Now I am not scared of testing for HIV

THABO MOLELEKWA writes: When Samkelisiwe Chiliza from Durban heard about Pre-Exposure Prophylaxis or PrEP, she did not hesitate to join the PrEP study through the Centre for Aids Programme and Research in South Africa (Caprisa).

PrEP is the use of anti-HIV medication to keep HIV negative people from becoming infected. PrEP has been shown to be safe and effective in clinical trials that have taken place in many countries, including South Africa, and is approved by the South African Medicines Control Council (MCC). Taken as a single pill once daily, it is highly effective against HIV when taken every day. The medication interferes with HIV’s ability to copy itself in one’s body after one has been exposed. This prevents HIV from establishing an infection and making one sick.

Samkelisiwe is one of the young women who are currently on PrEP in South Africa and she is encouraging other young women to participate in one of the PrEP projects taking place around the country  so that they can help stop the spread of HIV and keep themselves safe.

“I have been taking one pill every night for the past 14 months and I am not willing to stop as I am saving my life,” said Samkelisiwe, adding that she is not scared of testing for HIV because she knows what results to expect since she is on PrEP.

According to Samkelisiwe, many young women are already infected and are not eligible for PrEP as it is only for HIV-negative people.

“Lots of people don’t know about these kind of studies but I do spread the word as much as I can,” she said.

She said that her grandmother was happy to hear that she is taking a pill to protect herself from contracting HIV.

According to Professor Linda-Gail Bekker of the Desmond Tutu HIV Centre, PrEP is a prevention option, not a treatment. It works properly when taken correctly and consistently, but that, currently, only 13,000 people who are receiving PrEP from the government. These are sex workers and men who have sex with men. And there are only 1,387 people who are taking PrEP through demonstration projects run by various organisations.

Prof Bekker said that, while PrEP is not yet widely available, “there is advocacy going on to make sure that the government rolls out PrEP to everyone who needs it.”

The high cost of PrEP is what stops the government from rolling it out to everyone who needs it. Currently, there are only two ways to access PrEP – “People can buy it at a chemist or they can join the demonstration projects that are taking place in the country,” added Bekker.

Bekker said that educating people in the communities about PrEP is important because that will give them knowledge of what the intervention is so that they can make decisions about protecting themselves from HIV and preventing the spread of the disease.

According to World Health Organisation guidelines, PrEP is rolled out to people at substantial risk of contracting HIV. Deborah Baron of Wits Reproductive Health and HIV Institute (WRHI), believes that in South Africa, PrEP should also be rolled out to young women because 7,000 young women become newly infected with HIV every week in Eastern and Southern Africa.  “And a third of those women are right here in South Africa.” Said Baron.

Baron said that in order to make PrEP interesting for young women there is a need for youth-friendly PrEP delivery models and tools. “We need to be responsive to realities of young women’s lives.”

In late 2015, the South African Department of Health developed policy and guidelines for oral PrEP as well as test-and-treat implementation to protect groups at high risk in line with World Health Organisation guidance. The ARV drug,  TDF/FTC, was approved for use as PrEP by the Medicines Control Council.

 The National Department of Health, together with the implementing partners, like Baron’s organization, continue to work together to move PrEP forward and get it to the people who most need it. Individuals like Chiliza who take PrEP and talk about it their peers are helping to expand an important HIV prevention option for South Africans.

New strategic plan to support the LGBTI community

BULELWA MAPHANGA writes: The South African National Aids Council (SANAC) has produced South Africa's first comprehensive LGBTI HIV plan, launched by  the Premier of KwaZulu Natal, Senzo Mchunu and SANAC co-chairperson, Steve Letsike.

The plan was created by the LGBTI sector, workers' sector and civil society to deal with HIV, STIs and TB. It recommends a full range of interventions.

SANAC had come under fire from civil society organisations at the conference for  merely paying lip service” to vulnerable communities such as LGBTI "without allocating resources or setting objectives and targets for the delivery of services.” 

At the launch, Steve Letsike said: "It took us almost 10 years to come up with this strategic plan for the LGBTI community. We need to acknowledge the LGBTI community to say to the rest of the world that we are starting to be inclusive.

