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BRIEF REPORT
Whoonga and the Abuse and Diversion of Antiretrovirals
in Soweto, South Africa
Kathryn Rough •Janan Dietrich •Thandekile Essien •
David J. Grelotti •David R. Bansberg •
Glenda Gray •Ingrid T. Katz
Springer Science+Business Media New York 2013
Abstract Media reports have described recreational use
of HIV antiretroviral medication in South Africa, but little
has been written about this phenomenon in the scientific
literature. We present original, qualitative data from eight
semi-structured interviews that characterize recreational
antiretroviral use in Soweto, South Africa. Participants
reported that antiretrovirals, likely efavirenz, are crushed,
mixed with illicit drugs (in a mixture known as whoonga),
and smoked. They described medications being stolen from
patients and expressed concern that antiretroviral abuse
jeopardized the safety of both patients and users. Further
studies are needed to understand the prevalence, patterns,
and consequences of antiretroviral abuse and diversion.
Keywords Antiretroviral diversion Recreational
antiretroviral abuse Whoonga Efavirenz South Africa
Introduction
Since 2008, scattered media reports have described a mul-
tidrug cocktail known as ‘‘whoonga’’ being smoked by
individuals in South Africa. Whoonga is suspected to contain
illicit substances (marijuana, methamphetamine, and/or
heroin), household products (detergent or rat poison), and
antiretroviral medications [1–4]. Several news articles
mention efavirenz, in particular, is being used recreationally
[1,5], and there are reports of HIV-positive patients being
robbed or selling their drugs on the black market [1].
However, the phenomena of recreational antiretroviral
use has not been well documented in the scientific literature
[6]. Grelotti and colleagues’ recent findings from a quali-
tative study in Durban, South Africa provide important
insights into the use of whoonga and its potential conse-
quences [7]. This brief report complements their findings,
presenting original qualitative data that further documents
recreational antiretroviral use in Soweto, South Africa.
Methods
Between March 2012 and February 2013, semi-structured
interviews with 43 purposively sampled, HIV-positive,
treatment-eligible adults in Soweto, South Africa were
conducted to better understand decision-making regarding
treatment refusal. Participants were asked general ques-
tions about their perceptions of antiretroviral treatment; no
scripted questions were asked about drug or antiretroviral
abuse. The 43 interviews were conducted, transcribed, and
K. Rough D. J. Grelotti
Department of Epidemiology, Harvard School of Public Health,
Boston, MA, USA
K. Rough I. T. Katz (&)
Division of Women’s Health, Brigham and Women’s Hospital,
1620 Tremont Street, 3rd Floor BWH, Boston, MA, USA
e-mail: ikatz2@partners.org
J. Dietrich T. Essien G. Gray
Perinatal HIV Research Unit, Soweto, South Africa
D. R. Bansberg I. T. Katz
Harvard Medical School, Boston, MA, USA
D. R. Bansberg I. T. Katz
Massachusetts General Hospital Center for Global Health,
Boston, MA, USA
D. R. Bansberg
Ragon Institute of Massachusetts General Hospital, Boston, MA,
USA
123
AIDS Behav
DOI 10.1007/s10461-013-0683-x
(when necessary) translated by trained, multilingual inter-
viewers. Interview transcripts were coded according to
inductively identified themes and analyzed using N-Vivo
software (Version 10). All references to whoonga, anti-
retroviral diversion, or antiretroviral abuse were reviewed
for this analysis. The University of Witwatersrand Human
Research Ethics Committee in Johannesburg and the
Partners Institutional Review Board in Boston provided
ethical approval for this study.
Results
Of the 43 participants interviewed, eight participants spon-
taneously discussed recreational antiretroviral abuse and
diversion without probing from the interviewer. These eight
participants were all South African nationals who ranged in
age from 24 to 50. Four were male, seven had a high school
education or less, and six reported being unemployed. Four
interviewees reported being of Zulu ethnicity, two were
Sotho, one was Tsonga, and one was Xhosa.
Participants reported that antiretrovirals were being
crushed, mixed with illicit drugs, and smoked for their
psychoactive effects:
Other people smoke [antiretrovirals] within our
community. It’s a drug. They crush it, crush until it’s
fine, then they mix it with something called ‘‘skets.’’
Skets [are] the crumps of dagga [marijuana]. And
then they smoke that thing like dagga. This is a drug.
They become paranoid and high.
One participant acknowledged that only certain antiret-
rovirals were being diverted, saying, ‘‘They are not taking
them all […] but I don’t know which tablets they take and
which ones they don’t.’’ Another participant identified
Stocrin—the brand name for efavirenz—as the antiretro-
viral people were abusing.
Participants reported that antiretrovirals were being
stolen from HIV-infected patients on treatment and then
sold for recreational use:
People who take [antiretrovirals] have the problem
of drug dealers. They rob people because they know
about their appointments and take their treatment.
[…] Older men send youngsters to steal the pills,
even in the house. They sell the pills. So we had a
meeting in the past three weeks as a community, and
discussed a way to approach the government, a way
to protect these people because they should not
default on medication.
Furthermore, abuse of antiretrovirals was perceived as
putting both abusers and patients at risk:
They are misusing tablets for the sick people. People
are sick and running short of tablets and they are
taking the [antiretrovirals] and making the whoonga
and smoking it. The minute they smoke these drugs,
many people die. People are dying.
Discussion
This report provides the first qualitative evidence of recre-
ational antiretroviral use in Soweto, South Africa. Multiple
study participants spontaneously described the phenomenon
of antiretroviral abuse, though these responses were com-
pletely unprompted by the interviewer. This independent
report of recreational antiretroviral use in Soweto—350
miles from where Grelotti and colleagues collected data
[5]—further substantiates the phenomenon of recreational
antiretroviral use in South Africa.
Consistent with the findings of Grelotti and colleagues,
our data suggest that recreational abuse of efavirenz may be
occurring in South Africa [5]. Efavirenz is known to have
neurological and psychiatric side effects and has activity at
5-HT2A receptors of the brain, similar to LSD [8]. Further,
case reports of intentional efavirenz overdose describe visual
hallucinations, impaired motor ability, manic episodes, and
‘‘feeling high’’ [9,10]. Reports of efavirenz abuse from
interviews with HIV-positive patients in the Western Cape
[11] and club-drug users in Miami [12] provide additional
evidence for the plausibility of efavirenz’s abuse liability.
To the best of our knowledge, this is also the first scientific
report to document that the source of antiretrovirals used to
make whoonga may be from medications distributed to HIV-
infected persons. South Africa has the largest antiretroviral
therapy program in the world, with approximately 1.7 mil-
lion people receiving treatment [13]. The abuse of antiret-
roviral medications could have implications for the health
and safety of these patients, as well as for those who abuse
antiretroviral medications. Additional research and moni-
toring of the country’s recently introduced a single-pill fixed-
dose combination of efavirenz, emtricitabine/lamivudine,
and tenofovir may be warranted, to ensure diversion and
abuse do not occur.
This study’s small sample size and qualitative design
limit the inferences that can be drawn from this data.
However, alongside the findings of Grelotti and colleagues
[5], these findings highlight the need for larger, epidemi-
ologic studies to quantify the prevalence, patterns, and
consequences of antiretroviral abuse and diversion, as well
as its effects on both patients and abusers.
Conflict of interest We have no conflicts of interest to declare.
AIDS Behav
123
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