a; WHO, 2022).

With an estimated 55,000 illicit drug users in 2021 and approximately 6600 injecting drug users with an average age of 21 years at first injection, the impact of drug use on the youth remains high (Ministry of Health & Wellness, 2023a). Young people aged 15–24 represent 20% of new HIV cases detected since 2010 (Ministry of Health & Wellness, 2020b, 2024a). This specific demographic group is important for HIV and HepC prevention programmes following their increased risk of infection and the consequences for themselves, their environment, the health system and society at large over a longer period than older individuals.

1.2. Harm Reduction and Young People in Mauritius

Mauritius is one of the few countries in eastern and southern Africa providing both a needle and syringe programme and opioid agonist therapy, together with Kenya, Mozambique, Seychelles, South Africa, Tanzania, and Uganda.

The challenges in accessing and using HR services for young heroin users in Mauritius have been documented for more than a decade (NATRESA, 2010; Krug & Pollard, 2013). It is known that young people who inject drugs are at a higher risk of HIV and HepC infection because of their lack of experience with safe injecting techniques (CUT, 2010). Our previous findings from the same study showed that young injectors may also be misled by peers or choose alternative ways to meet their needs through polydrug use (White et al., 2020). Polydrug use emerged as a recurrent coping mechanism resulting from the changing dynamics within the heroin market, with detoxification and informal opioid agonist therapy even acting as regulators for the amount they consumed in some cases. Several participants were also uncertain about what they were consuming at times.

While the United Nations has made recommendations to improve access to HR for young people (even those under 18), the deep-rooted stigma experienced by people living with HIV and injecting drugs remains a major obstacle to the optimal use of HR services (United Nations, 2019). “The People Living With HIV Stigma Index”, conducted in 2017, showed that 40% of respondents reported being subjected to gossip by others (PILS, 2017). Forty-two percent of the individuals interviewed attributed this to their HIV status as well as other reasons, which included injecting drug use. Hence, clients of HR services cannot be viewed in complete isolation from their drug use.

1.3. The Evolving Harm Reduction Environment

The Dangerous Drugs Act 2000 provides the foundation for reducing illicit drug demand and supply via the National Drug Control Master Plan, which is reviewed and implemented every few years (Government of Mauritius, 2001). It is the HIV/AIDS Act 2006 and its subsequent amendment bill in 2022 that provide the legal framework for HR (Government of Mauritius, 2007, 2023a). Methadone Substitution Therapy (MST), the local opioid agonist therapy and the Needle Exchange Programme (NEP) were introduced as joint governmental and Non-Governmental Organisation (NGO) strategies to mitigate the spread of infectious diseases through injecting drug use at no charge to the user.

In 2017–2018, when we conducted our study, the Ministry of Health & Wellness operated 35 NEP sites while NGOs such as Collectif Urgence Toxida (CUT) and Aides Information Lutte Espoir et Solidarité Mangalkhan (AILES) were present in 12 Needle and Syringe Programme (NSP) sites. Five thousand individuals were on MST and could access their daily dose through 44 methadone dispensing sites. Twenty-three MST delivery points were found within the premises of police stations. In parallel, the Commission of Inquiry on Drug Trafficking was holding interviews to assess the effectiveness of current drug policies and ways to improve services (Government of Mauritius, 2018).

As seen in Figure 1, the delivery of HR services was marked by a lengthy period of conflicting trends and challenges before recent positive changes took effect. A proportional increase in police arrests for what is categorised as “possession of heroin” since 2009 was noted (Statistics Mauritius, 2021, 2022). These statistics include users caught with empty needles and syringes only, despite the provision made in the HIV/AIDS Act 2006 for free access to clean injecting equipment.

Data for subsequent years were not compiled following the impact of COVID-19 on police activities. Methadone procured through informal networks is also a recurring theme that continues to appear both in the press and annual monitoring exercises since we carried out data collection for our study (Thomas, 2022; National Drug Secretariat, 2020, 2022; Bissière, 2022; Thomas, 2023a). Moreover, the fact that only 50% of known people who inject drugs were obtaining clean needles and syringes through official channels implied significant under-utilisation of services that remain free. A high rate of relapse (92%) was also noted among men using hard drugs, according to research carried out during that period (Ramsewak et al., 2020).

The most recent National Drug Control Master Plan (2019–2023) formally acknowledged the role of HR in mitigating the impact of illicit drugs by reducing stigma and improving psychosocial support to people using drugs (Prime Minister’s Office, 2019). Recent positive changes in how police apprehend drug offenders include the implementation of The Dangerous Drugs (Amendment) Act 2022 (Government of Mauritius, 2022). This act focused on reducing drug supply and demand and established a Drug Users Administrative Panel, with formal ties to HR services, as a preferred intervention (Government of Mauritius, 2023b; Thomas, 2023b).

Other positive changes noted are linked to the guidelines for the treatment of illicit drug use elaborated by the Ministry of Health in collaboration with NGOs (Ministry of Health & Wellness, 2023b). This document conceptualises addiction to illicit drugs as a medical issue and has set standards for treatment and care. Patient groups covered include people addicted to opioids, cannabis and other drugs, as well as specific groups such as pregnant women and those aged less than 18 years old. Services covered include MST (including take-home methadone) to stop using drugs, needles and syringes to prevent infections. Unfortunately, the satisfactory implementation of all these services remains to be seen. More recently the existence of informal detoxification service providers and their lethal methods became public knowledge following the deaths of clients attempting to wean themselves off drugs (Thomas, 2024).

Recent public discussions brought different stakeholders together and extensively covered the state of HR in the local context, its gaps, and the dangers of adapting best practices from other countries without an in-depth understanding of the local dynamics (CUT, 2024). Recurrent themes noted include the move to dispense methadone in health facilities again as well as increasing access for those aged under 18 years old, following repeated requests from users (Laurent, 2024; St Cyr, 2024; Defimedia.info, 2024). Ministries and NGOs such as Développement Rassemblement Information et Prévention (DRIP) are increasingly working with the youth to raise awareness of the impact of drugs (Le Mauricien, 2020). The Harm Reduction unit at the Ministry of Health and Wellness now links with the drug prevention, detoxification and rehabilitation programmes (Ministry of Health & Wellness, 2024b). The government has created the Nenuphar Centre for young people aged 12–22, a special unit at the national mental health hospital to treat young people aged 18 and above addicted to New Psychoactive Substances, as well as the Orchidée Centre, another unit for women within the same hospital (Defimedia.info, 2021; Defisante.mu, 2024).

