Trust, Stigma and Policing in Needle and Syringe Programme Access in Tshwane, South Africa: A Qualitative Study

Abstract Needle and syringe programmes (NSPs) reduce HIV and hepatitis C transmission among people who inject drugs (PWID), but their effect depends on the urban environments in which they operate. Evidence on how PWID experience NSPs in African cities, where homelessness, informal settlements and policing shape daily life, is limited. This qualitative study explored how PWID experienced NSP access and effectiveness in Tshwane, South Africa. Four focus-group discussions were conducted in 2023 with 31 PWID (24 men, seven women) purposively recruited from four sites of a community-oriented primary care-based harm-reduction programme serving the inner city, a suburban area, a township and an informal settlement. Data were analysed using reflexive thematic analysis informed by social constructivism and the risk-environment framework. Participants valued the NSP for sterile equipment, education and linkage to opioid agonist therapy. Three processes shaped these benefits. First, consistent peer and service interactions produced trust and programme legitimacy, whereas inconsistent distribution and perceived diversion weakened both. Second, fixed allocations of 15 syringes that did not match injection frequency, combined with weekend service gaps and peer obligations, converted supply constraints into syringe reuse and sharing. Third, stigma and policing made access spatially uneven: confiscation in public space undermined the return-based exchange model, particularly for participants experiencing homelessness and those in informal settlements. NSP effectiveness was socially and spatially produced rather than determined by service availability alone. Needs-based supply, decoupling supply from return, and coordinated engagement with municipal police are required for NSPs to protect the most exposed urban PWID.