"HIV, STIs and TB also affects us as the LGBTI community. This plan is for us and about us, it will ensure that our rights are also taken into consideration," said Letsike.

 Despite our progressive constitution protecting the rights of LGBTI community, discrimination is still severe. Many LGBTI face social exclusion, violence, targeted discrimination, negligence and even murder.

Many LGBTI avoided public health services, fearing discrimination, judgement and lack of confidentiality.

"There is an urgent need for services that are designed for them and health is just the start. Many other public services need to consider the needs of the LGBTI community," she said

One of the main objectives of the plan is reduce HIV by 63%,STIs by 70% and TB by 30%. 

Fareed Abdullah on 'missed opportunities' in the National Strategic Plan

ASHLEIGH FURLONG writes: There are many “missed opportunities” in the National Strategic Plan (NSP) for HIV and TB, said Fareed Abdullah, the head of AIDS and TB research at the Medical Research Council and former SANAC CEO, at the closing of the South African AIDS Conference.

The NSP has been criticised by a number of civil society groups and this has culminated in two demonstrations being held during the conference – one by a general group of activists and another by sex worker activists.

At a press briefing on the closing day of the conference, the South African National AIDS Council (SANAC) defended the NSP, saying that while it was “imperfect”, it had incorporated viewpoints from many sectors of society. SANAC largely blamed the critique of the plan on individuals and organisations who were unhappy with their loss of leadership in SANAC and the transformation that was taking place within its structures. They also rejected claims of corruption within the council.

“We now know that we cannot treat our way out of this epidemic,” said Abdullah. Rather, prevention interventions would be the answer, where the social and structural drivers around HIV were focussed on.

He said that a lot of work would need to be done to find the “sweet spot” of how much money should be invested in specific interventions such as the contribution of gender-based violence to HIV transmission, the role of alcohol as well as social factors such as hunger.

While the NSP provides a “good broad framework”, there are areas that are lacking, believes Abdullah. However, he said that there is still the possibility of improving the NSP.

One of Abdullah’s concerns is that the “toolbox” provided in the NSP “doesn’t match the impact that we’re looking for”. The NSP aims for a 37% reduction in new HIV infections by 2022.

He said that there is the need for a prevention agency that has substantial resources, a large reach and is able to implement multiple programmes at community level.

“But at the moment we don’t really have an agency with the wherewithal, the authority and the institutional capacity [to do this].”

While there were “many steps forward on TB”, Abdullah said that “TB is nothing short of a national crisis”.  A crisis that he believes needs to be addressed through leadership, management, logistics and an investment in drugs.

“It needs nothing short of a revolution in a short space of time,” said Abdullah.

As for the NSP’s much-talked about failure to include a recommendation for the decriminalisation of sex work, Abdullah said that this was another “missed opportunity”.

Low targets were set for pre-exposure prophylaxis (PrEP), something that could be rapidly scaled up for key population groups such as sex workers, men who have sex with men and transwomen, said Abdullah.

“For 20 years [we] have always said that key populations are not essential but I think [we have] been proven to be fundamentally incorrect about that.”

He also warned about drug use becoming a major contributor to HIV transmission in the next five years.

SANAC hits back

ASHLEIGH FURLONG writes: The South African National Aids Council (SANAC) has rejected claims of corruption and that there is a lack of confidence in the council.

SANAC civil society leaders responded today at the South African National AIDS Conference to a statement signed by five civil society organisations who alleged that SANAC has a “crisis of governance and legitimacy”. These organisations also said that the National Strategic Plan (NSP) for HIV and TB had various omissions and failed to provide “much-needed direction and leadership”.

SANAC guides and coordinates the writing of the NSP that deals with the period of 2017 to 2022.

The organisations who signed the statement are the Treatment Action Campaign (TAC), SECTION27, Legal Resources Centre (LRC), Masithandane End-Hate Crimes Collective and Rural Health Advocacy Project (RHAP).

Speaking to the media during the South African National AIDS Conference, the co-chairperson of SANAC’s civil society forum, Mabalane Mfundisi, called the NSP a “perfect imperfection”. He said it was a “culmination of many different voices” and that all these voices were reflected in the NSP.

If anyone wanted to question the legitimacy of the make-up of SANAC, Mfundisi said they should go to the IEC as it ran the election process.