Treatment of HepC has improved considerably following a substantial donation from a pharmaceutical company (Prime Minister’s Office, 2022). This donation and the partnership between the government and NGOs have made curative services more accessible (Gilead, 2024). Such reforms imply that the Mauritian HR system is dynamic, reactive and evolving.

1.4. Mauritian Harm Reduction as a Complex Adaptive System

The confirmed existence of informal networks within Mauritian HR services implies that the system is bigger and far more complex than the individual parts described in policy documents, drug consumption and official HR programme monitoring reports. When taken as a whole, with both its formal and informal components, the Mauritian HR system can be better understood from the ground up and through the eyes of its actors. It exhibits the same core characteristics as a Complex Adaptive System (CAS) from such a vantage point. These characteristics are summarised in Figure 2.

CAS are dynamic networks of interacting agents that operate in parallel and influence the overall system. They follow non-linear dynamics and appear unpredictable at the onset. CAS have known properties where diverse values and goals coexist (De Ridder et al., 2017). Healthcare systems, in addition to more mechanical and biological systems, are prime examples of human-driven CAS (Ratnapalan & Lang, 2020; Pype et al., 2018; Institute of Medicine, 2001).

So far, the CAS framework has been used in Africa, with two main focuses: understanding the evolution of HR in Tanzania and exploring the link between HIV drug resistance, community viral loads, and related factors in South Africa, Tanzania, and the sub-Saharan region (Ratliff et al., 2016; Burman & Aphane, 2016; Kiekens et al., 2021, 2022). However, the systemic dissonance created by informal networks in countries offering needles and syringes, opioid agonist therapy and detoxification concurrently is yet to be understood. Identifying the potential ripples of such networks could be important when investigating the real effectiveness of HIV and HepC interventions.

1.5. Aims and Objectives

The initial aim of our study was to gain insights into the motivations and needs of young heroin users when accessing needles and syringes. This was gradually broadened following an iterative process to encompass all elements of HR services that participants deemed relevant following their personal experiences. The resulting objectives of the study were the following:

• To understand the perceived facilitators and barriers to accessing HR services;
• To map the underlying dynamics within and between different HR services;
• To assess how to increase the effectiveness of HR services for young people.

2. Materials and Methods

2.1. Study Design

Our study had an inductive design, which combined recommended elements for different forms of qualitative studies and analyses to create a coherent whole. Inductive logic implies creating categories and reaching conclusions based on the data, with meaning emerging from the data instead of using a predefined framework or theory (Thornberg & Charmaz, 2014).

Thus, data were collected from young people who injected drugs, and in parallel, interviews with service providers helped to improve our understanding of the context and gradually assess the validity of what was shared with us. This approach was developed to examine the interaction between what is referred to as the “hardware” (organisational structure, resources, etc.) and “software” (values, norms, power relationships, etc.) of the Mauritian HR system through the subjective lens of young heroin users (Nuggehalli Srinivas, 2015). Our approach allowed new elements to be integrated within the study as data were collected and to examine how the HR software shaped the HR hardware in ways that had not been captured through traditional programme monitoring and integrated behavioural and biological studies. We also developed qualitative case studies for informal HR service providers collaborating with NGOs, as seen in Appendix A.

2.2. Sample

Different schools of thought provide different recommendations for achieving saturation of perceptions. An acceptable sample size can be achieved with 5 to 25 participants for phenomenological studies, and a maximum of 30 is required for grounded theory (Creswell, 1998; Glaser & Strauss, 1967). Hence, 27 interviews were carried out until thematic saturation occurred: 22 with young heroin users and 5 with service providers.

Fieldworkers who were peers employed by various NGOs screened potential participants within the 18–24 age group before each interview. The inclusion criteria for drug users included forming part of the targeted age group, which had to be proven with identification documents; not being under the influence of illicit substances at the time of the interview; and willingness to participate at a set time and place. After participating in an interview, we then asked participants to invite people who might be interested to join the study through snowball sampling. Interviews were carried out in urban and rural regions of Mauritius, thus going beyond known HIV and illicit drug clusters in and around the capital city known as Port Louis. The heroin users interviewed were residents from various parts of the island. They belonged to different socio-economic groups (low to high income) as well as ethnic backgrounds (General Population, Hindu, Muslim, etc.). The flexibility of the approach chosen enabled participants to come forward as sex workers, former prison inmates as well as MST and detoxification clients. A more purposeful approach was adopted for service providers, including those working for or with NGOs and the government. We received recommendations for the type of service providers to be included by field workers and peers working with injecting drug users during the kick-off meeting for the study held in September 2017. A highly experienced individual injecting drugs referred to as a “hit doctor” who guided younger and less experienced drug users, and a volunteer were included following the growing importance of informal service providers in the field.

2.3. Data Collection

Following the gaps noted in the literature on young people who inject drugs, a semi-structured interview guide was designed and pre-tested in Mauritian Creole during the pilot stage with 5 participants. The main themes we touched upon were (i) drug use, (ii) their understanding of HR, (iii) the services that they accessed and (iv) how we could improve them. A more unstructured and conversational approach was gradually favoured as we carried out more in-depth interviews since the factors and barriers related to needles and syringes were far more complex than anticipated. Themes were maintained, but we did not follow a set sequence of questions and encouraged our participants to elaborate as far as possible. Our interviews were conducted in Mauritian Creole before being transcribed and translated to English for analysis. We paid attention to “In Vivo codes” during the translation process. Interviews were carried out between June 2017 and March 2018.

