South Africa has the world’s largest HIV treatment programme, and has made considerable progress towards the UNAIDS goal of 90-90-90, but key populations face barriers in accessing prevention, treatment or services. (Photo: Aurum Institute)
End inequalities. End AIDS. End pandemics.
While organisations such as UNAIDS acknowledge that tremendous strides have been made since the first recorded AIDS case in 1981, the world is still far away from ending the HIV pandemic. The theme for World AIDS Day 2021 is End Inequalities. End AIDS. End pandemics. Advocacy organisations agree that to end the duel pandemic the world faces, complacency must end and the inequalities fuelling both HIV and Covid-19 must be tackled.
Since 1988 World AIDS Day has been commemorated each year on 1 December, providing the opportunity for every community to join hands and unite in the fight against HIV, while showing support for those who still live with HIV and remembering those who died.
HIV/AIDS remains one of the most serious health concerns in South Africa. According to 2019 statistics from the United Nations, South Africa has the highest number of people living with HIV in the world, and at 19% has the fourth-highest adult HIV prevalence for adults aged 15-49. Eswatini has a HIV prevalence rate of 37%, and both Lesotho and Botswana have a 25% HIV prevalence rate. Experts, however, say it is important to note that HIV prevalence does not necessarily indicate that a country has an AIDS crisis; HIV prevalence is an indication that people remain alive despite their infection.
The opening act of the HIV and AIDS pandemic that played off in the 1980s and 1990s sounds familiar — illness, fear and death, as the world faces a new and unknown virus. Fast forward 40 years and a diagnosis of HIV is no longer the death sentence that it once was. Due to scientific advances, which include the development of antiretroviral drugs, people with HIV have been able to access treatment and live long and happy lives.
South Africa has the largest HIV treatment programme in the world, and has proved over and over again that with the correct medication HIV is a manageable chronic condition, not unlike hypertension or diabetes. The treatment programme, launched in the early 2000s, has seen the country’s HIV statistics change drastically since its implementation. Since the national antiretroviral therapy programme was rolled out, the country’s life expectancy has risen by almost 10 years.
Executive Director of UNAIDS, Winnie Byanyima, says world leaders must be courageous when it comes to matching words to actions: “There’s no choice to be made between ending AIDS and preparing for future pandemics; only the successful approach will achieve both. As of now, we are not on track to achieve either. If we take on the inequalities that hold back progress, we can deliver on the promise to end AIDS by 2030.”
She adds that without the inequality-ending approach needed to end AIDS, the world will also not be able to end the Covid-19 pandemic, and will not be prepared for the pandemics of the future. “And that would be profoundly dangerous for us all,” she warns.
Australia’s UN Ambassador Mitch Fifield pointed out that existing HIV infrastructures have been instrumental in both detecting and preventing Covid-19 globally. A core principle of the UN’s 17 Sustainable Development Goals (SDGs) — and of the AIDS response — is that no one should be left behind. The South African Human Rights Commision (SAHRC), in a statement, acknowledges that the Covid-19 pandemic has threatened the progress that the world has made in health and development over the past 20 years, including the gains we have made against HIV.
It says: “The Commission has noted that many people living with HIV and AIDS could not access healthcare facilities and, consequently, their HIV treatments during the Covid-19-related lockdown in South Africa. Gender inequality, racial inequality, social and economic inequalities have been exacerbated by the pandemic, and thus globally we see the emergence of a more unequal world.”
Despite the stark statistics, the SAHRC notes the massive progress that the state has made in addressing the prevalence of HIV within South Africa. “South Africa is making good progress towards the UNAIDS 90—90—90 (90% of all people living with HIV will know their HIV status, 90% of all people with diagnosed HIV infection will receive sustained treatment, and 90% of all people receiving treatment will have viral load suppression) targets, particularly with regards to testing and viral suppression.
“In 2018, 90% of people living with HIV were aware of their status, of which 68% were on treatment. Of those diagnosed and on treatment, 87% were virally suppressed,” the statement reads. “For the Commission, World AIDS Day highlights the intricate link between human rights and the prevalence of HIV. Socioeconomic disparities, poverty, unemployment, inequality on the basis of sex and gender — particularly for women — places an inordinate burden on certain segments of the population.”
While addressing issues like access to healthcare and life-saving antiretroviral treatments are important, the South African government also says that an important part in the fight against HIV and AIDS is addressing the stigma and discrimination that is still rife in many communities. According to former president Nelson Mandela: “Many people suffering from AIDS are not killed by the disease itself, but are killed by the stigma surrounding HIV and AIDS.”
In a statement, the South African government calls on all South Africans to recognise that regarding HIV, AIDS and chronic diseases: “Stigma and discrimination can be as devastating as the illness itself and may mean abandonment by a partner or family, social exclusion, job and property loss, school expulsion, denial of medical services, lack of care and support, and violence for those affected by them. These consequences, or fear of them, mean that people are less likely to come in for HIV testing, disclose their HIV status to others, adopt HIV-preventive behaviour or access treatment, care and support.