The chairperson of SANAC’s National Civil Society Forum, Steve Letsike, said that “due processes” were followed. She said that the “root cause of the problem was about the power of resources” and that members of civil society are malicious and “violate each other”.

“Today we say this must come to an end.”

Referring to allegations that she was involved in corruption at SANAC, Letsike said “bring the evidence”.

“Tell me where I have at all been corrupt in SANAC. If you can’t bring that evidence, stop abusing us,” she said.

As for the R240,000 that was allocated to the office of deputy chair of SANAC (a position that Letsike also holds), Letsike said that this money was used to pay for things such as refreshments and administration. She didn’t receive this money, said Letsike, as her position was voluntary.

She was also questioned about not signing a declaration of her interests. Letsike said that she had delayed signing the declaration because she had unanswered questions regarding it, but that she has since signed it.

Mbulelo Dyasi, the secretary general of the Men’s Sector at SANAC, then questioned where and on what, money was spent in the AIDS sector. He called on Parliament and the Public Protector to assist them as they “must investigate the entire AIDS sector”.

“Who is funded and where is that money going to?” asked Dyasi. “They must tell us why only four white organisations are funded in South Africa, yet AIDS is black,” he said.

Jacqueline Bodibe, part of the Global Fund Coordinating Mechanism, said that a sex worker had been intimidated to prevent her from participating in the media briefing by an organisation that was “supposed to be protecting workers”. It is unclear which organisation she was referring to.

Bodibe said that it didn’t mean that if one was no longer in leadership at SANAC, things weren’t working. This was reiterated by a number of those from SANAC.

The leader of the Women’s Sector at SANAC, Khanyisa Dunjwa said: “The activism space is becoming a space of the privileged. [We] see ourselves fighting the different levels of the privilege.”

She also alleged that some people who belonged to organisations who signed the statement didn’t even know about the statement’s existence.

Improved HIV services for schools

THABO MOLELEKWA writes:  Access to HIV services has been made easier for school-going children and basic education employees thanks to a new national policy by the Department of Education.

The policy, launched by the Deputy Minister of Basic Education, Mohamed Enver Surty, emphasizes access to information on prevention, counseling, testing, treatment, care and support, as well as active referrals where necessary.

This means that learners, educators, school support staff, and officials living with or affected by HIV, STIs and TB in the basic education sector will have access to an essential and holistic package of health and social services.

However, speaking on the sidelines of the launch, the Director of the Catholic Health Care Association of South Africa Yvonne Morgan, said the youth in schools should be allowed to make decisions on what they want, based on what they know.

“I think peer education is also going to play a role in schools because peers trust what they hear from each other,” Ms Morgan said adding that, for the policy to succeed, the department should cultivate peer educators in schools.

The Treatment Action Campaign (TAC), which has so far unsuccessfully advocated condom availability in schools, criticized the policy for being top-down rather than bottom-up.

Speaking for TAC, Ms Portia Serote said, “This is a top-down approach. Young people at the ground level, who are faced with a lot of challenges regarding HIV, were not involved in developing this policy.”

She said Mr Surty did not explain what the department means by comprehensive sex education. “We don’t know if condoms will be provided in schools or not,” she added.

She also criticized the formation of “adherence clubs” for HIV in schools. “This will violate the rights of young boys and girls as everyone will conclude that those attending the club meetings are HIV positive,” said Ms Serote.

However, Mr Surty said the policy, which is aligned to the 2017-2022 National Strategic Plan on HIV, STIs and TB for South Africa, was developed through a participatory consultative process with stakeholders inside and outside the basic education sector.

He added, “We will train teachers on new approaches as well as on life sexuality education to enable them to provide student-friendly classes and advice."

Sex workers protest during Ramaphosa's speech

ASHLEIGH FURLONG writes: Sex worker activists demonstrated during deputy president and chairperson of South African National AIDS Council (SANAC) Cyril Ramaphosa’s speech at the South African National AIDS Conference today, criticising the failure to include decriminalisation in the final National Strategic Plan (NSP) that deals with HIV and TB for the next five years.

“Shame on you SANAC and SA government! Why was the decriminalisation of sex work removed from the final NSP 2017-2022?” read a poster.