2.4. Analysis

The analytical process involved listening to recordings and reading transcripts several times. Memos were used to build reflexive notes as we went through transcripts and continued with the literature review in parallel. We employed the standard three-stage process aligned with the grounded theory approach, which favours axial coding over theoretical coding (Choe, 2005). We enhanced this process with additional steps to ensure reliability and validity. Open coding was used during the first stage of the analysis, following the pilot, to explore the data generated during interviews and build a preliminary coding tree focusing on access and barriers to needles and syringes. This preliminary framework was refined as interviews with both heroin users and service providers progressed to include methadone, detoxification and rehabilitation services. Tables were built to streamline the analytical flow from major themes to analytical codes, as can be seen in the appendices.

Our previous analysis focused on risks. Risk perceptions, defined as how individuals perceive a threat by interpreting and weighing the risk for consequences against benefits, became a recurring aspect of the study upon hearing the choices, behaviours and preferences expressed by young people who use heroin and service providers working in HR (Ferrer & Klein, 2015). This analysis was kept separate from the present qualitative structural analysis, which focuses on the experience of the same sample in accessing what they deemed to be HR services.

Following the depth and breadth of the data collected from our participants, the qualitative structural approach allowed for a systemic exploration of patterns of HR utilisation during the second stage of the analysis. Qualitative structural analysis eased both qualitative modelling and subjective analysis. This approach combined the strengths of ego networks/social network analysis with grounded theory and phenomenological approaches to explore individual experiences (Herz et al., 2015). Emerging codes gradually went beyond factors linked to the NSP to include access to different “types” of methadone and detoxification services available. Codes were compiled according to factors impacting utilisation of services such as “Access”, “Motivations” and “Barriers”. The motivations of redistributors were further examined under “informal network dynamics”. We strayed from grounded theory at this point to follow a more phenomenological approach by relying on the lived experiences of service providers to assess the reliability and validity of what young heroin users shared with us.

During the third stage of the analysis, comparative analyses were carried out to generate structural networks for each service and later assembled to create a qualitative structural network for the whole system. The mental models of participants were compared, as per new guidelines for qualitative systems mapping of complex public health problems (Kiekens & Vandamme, 2022). As the analysis progressed, the traditional dichotomy that exists between detoxification programmes and HR services was bridged, and the HR system as a whole emerged as a CAS following its dynamic nature. The NVivo software version 11 was used to analyse transcripts and manage the codes generated. Case studies were designed for emerging categories of informal service providers to further explore their life histories and motivations.

2.5. Ethics

Following the pilot carried out with exclusive CUT clients and one service provider, a request for ethical approval to carry out this study on a larger scale was obtained from the National Ethics Committee at the Ministry of Health in August 2017. All participants were given a consent form to sign before the interview that provided an outline of the study and guaranteed both anonymity and confidentiality before, during and after the interview. We assigned codenames to participants when analysing data. The letters “SP” were inserted into each service provider’s code name to differentiate between heroin users and service providers. Young heroin users and two service providers (the volunteer and the “hit doctor”) were given a voucher for food or clothes instead of cash, as is usually done during programmatic surveys, as an incentive to participate. Our team opted not to provide money to buy drugs. Informing participants of the study outcomes was also one of the conditions set in the consent form. All fieldworkers signed a contract for this project that explained the terms and conditions of their employment and resulting remuneration.

3. Results

The sample consisted of 27 people: 11 men and 11 women, aged 18–24, who either injected or smoked heroin within the past 4 months as well as 5 service providers. Our participants included a programme coordinator, an NGO coordinator, a hit doctor (individual case study 1 in Appendix A), a volunteer (individual case study 2 in Appendix A) and a peer educator. Two female participants and 1 male participant disclosed that they were living with HIV. Participants spoke of NSP and NEP services in general terms without elaborating on the exact nature of the services accessed. Several participants could not tell the difference between services provided by the government or by NGOs. They also did not provide specific information on the exact type of service used: if they used mobile services referred to as “caravans”, services available in a fixed location known as a “container” or services provided by individual fieldworkers distributing equipment referred to as “backpacks”. Eighteen participants out of 22 expressed some views on MST. One participant had recently been inducted into MST over the past month, while two expressed their intention to join the programme as soon as they had an opportunity.

Although detoxification and rehabilitation programmes are officially separate from HR services, as per the HIV/AIDS Act 2006, participants made no such distinction when describing their HR experiences. One participant was on the codeine phosphate programme and injected occasionally, while another no longer used heroin after spending a few months in a rehabilitation centre. Several participants mentioned seeing private medical professionals (general practitioners, psychiatrists) informally and being prescribed medication with mixed results. One of our participants managed to stop using, but, in other cases, such treatment provided temporary relief only. Others tried different forms of supervised treatment such as tramadol, suboxone, methadone and olanzapine for heroin detoxification. One participant had been in 3 different centres and others had tried or knew peers who had combined different approaches to stop using illicit drugs, including unsupervised detoxification. The main characteristics of our participants are summarised in

Table 1. Characteristics of participants, N = 27.

	Young Heroin Users (18–24 Years)	Service Providers (Including Informal Providers)
Number per group	22	5
Characteristics
Currently using heroin (inject/smoke)	19	1
Enrolled on methadone but injected in the past 2 months	1
On codeine phosphate but injected occasionally	1
Were drug-free at the time of the interview	1 (injected in the past 4 months)	2
Combined heroin with other substances	7	2
Were HIV-positive (disclosed during the interview)	2	1
Were HepC-positive	Undisclosed	Undisclosed

.

3.1. Access to Needles and Syringes

Participants explained that needles and syringes could be obtained from NGOs (CUT, Ailes) and exchanged at the Government’s NEP sites during the data collection stage. An NGO working with Commercial Sex Workers called “Parapli Rouz” was also set to become a NEP service point. Needles and syringes were also available for MUR 10 (USD 0.30) in private pharmacies “where some ask for prescriptions whereas others do not”.

3.1.1. Facilitators for Accessing Needles and Syringes

The fact that peers endorsed such services encouraged heroin users to either overcome their initial apprehension or to keep using the service. How these services were delivered and by whom also played an important role in both service use and client retention. The capacity of outreach workers to nurture a good relationship with clients, based on their own experiences, and in a non-judgemental manner, impacted positively on their overall satisfaction with the service. An outreach worker who was also a peer explained how young users could connect with him almost instantly with little being said. He attributed this immediate connection to shared mannerisms among users. Most participants showed appreciation for the registration process, which was free and granted immediate access to the service. Both service providers and heroin users agreed that a fast registration process for both NSP/NEP was a good starting point in the relationship between users and service providers. Potential users were usually asked for their identity cards, but in some cases, registration could be done with only the full name and date of birth. More information on facilitators and illustrative quotes from our participants can be found in Appendix B.