“We each have a responsibility to treat those who are struggling with an HIV-positive diagnosis with compassion, those struggling with AIDS with care, and ourselves and our sexual partners with respect. Addressing stigma and discrimination is important in mitigating the impact of HIV.”
Predatory male behaviour threatens fight against HIV: Tekano
As the world recognises World Aids Day on 1 December 2021, 40 years after the first AIDS cases were reported, much has changed in the world and South Africa has indeed made great progress in tackling the HIV pandemic.
Patrick Mdletshe, a Lifelong Fellow at Tekano and national deputy chairperson of the Treatment Action Campaign (TAC)
“South Africa has made huge strides in the fight against HIV. All of our aspirations are captured within the National Strategic Plan, which lays out how we are responding to HIV, AIDS and tuberculosis,” says Patrick Mdletshe, a Lifelong Fellow at Tekano, National Deputy Chairperson of the Treatment Action Campaign (TAC) and Head of the CAPRISA (Centre for the AIDS Programme of Research in South Africa) Community Programme.
While much progress has been made, structural inequalities — which have worsened in the decades since South Africa’s widespread prevention campaigns began in the early 1990s — continue to obstruct HIV prevention and treatment efforts.
Tekano, as an organisation situated at the intersection of health and social justice, is keenly aware of the ways in which the Covid-19 pandemic — and the nation-wide lockdown — exacerbated existing socioeconomic inequalities, as well as the crises of poverty, unemployment and deeply-entrenched racial divides. The pandemic has subjected those already vulnerable — women, children, people with disabilities and gender-non-conforming individuals — to further victimisation and economic disempowerment.
Tekano was also aware that the pandemic would, inevitably, have an impact on the sexual and reproductive health and wellbeing of women and girls, and drive sexually transmitted infections, including HIV.
The crime statistics released by Police Minister Bheki Cele on 21 November 2021 have vindicated the worst — but not entirely unexpected fears — of those of us who work for social justice and for whom “health” is much more than being the “absence of disease”, but the total economic, social and environmental wellbeing of all South Africans.
The rape statistics and the high rate of child rape, which often leads to children getting pregnant, are cause for national concern. While we have managed to put 6.4-million HIV-positive people on antiretroviral therapy (ART), treatment without concerted efforts to prevent new infections — including preventing the rape of women and girls — will be to no avail.
Thirteen thousand of the 73 000 cases of assault reported between July and September were domestic-related, and the rate of child murders has climbed by nearly a third. These statistics illustrate that South Africa is not doing enough to help women, especially young women and children, to prevent HIV infection.
How do we claim success when 10- to 14-year-olds are giving birth to children? Why is there no uproar, and why are we not seeing all perpetrators of child rape brought to book and made to account? What silences us? What enables us to call it “teenage pregnancy” and not “predatory male behaviour” that is putting the children of South Africa at risk?
The pandemic of violence against women and children in South Africa is one of the biggest structural obstacles in the attainment of health and wellbeing for women, children and other vulnerable groups; and in the country’s efforts to combat the spread of HIV.
“Health and justice are interrelated, interdependent, and indivisible human rights,” says Tekano Chief Executive, Lebo Ramafoko.
“An equitable society is one in which justice has been served — and justice is served when health disparities are not entrenched by structural social advantage or disadvantage.
“The current scourge of violence against women and girls and other vulnerable groups, coupled with rising inequalities among key and vulnerable population groups, and the impact of the global pandemic, bring a renewed sense of urgency to address the entrenched structural and socioeconomic inequalities driving HIV, including the wide-spread male predation driving GBV [gender-based violence] and HIV infections,” adds Ramafoko.
For more information, please call Bongani Maseko on 061 545 9425 or visit www.tekano.org.za
Collaboration key to SA’s HIV/AIDS response
When it comes to South Africa’s HIV/AIDS response, collaboration is key to ensure that no one is left behind. This was the main takeaway from the Health Implementing Partners Group (HIP-G) conference that was held ahead of World AIDS Day in November this year.
To strengthen community support approaches to promote uptake of services, there was an increase in the availability of self-testing and rapid test screening in non-health settings, given that “traditional” testing clinics were re-prioritised to provide care for Covid-19. (Photo: The Aurum Institute)
HIP-G, a forum established by a collective of health implementing partners supporting the National Department of Health, convened to take stock of the current AIDS programme status, including the impact of the Covid-19 pandemic on HIV and the country’s HIV responses.
South Africa has made considerable progress towards the UNAIDS goal of 90-90-90 (90% of all people living with HIV will know their HIV status, 90% of all people with diagnosed HIV infection will receive sustained treatment, and 90% of all people receiving treatment will have viral load suppression), but this is not enough.