Other posters read: “Carry condoms? Go to Jail! South Africa uses condoms as evidence of crime” and “Decriminalise sex work now”.

The demonstrators who are part of the Asijiki Coalition, which includes several civil society organisations, believe that the decriminalisation of sex work is essential for the protection of the human rights of sex workers.  

The latest NSP does not recommend the decriminalisation of sex work. SANAC guides and coordinates the writing of the NSP. The recent release of the long awaited report on sex work from the South African Law Reform Commission (SALRC) was also a disappointment for sex worker activists as it advocated for either continued criminalisation of sex work or partial criminalisation.

In a statement released during the demonstration, the Asijiki Coalition demanded that the NSP be amended by SANAC to include the decriminalisation of sex work.

“Earlier, civil society organisations expressed concerns about SANAC’s efficacy and ability to address the material conditions of the most marginalized sectors of society. The removal of decriminalization of sex work, together with a number of other robust sections on targets and human resources from the final draft of the NSP, are deeply worrying,” said the statement.

During his speech, Ramaphosa said that the contributions made to the NSP are an example “of a strong and successful social compact”. “Through this NSP, many of us right across the length and breadth have succeeded in putting together an effective social compact,” he said.

SANAC, which guides and coordinates the writing of the NSP, has denied that there was ever the recommendation for the decriminalisation of sex work in a draft version of the NSP that was sent to cabinet. This denial came from the co-chairperson of SANAC’s civil society forum, Mabalane Mfundisi, in a media briefing rejecting allegations made against SANAC.

“Our position as civil society has always been that sex work must be decriminalised but it wasn’t included as a call in NSP because we said let the law reform process [go ahead]. SANAC cannot change law in the country. Parliament changes the laws,” he said.

“Our push was to say release the report,” said Mfundisi, referring to the long delay in the release of the SALRC report.

 

Some style tips for conference-goers

Our vaginas are our own affair

THABO MOLELEKWA writes: Dr Tlaleng Mofokeng, 33, has harsh words for those who want to own women’s vaginas. “Everyone has an opinion about the vagina,” she said. Young women in particular, she said,  are constantly judged.

“They are told to keep their legs closed; stay in school: use birth control and say no to blessers. Yet when we ask for services such as contraceptives and abortions, we are criticised."

Dr Tlaleng is the chairperson of the track examining social, political, economic and Health Systems at the 8th SA AIDS Conference in Durban. It was about a decade ago in medical school when Free State-born Tlaleng Mofokeng realised that her interest lay in sexual health care, reproductive health care and ethics and rights. She now a runs medical practice in sexual health  at DISA clinic in Sandton, Gauteng.

She is also widely known for her Sunday Times column on reproductive health and her no-nonsense radio slot on the same subject on Khaya FM.

Every week, around 2000 young women are infected with HIV. But most of the HIV prevention campaigns are male-centred. Female condoms are not really available, for example, says Dr Tlaleng. “When having sex, we must wait for the man to put on a condom. Yet we are the ones who are a higher risk of getting infections.”

Dr Tlaleng  believes that the policies on HIV and STIs in schools are not implemented correctly. "They talk mainly about abstinence instead of talking about other prevention methods. There are young people right now who are HIV (positive) in school and no one is talking to them.” 

Dr Tlaleng is also concerned that young people born with HIV have very little information about how to disclose their HIV status to their partner.

“During my last year in medical school I launched the first youth friendly clinic as a ground breaker in Matatiele.” Said Dr Tlaleng  “And with support from my University  we did a very good job to ensure that the young people there were connected to  other people in terms of institutional support."

  

Eighty five per cent of patients on ARVs have got the virus under control

ASHLEIGH FURLONG writes: A massive study has shown that about 85% of patients on antiretrovirals had got the virus down to acceptable levels. Those who had higher levels of the virus in their blood tended to be male and/or patients who were children or adolescents at the start of antiretroviral treatment.

Dr Dvora Joseph Davey from BroadReach Healthcare and the University of Cape Town described a study that looked at the factors associated with unsuppressed viral load in patients with HIV and on the “first line” of antiretroviral treatment (ART) in South Africa.