3.1.2. Barriers to Needles and Syringes

Despite the high demand for injecting equipment in some areas where clients even made daily requests, caravans could only distribute paraphernalia during set days and times. This often implied that clients were away, studying, or at work when services were available in their home environment. In such cases, participants were unaware that registration also allowed access to injecting equipment in other areas on the island. Knowledge and awareness of geographic coverage were usually obtained from fellow heroin users only, as other sources of information were unavailable.

Participants viewed the quality and safety of the injecting equipment provided as a recurring issue. They expressed different preferences for the types of needles and syringes they used and were concerned about what was available on NSP and NEP. Besides creating some discomfort, injecting with inappropriate equipment increased health risks for oneself and others. A participant living with HIV mentioned a few incidents when she had to cut herself because the needle broke in her veins when injecting. Not having a choice in the type of injecting equipment available led participants to use items that they could not handle properly and provoked discomfort. Such items easily fell apart, and others were difficult to clean.

Most participants also explained that the fear of being caught by the police for syringe possession limited their capacity to fully benefit from services, even when they were willing to take the risk to go to a caravan. Besides increasing the appeal of the black market, that fear implied that several participants kept using the same syringes for several weeks despite how quickly these items became unfit for use and unsafe. Despite the efforts of various service providers, some heroin users remained distrustful of having to register for services, as they were concerned that their personal information would be shared with government authorities. Appendix C contains additional details on the perceived barriers to needles and syringes services described by participants.

3.1.3. Redistribution of Needles and Syringes

Due to the stigma surrounding injection drug use, several of our interviewees were willing to pay more and use alternative channels when obtaining their drug paraphernalia, to maintain the same level of discretion as when purchasing the illicit drugs themselves. Items bought from pharmacies consisted mainly of syringes used by diabetic patients to inject insulin and were described as fairly easy to procure.

“The ones used for insulin. With the yellow cap… it has two yellow caps”

F-P1

Such needles also had the additional benefit of not leaving any external sign of injection. Participants described two main strategies to obtain such equipment. The first option consisted of asking an acquaintance to buy items on their behalf. The second one involved using a fake prescription. In such cases, syringes for insulin injections were obtained for cheaper (MUR 7/MUR 8 or USD 0.21/USD 0.23 as at the average currency exchange rate of USD 1 = MUR 34.50 for 2017 and 2018 (ExchangeRates.org.uk, 2017–2018)

“Because if you don’t have a prescription, you’re buying it on the black market. Whereas when you have a prescription, they think you’re really ill. And that you need insulin.”

M-P1

Additional queries into informal HR networks, or the “black market”, showed that needles and syringes could also be bought at a higher price than available in pharmacies (MUR 25 vs. MUR 10 or USD 0.71 vs. USD 0.29). Injecting equipment could also be purchased at the same time as drugs in many areas, despite the services provided for free by both NGOs and the government. The 3 main parallel redistribution channels for injecting equipment consisted of registered clients who injected drugs: regular heroin users and experienced users, known as “dokter” or hit doctor, and individuals who did not inject drugs.

Motivations for redistributing paraphernalia differed across these 3 main categories, as shown in Appendix D. Personal use was common across all emerging categories except for individuals who did not inject drugs. Participants noticed that fellow heroin users, hit doctors and individuals who did not inject drugs but redistributed injecting equipment were motivated by monetary gain and commercial intentions. More experienced users and hit doctors who helped their peers in administering their doses considered mutual gain. This form of barter involved asking individuals who only started to inject recently to share their dose or paraphernalia. Some heroin users, hit doctors and individuals who did not inject drugs also redistributed equipment to reduce risks of infections among users for altruistic reasons. According to the interviews made, redistribution occurred mainly through registered clients. Thus, the combined experiences of our participants portrayed access to needles and syringes as multi-layered and driven by a variety of actors with different sets of motivations, as summarised in Figure 3.

3.2. Access to Methadone Substitution Therapy

Most heroin users interviewed were aware of methadone and the different ways of obtaining it through both official channels and parallel networks. At the time of data collection, MST was officially available at police stations, selected healthcare facilities and in prisons. Potential clients for this service went through a screening process that began with referrals from NGOs that recommended users based on their ability and willingness to stop injecting drugs.

3.2.1. Facilitators for Methadone Substitution Therapy

Participants who were already on methadone as well as others who wished to join the programme viewed it as an empowering medication that offered better prospects than staying on heroin. One of the greatest facilitators in using MST was how it decreased the severe pain associated with withdrawal and allowed users to be more productive. It also reduced the pleasure derived from consuming drugs in some cases, hence making polydrug use less appealing. For many, methadone decreased the constant reliance and strain on family members and close ones for money caused by uncontrolled addiction. One participant and his partner were both planning to enrol on methadone and work together to start anew.

Participants who were recently induced on MST no longer felt like a burden to their environment and were more in control. Thus, several participants saw the MST programme as a second chance in life and a temporary measure to become truly drug-free.

“Whereas if you’re on methadone, you’re active, you can do whatever you want, you don’t need to use drugs”

PL-P3

Further details on the perceived facilitators for MST are available in Appendix E.

3.2.2. Barriers to MST

Several participants perceived methadone as causing serious side effects, as seen in Appendix F. Although useful in reducing heroin consumption, some participants explained that MST was more addictive or “stronger than the brown”. In most cases, young heroin users perceived the side effects of methadone as very negative as a result of what they heard from peers. Our interviews with the hit doctor and outreach worker also confirmed this. Other participants believed that methadone was not a solution as it replaced their addiction with another one since “methadone is also a drug”. This perception was also endorsed by the service provider working as a volunteer. At times methadone was mixed with other drugs such as cough syrup for a better high.