Speaking at the webinar, Celeste Madondo from the South African National AIDS Council (SANAC) told attendees that despite the strides that have been made, South Africa still has the highest HIV burden globally, with around eight million of the country’s 60-million residents living with HIV. The country also ranks amongst the top 30 high-burden countries for drug-sensitive tuberculosis (TB), drug-resistant TB and for TB/HIV comorbidity. She emphasised that high rates of HIV infection, coupled with social and structural inequalities, continue to drive the country’s TB burden; South Africa alone accounts for 3.6% of the global TB burden. Other STDs, she added, have a high prevalence but are neglected.
This neglect has been exacerbated by the advent of Covid-19, which took the country and the world by surprise, and has had a far-reaching impact on every aspect of life, health and social interaction. Understandably, she said, Covid-19 has become the primary health priority globally — but this does not mean that other areas of concern should be forgotten, lest we lose the valuable progress that has been made. The coronavirus outbreak has led to decreased health access for many of South Africa’s most vulnerable populations, and has seen a decline in routine HIV and TB testing and treatment initiation.
Firstly, she said, condoms were classified as “non-essential” at most retail outlets during the country’s lockdowns, which impacted on the overall distribution. Health resources, including health workers, were diverted from other areas and deployed to assist in the fight against Covid-19. The diagnostic and laboratory capacity needed to support the detection of HIV and
TB was severely reduced, with the molecular diagnostic tools for TB being repurposed for Covid-19. Fewer people attended clinic appointments, either because of facility closures or because of fear of contracting Covid-19 if they visited the clinic. This also drove high levels of defaulting on medications.
These, said Madondo, are just some of the factors which have led to further delays in achieving the targets and goals set out by the National Strategic Plan (NSP), a 2017-2022 roadmap towards a future where HIV, TB and STIs are no longer public health problems.
The Covid-19 pandemic, she added, have also exacerbated factors that make people more vulnerable to infections, such as unemployment, food insecurity (which impacts on medication adherence), increased gender-based violence (GBV) and sexual violence, compromised child safety and decreased sexual education because of school closures.
According to SANAC, several key priorities need to be addressed if South Africa is to get back on track, namely: integrating GBV into the HIV response; putting communities at the centre of the HIV, TB and STI responses; addressing social inequalities that continue to impact behaviours; identifying game changers for adaptation; and addressing stigma, discrimination and human rights violations against key vulnerable populations.
The conference also aimed to get a clearer perspective from civil society based on community-level monitoring, as well as share good practices from 90-90-90 while sharing ideas about how to escalate interventions to rapidly achieve the new goals of 95-95-95.
PEPFAR (US President’s Emergency Fund for AIDS Relief) said that of the eight million South Africans living with HIV, 7.4 million know their status and 5.5-million are receiving treatment. Unmet antiretroviral treatment (ART) needs remain the largest barrier to achieving 95-95-95 in South Africa.
Ritshidze (which in Venda means Saving our Lives) is a partner advocacy organisation developed by people living with HIV and activists to hold the South African government and aid agencies accountable to improve overall HIV and TB service delivery. The organisation’s Ndivhuwo Rambau said that while South Africa has the world’s largest HIV treatment programme, poor quality services continue to undermine its responses, adding that key populations face additional barriers in accessing prevention, treatment or services.
Rambau said the failure to make sufficient progress towards the 95-95-95 targets can be linked directly to the crisis in South Africa’s clinics and the poor quality of public healthcare services nationally. Staff shortages, personnel attitudes, lack of resources, long waiting times and unextended clinic hours are among some of the challenges reported by patients and clinic managers.
Dr Tshepo Molapo is the HIV, AIDS & STIs Strategic Information Manager at the National Department of Health. Addressing attendees, he acknowledged that Covid-19 has disrupted essential health services, further undermining programmes addressing HIV and other global health priorities. Despite this, however, he added that the Covid-19 crisis also presented the opportunity to do things differently, through innovative interventions and the upscaling of service provisions.
The lack of progress is not unique to South Africa, however. In her presentation, Eva Kiwango from UNAIDS laid out the statistics: in the 40 years since the first AIDS case was detected, there have been 79-million people infected with HIV and 36-million people have died from AIDS; there are believed to be around 38-million people currently living with HIV.
It is evident that new HIV infections are declining globally, but not fast enough. In 2020 there were 1.5-million people newly infected with HIV — three times higher than the target of 500 000 people for that year. AIDS deaths, Kiwango said, are also declining, but again not fast enough. In 2020 there were 680 000 AIDS-related deaths, exceeding the target of less than half a million deaths globally. Not a single region achieved the target of a 75% reduction in new infections or AIDS-related deaths from 2010.
Kiwango added that the Global AIDS Strategy for 2021-2026 would be in line with the theme of this World AIDS Day: “End inequalities. End AIDS. End pandemics”. Only by addressing the inequalities that continue to plague the most vulnerable of populations will South Africa and the world manage to effectively end the double pandemics that currently plague society.
For this to happen, experts and advocacy organisations agree with PEPFAR — a tailored approach is needed to address the needs of different groups, populations and communities. And for this tailored approach to be successful, collaboration is key. Only by working together can the world end inequality, end AIDS and ensure that no one is left behind.