An unsuppressed viral load is when a patient is on ART but the treatment doesn’t bring the levels of HIV down to an acceptable level. This means they are more likely to die at a younger age and can pass on the virus to others more easily. First line treatment refers to the medicines that a patient is put onto first. If the treatment doesn’t work they may need to be put onto what is called “second line treatment”, which consists of a different set of medicines.

The study looked at all patients’ files who were on “first line treatment” for more than six months between January 2004 and were still on treatment by April 2016.

There were 244,370 patients in the study, with only 15% of them (37,487) being virally unsuppressed. The patients in the study were from 271 public health facilities in four different provinces. The most recent viral load result had to be unsuppressed for the patient to be classified as such.

The fact that 85% of these patients were virally suppressed is good as it is close to the national target of 90%.

Joseph Davey also found that patients with a low CD4 count (a measure of the strength of the immune system) at the start of treatment and those on TB treatment had higher odds of being virally unsuppressed. An additional factor increasing the odds of an unsuppressed viral load was being on treatment for either between six months and a year or over five years.

Joseph Davey called for a re-evaluation of policies and guidelines on the initiation of treatment in adolescents, children and men. She also said that there needs to be specific interventions for patients identified as at high-risk of having unsuppressed viral loads.

One example was changing adherence counselling and targeting resistance testing to make sure that those who acquired drug resistance are on the correct treatment regimen.

She said that a limitation of the study was that it was cross-sectional, meaning that it only looked at a specific point in time. She also said that 25% of all the possible patients they could have studied did not have a viral load in their file, meaning that the study could have underestimated the real proportion of patients on ART with an unsuppressed viral load.

Meet Themba, TB's poster boy

CYNTHIA MASEKO writes: Vulnerable populations are the target of a new public awareness campaign to encourage adherence to TB treatment. The campaign, called Sanofi TB Themba, was launched on Wednesday.

Working side by side with public health initiatives, Sanofi, a pharmaceutical company, will take the campaign to the townships, prisons, informal settlements, clinics and hospitals.

According to Neo Molusi, product manager at Sanofi, “The character Themba was created to epitomize the ideal TB patient to help other patients with their own treatment journey.”

Every 18 seconds a person dies from TB; in 2015, 10.4 million new TB cases were diagnosed; and TB is among the 10 leading causes of death worldwide.

“The key messages of the campaign are that TB is curable; it takes six months to complete TB treatment, and what the key symptoms of TB are,” said Mr Molusi.

Mr Molusi also announced that Sanofi is working with WHO to intensify the battle against TB with the aim of eventually eradicating it.

Themba, which means hope in Nguni languages, seeks to give hope to patients and future patients that they too can overcome TB. 

At the launch, Jabulo Zulu, said: “In 2014, I was diagnosed with HIV, and early last year, I had TB of the lungs. I was put on TB treatment immediately and thanks to family support, I completed treatment and the TB was treated successfully.”

A nurse who attended the launch, Ms Zanele Zwane, emphasised that early diagnosis, treatment, healthy eating and support all contribute to the successful treatment of TB. “There is no need for anyone to die from TB or HIV. Let’s work together to end the stigma and discrimination against people with TB or those living with HIV,” she said.

Circumcising babies 'would be acceptable'

ZIZO ZIKALI writes: The department of health in partnership with USAID and The Centre for HIV and AIDS Prevention Studies (CHAPS) are working together to fight the HIV/AIDS epidemic by developing a safe and sustainable service delivery model for early infant male circumcision in South Africa. 

Chief executive officer of CHAPS Dirk Taljaard said CHAPS conducted a study examining the feasibility of early infant male circumcision in Soweto and Orange farm in Johannesburg, Gauteng.  Nearly 70% of 304 urban mothers and 142 fathers showed interest of circumcising their sons before they were six weeks old.

“The study concluded that early infant male circumcision would be acceptable in the country; despite the pull of traditional circumcision during adolescence among certain ethnic groups. However,  there should still be discussions at national, provincial, district and local level as soon as possible.”

There was some dissent. Siyabonga Zulu, a 34-year-old man from Umlazi, south of Durban, believes that circumcising a minor would be violating their rights. He believed a child should be circumcised only when he has reached an age when he could decide for himself whether to opt for medical or traditional circumcision.