Stigma also played an important role in motivating young users to enrol on MST. Young heroin users were often reluctant to go through official channels to obtain methadone out of fear of exposing their history of drug use. Participants were extremely concerned about close ones finding out about their heroin use. A government service provider also noted the impact of self-stigmatisation, where users deny themselves access to services out of fear that their peers will associate and identify them as drug users. Women who had young children did not want to bring them to police stations to receive their daily dose in public. Such participants preferred to either stop completely or enrol in detoxification programmes when they felt ready.

3.2.3. Redistribution of MST

The redistribution of methadone described during our interviews implied parallel distribution channels as well as different forms of the medication available on the street. This “street methadone” referred to 3 variants: clean methadone, diluted methadone and “methabav”, i.e., methadone mixed with saliva. Participants reported that clean methadone could be obtained directly from the police in a bottle and redistributed. Diluted methadone was redistributed methadone cut with water. Methabav was methadone taken in front of other clients but spit back in a cup or bottle. These different types were difficult to differentiate unless users were present at the time of distribution. However, these methadone variants were often sold at the same price in some areas and ranged from MUR 100 to MUR 300 (USD 2.9 to USD 9), irrespective of quality.

At the time of the interviews, methadone could only be procured through police officers or from registered clients. Participants described 3 main categories of registered MST clients: those who adhere to treatment and occasionally redistribute (personal use), those who alternate between methadone and other substances (polydrug users) and those who sell their methadone at the prices mentioned previously (redistributors).

Participants knew several MST clients who were not interested in completing the programme but used MST as both insurance and a source of income to meet their daily needs. One of the participants who had recently enrolled in the programme was also using New Psychoactive Substances occasionally but did not sell her dose. MST enabled her to strike a balance between her treatment and recreational drug use, which she shared with her partner. Participants provided examples of registered clients who adhered to the programme but occasionally sold their daily dose to help friends or to procure other drugs. A participant who was receiving codeine treatment would occasionally obtain methadone and redistribute it to young people who were too young to purchase it from registered clients or police officers but were already experiencing severe withdrawal symptoms from their heroin use. Illustrative quotes from our sample on the different motivations for redistribution can be accessed in Appendix G. Our interviews also suggest that a more accurate depiction of access to methadone should include informal redistribution as a recurrent element, as depicted in Figure 4.

3.3. Access to Detoxification and Rehabilitation

Centres for detoxification and rehabilitation mentioned during interviews included Sangram, Chrysalide, Idrice Goomany Centre, and Centre de Terre Rouge. Suboxone treatment was accessed at Mahebourg hospital. Participants also sought care in the private sector.

3.3.1. Facilitators for Detoxification and Rehabilitation

Friends played a crucial role in the decision to stop using drugs for many participants. Several participants learned about the available services and their effectiveness through friends who had personal experience. Those who were able to stop using drugs were viewed as role models and could provide relevant support. Friends also served as conduits, connecting individuals seeking treatment with the appropriate treatment centres.

Users who were unsure about joining or reintegrating a programme after a relapse responded positively to the encouragement received from medical professionals. Participants who were willing to try detoxification or rehab were also aware that the substitute provided in centres might not help them to effectively manage the severe withdrawal pains caused by detoxification. Such participants were looking for effective substitutes that would neither disrupt their work nor be as addictive as methadone.

“No, something that I can take while I keep living a normal life, where I can work and do stuff.”

BV-P2

Appendix H summarises the main facilitators for detoxification and rehabilitation as shared by our participants.

3.3.2. Barriers to Detoxification and Rehabilitation Programmes

Attempting detoxification was described as a major challenge in the lives of users. Quitting was hard, according to young users, and required a significant amount of mental strength and family support. The absence of such factors would explain why only a few succeeded on their first attempt. Participants who tried such services and already suffered a relapse were not as willing to keep trying because “it didn’t work”. Such repeated failures deterred young users from trying again without the proper support.

The fear of being diagnosed with HIV and the emotional burden that came with it were major barriers for young people considering going to rehab. In such cases, a fatalist mindset settled in where young people continued to use illicit substances without being able to seek help or confide in close ones because of the stigma.

Participants who had not been using for a long time mentioned stigma and isolation from close ones as strong barriers. The stigma associated with using detoxification and rehabilitation services was deemed very high by our participants whose environments were unaware of their drug use. Other participants were uncomfortable with residential programmes that implied leaving their families behind. This fear of isolation was something that not all centres could cater to, as each institution had its own approach to treatment. Moreover, the stigma and discriminatory behaviour experienced by participants in the private sector acted as a very strong barrier to those wishing to pay for more discrete care in such institutions.

The effectiveness of the treatment provided in several centres was discussed by participants who had tried but experienced a relapse. Some of the issues highlighted were related to how the treatment was administered. These participants explained that some substances, like olanzapine, were not effective on them. In some cases, detoxification happened too fast and did not allow users to gradually get used to the dosage. A distinct lack of personalised care, which neither took into consideration the type of substance(s) used nor the amount consumed before trying detoxification, was noted during interviews. There were no specific programmes for polydrug users at the time of data collection. Additional insights into the barriers to detoxification and rehabilitation can be found in Appendix I.

3.3.3. Informal Access to Detoxification and Rehabilitation

The existence of informal detoxification and rehabilitation services also surfaced during interviews. Heroin users could access medical support on their own or try to wean themselves off illicit substances with no formal supervision. In both cases, there was no need to register and no monitoring compared to official channels, which greatly increased confidentiality. Although such services were easier to access, their effectiveness was perceived as mixed.

Other forms of informal care also included using prescriptions received by peers from private medical practitioners to attempt detoxification or experimenting with other substitutes. A participant explained that he was able to stop using drugs for four months by using cough syrup only. The former user who was now working as a volunteer in NSP explained how she used the prescription given to one of her friends and isolated herself completely for 2 weeks. Two months later she was able to quit on her own, without any external support. Such scenarios were the result of the stigma associated with drug use. The service providers involved were motivated by financial gain, but it was the user’s desire to preserve confidentiality that encouraged such informal services as seen in Appendix J. Figure 5 illustrates detoxification services from the perspective of the participants interviewed.

4. Discussion

Exploring the factors facilitating and deterring access to needles and syringes for heroin users gradually highlighted the need to take a more holistic approach rather than examine each HR service in isolation. Our findings are discussed according to the 3 main objectives of the study.

4.1. Facilitators and Barriers to Accessing HR Services

Our study shows that factors easing access to HR services for young people cut across services. Young users interviewed were more inclined to trust effective services endorsed by peers. They also required reassurance and encouragement from professionals and close ones to face the stigma experienced when openly asking for help. The stigma associated with accessing HR services through conventional channels was so high that informal networks often became more appealing. Participants assessed the quality of services according to ease of access, quality of the product offered and the credibility of service providers. Such elements generated enough trust for users to expose themselves to procure the required injecting equipment, take methadone or enrol on a detoxification programme.

In terms of mindset, participants often spoke about the desire to make a significant change and willpower as prerequisites to benefit from HR services. Participants found reducing personal risks and impacts of illicit drugs appealing. Such benefits included less reliance on close ones, increased personal autonomy, improved well-being by becoming drug-free, and reduced withdrawal pains. Using HR services was associated with the responsible use of illicit substances and as a potential door to a better life for many.

Recurring barriers to accessing HR services could be found at the societal level, in service design and concerning products offered, but also included some very individual-level factors. Arbitrary arrests by the police reinforced stigma at the societal level. The young heroin users interviewed would often put themselves more at risk of getting arrested or risking their anonymity when accessing HR services in the public eye.

The geographic coverage of services, timing and quality of equipment provided were often mentioned by participants as additional barriers. The fear of family finding out about their drug use noted among the 18–24 age group implied some aversion to accessing HR services too close to home. Women in particular had apprehensions about taking their children where services were available, which made access even more challenging in some cases. The perceived quality of injecting equipment and the inadequacy of substitutes or treatment were also recurring issues. Moreover, the general lack of experience noted among this age group and the need to turn to more experienced users for help often created power relationships. Individuals who attempted to access services on their own faced increased risks, such as injuries from injecting or severe side effects from using substitutes or treatment, for which they were unlikely to seek professional medical help.

Our findings are in line with the emerging research on increasing the role of peers in delivering substance abuse and harm reduction services in low- and medium-income countries. Findings from such studies have shown that peer involvement can be impactful where there is low human capital, as noted in Mauritius (Satinsky et al., 2021; Owoeye et al., 2023). Involving peers can also help to decrease stigma in accessing such services, besides increasing trust among clients.

4.2. Dynamics Within and Between Different HR Services

Our previous analysis highlighted adaptive behaviours where young people who used heroin were regulating their consumption by switching and mixing illicit substances. This phenomenon appears to extend to HR services following the emergence and complexity of “polyservice use” made possible through informal channels.

Applying qualitative structural analysis to HR for this study has allowed for a bottom-up perspective and emerging trends in utilisation to be documented. This approach allowed the unofficial role played by detoxification programmes and informal redistribution networks within HR to come to light, as shown in Figure 6, which summarises the findings from our study. We were able to explore the underlying motivations of agents within informal networks at the time of the interviews, such as hit doctors, volunteers, private medical practitioners, pharmacies and some police officers.

Parallel harm reduction channels were facilitated by circumstances at various levels, reinforcing mechanisms, as well as both institutional and individual actors, which initially seemed disconnected. For instance, the availability of needles and syringes in pharmacies was influenced at the macro-level by the consistently high national prevalence of Diabetes Mellitus. According to the latest estimates, 1 person out of 3 among those aged 25 to 74 years old was either diabetic or pre-diabetic (Ministry of Health & Wellness, 2021). This specific epidemic implies a significant need for insulin injections, resulting in a constant supply of injecting equipment.

The decision to access either mainstream or informal HR services was ultimately determined by how heroin users handled barriers and their heroin consumption at different points in time. Keeping heroin consumption under control was challenging and often involved additional risky behaviours. These behaviours included uncontrolled polysubstance use, over-consumption and needle sharing in the moment. The consequences of these behaviours included but were not limited to overdose and/or HIV/HepC infection. The actual availability and quality of heroin and substitutes on the drug market also played an important role in shifting personal circumstances. Such external factors were determined by both HR policies and the overall government strategies in place for illicit drug control.

Participants often described their utilisation of HR services (whether mainstream or informal) as being cyclical. They used needles and syringes and methadone (MST or street methadone), either in isolation or sequentially, and would eventually try detoxification and/or rehabilitation programmes and/or “relapse” back into using needles and syringes and/or methadone. Some participants explained how they could procure street methadone before attempting detoxification on their own, without having to go through official channels, to maintain confidentiality. We also encountered cases where participants described using or planning to use more than one service at the same time, leading to polyservice use.

Our findings imply that a potential service user had 18 known ways into HR which could be accessed in any order at a single point in time (excluding those who might prefer informal channels only), as seen in

Table 2. Types of HR service users and combinations (broad categories).

Type of Service User	Combinations
Single Service Users	NSP or NEP (Official Needles and Syringes) MST Detoxification Programmes
Dual Service Users	Needles and Syringes + Street Methadone Needles and Syringes + Informal Detoxification Informal Needles and Syringes + Street Methadone Informal Needles and Syringes + Informal Detoxification MST + Informal Needles and Syringes MST + Informal Detoxification Detoxification Programmes + Informal Needles and Syringes Detoxification Programmes + Street Methadone
Triple Service Users	Needles and Syringes + Street Methadone + Informal Detoxification MST + Informal Needles and Syringes + Informal Detoxification Detoxification Programmes + Informal Needles and Syringes + Street Methadone

. For injecting equipment, this included pharmacies, NSPs and NEPs as registered users, or through hit doctors, volunteers and resellers. For methadone, one could enrol on MST or obtain it through registered users and the police. Participants would access detoxification services through private centres, NGOs, private medical practitioners and/or self-medication. Only 4 entry points out of 18 were through entirely mainstream channels, should detoxification be formally acknowledged as forming part of HR in Mauritius.

Shifting personal circumstances over time could also significantly increase the number of potential combinations (with repetition) to several hundreds of scenarios, implying even more categories of HR service users. Such scenarios are only made possible through the existence of informal distribution networks.

Complex Adaptive System Dynamics in Mauritian HR: Implications

The findings from our study also imply that a reductionist approach to Mauritian HR fails to recognise the systemic properties that are likely to shape its continued development and evolution. The CAS properties seen in the Mauritian context consist of the following:

Emergence: Although agents within the 3 main components of the system act independently since there are no formal links between them, the patterns that have emerged show that HR services form a dynamic whole. The current National HIV Action Plan (2023–2027) also acknowledges an additional disconnect between HR and the HIV response as well as the need to improve access. The starting point would be to continue to address gaps in legislation and policies rather than encourage fragmented actions.

Co-evolutionary: NSP, NEP and MST services evolve in parallel and in an uncoordinated manner in terms of the number of users accessing services. This can be seen when comparing NSP, NEP, MST and detoxification programmes. As NSP and NEP services have become more decentralised, more MST service points and detox centres became accessible as well. As mentioned in the introduction, the Dangerous Drugs Act 2000 has recently been revised through an amendment bill to become more tolerant towards users caught with illicit drugs for personal consumption. Such individuals appear in front of a Drug Users Administrative Panel to discuss their rehabilitation instead of being fined and sent to prison. Following additional amendments to the Dangerous Drugs Act, upcoming innovations include medical cannabis for cancer, epilepsy and multiple sclerosis patients and those suffering from chronic pain. Such treatment should be available on a case-to-case basis and could potentially be beneficial for consumers of illicit drugs and HIV patients experiencing the side effects of long-term treatment. However, potential HR reforms need to take into account informal networks and the barriers to mainstream services that reinforce them, and that can go as far as including parental consent in some cases (CUT, 2023).

Connectivity: The relationships between service users and redistributors are crucial for the system’s survival, but are not limited to the current individuals involved. A redistributor’s role can be passed onto others who can also take on additional functions like being a “hit doctor” or volunteer. However, this suggests the need to formalise the relationships to some degree between the primary service providers and the redistributors.

Self-Organising: Pharmacies, hit doctors, volunteers, redistributors of methadone and private providers of detoxification services respond to the pre-existing demand for HR, knowingly or unknowingly, and usually at a set price. Those who can afford it buy the right to use such items with increased privacy compared to those who access services from a mainstream distribution channel. Word of mouth among users and informal providers creates feedback loops instead of traditional price signalling along the supply chain. Such feedback loops also exist between service providers, programme administrators and policymakers such as the High-Level Drugs and HIV Council. Maximising such feedback loops implies raising awareness among end users to manage expectations about services and encouraging truly holistic evidence-driven discussions with policymakers rather than presenting sub-sectoral reviews.

Nested Systems: HR services accessed are nested within other sectors. In Mauritius, this includes governmental systems (health, law and order), NGO services, the private and informal sectors. This segregation of activities limits coherence and increases duplication of efforts following the absence of a truly inclusive and multisectoral HR strategic plan to tackle both uncontrolled drug use and infectious diseases such as HIV and HepC.

Simple Rules: Services can be accessed when registered with established service providers or with a medical prescription. Users who do not meet these criteria can access these services through informal networks and experience different benefits and drawbacks when compared to official channels.

Sub-Optimal: HR services do not process set inputs, resulting in outputs and outcomes, which are time-bound and monitored according to pre-defined indicators for effectiveness and efficiency. HIV infection and overdose while receiving services, relapse, loss to follow-up and duplication of services are likely to occur but are not monitored comprehensively, thus leading to the false impression that HR in its enduring configuration is sustainable and cost-effective. Similar issues were touched upon by the Commission of Inquiry on Drug Trafficking and are yet to be fully explored and adopted.

Iteration: Small changes within the system can have a large effect. This can be seen when uncovering how a few more entry points into the HR system can have significant implications for access, quality and systems abuse following duplication of services. Similarly, increasing needle and syringe points in high-demand areas could greatly improve coverage.

Diverse: In early 2023, methadone was distributed in 5 methadone day care centres and 48 methadone dispensing sites. A total of 47 needles and syringes service points remained and were operated by both the government and NGOs throughout the island in 2022. Besides the new day care centres, this included 4 more MST sites compared to when our study ended in March 2018. The number of individuals enrolled on MST increased from 5000 to 7000. Yet, geographic differences in accessing such services exist and informal networks are likely to complement but also duplicate existing services in several areas.

Brink of Chaos: Both dysfunctionality and contradictions have been noted within the Mauritian HR system. Based on Table 2, there are potentially hundreds of ways in which HR services can be accessed over time (assuming that users limit themselves to a maximum of 3 different types of services simultaneously, over time). Other reasons for concern include overdoses, geographic differences in access for users, police arrests for those found with needles and syringes despite the clear formulation against such practices in the HIV/AIDS Act 2006, user reports of inappropriate dosage for MST, interruptions in distribution during COVID-19 lockdowns and continuing redistribution of HR items and products through informal channels. While challenges exist, the 3 main HR components (needle and syringe programmes, MST, and detoxification programmes) play a role in reducing both HIV and HepC transmission and mitigating the harms associated with illicit drug use.

4.3. Ways to Increase the Effectiveness of HR Services for Young People

The impact of informal HR networks was still misunderstood at the time we conducted our interviews. Although informal distribution networks enabled polyservice use, they also helped young people access services more discreetly and bypass the persistent stigma often associated with HR. Redistribution, whether done with commercial intent or voluntarily, removed age restrictions for young people who were underage and even encouraged some solidarity among users at times, which should be taken into consideration by official service providers.

However, such networks also decreased the effectiveness of HR services. Young heroin users could not access complementary information on safe practices unless they obtained it from a volunteer or hit doctor who had been empowered and was willing to help. Informal networks also increased risks linked to the disposal of injecting equipment (as mentioned in our previous analysis) and risky approaches to injecting and detoxification.

Managing complex systems in the fight against HIV could involve working with positive agents of social change such as peers and striving towards what has been termed “Complex Adaptive Risk Reduction” in South Africa. Thus, increasing the number of trained peers with the same initial needs and lived experiences as clients could add value to how HR services are dispensed in the Mauritian context. Trained peers and volunteers would be uniquely qualified to provide additional psychosocial support and personalised care across HR services. Their increased support would align with and strengthen the Ministry of Health’s guidelines for treating people who use illicit substances. These guidelines have already facilitated low-barrier care, a set of highly effective practices for substance abuse and harm reduction with growing evidence of success in various settings (SAMHSA, 2023; Hood et al., 2020; Aronowitz et al., 2022). However, the presence of peers was quite low within MST and detoxification programmes while we conducted our research. This still appears to be the case following a lack of incentives and career track. Services tailored to the needs of young users and also offered by peers who are formally acknowledged as providers would be instrumental in creating a resilient system and securing sustainable outcomes. Peer outreach programmes in diverse settings also tend to be successful (Moorthi, 2014; Stengel et al., 2018).

While progress has been made in mitigating some barriers to HR since we conducted our study, decriminalising the consumption of hard drugs, as per the Portuguese model, appears challenging at this point (Rêgo et al., 2021). Thus, it is important to consider and adapt innovative practices from other contexts for Mauritius based on formal assessments and studies conducted by relevant public health institutions, including those related to law and order. For instance, formal guidelines for the police in the form of the “Malaysian Needle and Syringe Exchange Pilot Project Standard Operating Procedure for NSEP” outline the need for collaboration between NGOs and the police during the exchange of needles (UNODC, 2016). Similar practices have been observed in Pakistan and Kyrgyzstan and could potentially inform the upcoming National Drug Control Masterplan for Mauritius, which is yet to be released.

Acknowledging the impact of HIV, police officers from Calcutta in India have noticed a decrease in petty crime after initiating community programmes which include drug awareness rallies, educational activities in schools and facilitating NGO-provided needle exchange services, substitution programmes, the distribution of condoms in addition to health counselling activities.

New information mediums such as social media and chat groups for young people could be used by peers and volunteers to update users while nurturing relationships since young people tend to be technology savvy. Dedicated centres going beyond detoxification to include supervised injections and methadone distribution with the help of hit doctors, medical professionals and addictionologists should also be considered to reduce health risks and stigma. Quality injecting equipment should also be made available based on user preferences. Safe consumption sites based on best practices could help to decrease loss to follow-up, HIV infection, overdoses and misinformation among young heroin users and beyond (Yoon et al., 2022; Beletsky et al., 2018). Such services would improve the outcomes of current services, which mostly focus on well-being but without being able to prevent complications linked to unsupervised injections.

An important step towards revamping existing services for young people and fighting their exclusion would be to give young service users who have been empowered through research a voice in high-level committees at both the local and international levels to discuss both HR and drug policy reform (Stowe et al., 2022). However, such endeavours will not be feasible without a functional entity or network of local heroin users to collaborate with civil society, the private sector, government and academia. It is important to make research and outcomes of studies more accessible to those directly involved in HR and the fight against HIV to avoid persisting sub-sectoral dogma.

4.4. Limitations and Reflections

Our analysis was based on detailed interviews that were not originally intended to gather comprehensive data on the HR system in Mauritius. Thus, a focused longitudinal study designed to explore how the HR system would evolve through the eyes of specific client groups over two years could have provided additional insights. Such a study would also have considered the perspectives of policymakers as well as stakeholders working in detoxification programmes and law and order.

We did not probe our participants to provide additional details on their criminal history and subsequent events that followed police arrests linked to illicit drugs. We also did not ask them to disclose which other key populations they identified with. Hence, no participant was interviewed according to a specific category or as belonging to more than one category besides being a heroin user, despite some participants belonging to more than one vulnerable group.

Our small sample size meant adopting a rather gender-neutral approach during the analysis (despite some striking gender-specific differences noted and reported) to increase the internal reliability and validity of our potentially controversial findings. Information gathered from service providers was based on their lived experiences and helped to validate and provide additional context to the experiences shared by other participants, as per the phenomenological approach chosen for this sub-group within our sample.

The redistribution of HR items occurred mainly through registered clients, but additional channels whose significance remains unknown were also mentioned. These channels included buying and reselling injecting equipment from pharmacies outside normal hours, procuring equipment from hospital staff who were also using heroin, receiving pethidine shots at the hospital as a substitute and using undisclosed medication in prison to stop using. How prominent such channels remain following the COVID-19 pandemic would require further research but are mentioned in the press occasionally, which was what we had to rely on to stay in touch with emerging issues.

It is also possible that the facilitators and barriers to HR experienced by individuals aged 18–24 differ from users who were at different stages in life, as seen in the literature (Stockings et al., 2016). The participants interviewed appeared to have different user trajectories compared to older heroin users. Most of them started using in their teens, and some even went straight to using heroin without trying other substances. The young heroin users interviewed had less experience and would potentially view barriers and facilitators differently compared to those who were older and had more experience.

5. Conclusions

Our study showed that an inductive qualitative approach combined with an iterative process could generate new insights into the dynamics of the Mauritian HR system. Qualitative structural analysis has allowed for an in-depth exploration of HR which emerged as a complex adaptive system. The confirmed existence of informal networks and new types of users and providers highlights the need to address the growing demand for harm reduction services while upholding quality.

Despite its lateness, the guidelines recently developed for the treatment of people using illicit substances in Mauritius are a good start in the provision of low-barrier care and Universal Health Coverage. However, the implementation and transparent monitoring of these guidelines, together with complementary mechanisms against repression, such as the Drug Users Administrative Panel and the provision of MST in healthcare settings, remain key elements to end AIDS by 2030. Comprehensive HR monitoring would involve assessing the extent of informal networks to reduce health hazards but also to assess their impact. This could potentially help to reduce the waste of resources following the inappropriate use of equipment and substitutes observed in parallel.

Involving peers in the design and implementation of HR services as well as studies could also create positive feedback loops within the system while promoting community-based participatory research. Collaborative research, which takes the HR client’s perspective and explores existing interventions and innovations instead of fostering sub-sectoral ideologies, should be conducted regularly in countries aiming to achieve Universal Health Coverage. Informal networks are also likely to emerge in neighbouring countries offering needles and syringes, opioid agonist therapy and detoxification concurrently. Our findings may also inform the design of services in countries like Madagascar, where HR services are being expanded. Specific sub-target populations who could benefit from additional community-based participatory research in HR include women, those below the legal age and polydrug users.