AIDS 2016, the XXI International AIDS Conference - (with the theme of 'Access Equity Rights Now') which will be held in Durban, South Africa, from 18 to 22 July 2016, marks a dramatic change in the country’s AIDS response in the 16 years since XIII International AIDS Conference (AIDS 2000), which was also held in Durban.
"When Nelson Mandela addressed the 12,000 participants at the XIII International AIDS Conference in Durban in 2000, no one knew what the future held for the AIDS response. Access to lifesaving antiretroviral drugs in 2000 was sharply limited, and donor spending on AIDS activities amounted only to a small fraction of current funding levels. AIDS 2000 was characterised by conflict between politics and science, and vocal activism for access to universal HIV treatment, which was at the time excluded from South Africa’s AIDS policies" said Mr France K Morule, High Commissioner of South Africa in India in an interview with CNS (Citizen News Service).
Political will and domestic funding both key
"Today, South Africa is seen by the global community as having a model AIDS response. The biggest sea change in the national AIDS response has been a strong demonstration of political will and leadership to address the massive HIV epidemic. South Africa invests heavily in its own HIV response and now funds 85% of the national AIDS response through public and private sector funds" said Mr France K Morule.
In 2010–11, it successfully implemented a mass HIV Counselling and Testing (HCT) campaign, which saw 20 million people tested for HIV in 20 months. The HCT campaign was a catalyst for the rapid growth in the HIV treatment programme. The country now has nearly 3.2 million people on HIV treatment—the biggest HIV treatment programme in the world. As a result, HIV related deaths decreased from 330,000 in 2010 to 140,000 in 2014. The evidence-based, multi-pronged approach adopted for prevention of mother-to-child transmission programme in South Africa has seen the rate of babies born with HIV decrease significantly from 8% in 2008 to 2.6% in 2013. The number of 0‒14 years children living with HIV and on antiretroviral treatment, while still lagging behind, has also increased fourfold—from 42,000 in 2009 to 166,000 in 2014, informed Mr France K Morule.
What made all of this possible?
Education: Mr France K Morule said that part of South Africa’s dramatic strides in the battle against HIV/AIDS can be attributed to its education programme around the disease. The programme has targeted various levels of academic and social institutions through a multi-pronged approach. By engaging the population from a young age the programme has been able to reinforce the message, throughout the developmental years of children, about the need to practice safe sex. Coupled with the mainstreaming of knowledge about HIV/AIDS, the programme was also able to deal with the critical issue of de-stigmatising the disease.
In South Africa there was structural/societal as well as the personal/self-imposed stigmatisation of HIV/AIDS and TB. The relevance of stigma cannot be underestimated due to the causal relationship between stigma and people seeking alternative remedies, that are better concealed, than going to government run programmes, which may create/reinforce the already present stigma. These programmes have sought to change the perception that HIV/AIDS is a death sentence and further remove the myths relating to the transmission of the disease.
Planning and government support
The overall guidance and framework for the National Service Plan (NSP) was provided by the South African National AIDS Council (SANAC). The NSP provides a national framework that covers issues relating to basic education, safety and security, employment, skills development, economic infrastructure, rural development, human settlements, responsive local government, environmental protection, public service and citizenship, as well as health. It will guide the development of detailed implementation plans at provincial and sectorial levels for dealing with both HIV/AIDS as well as TB, shared Mr France K Morule.
The NSP is based on a 20-year vision for reversing the burden of disease from HIV, STIs and TB in South Africa. The NSP and related provincial implementation plans are based on evidence and experience, and at the same time are flexible enough to accommodate new research findings.
Interventions must also have high impact and must be able to be rolled out to scale. Finally, the plans must include all sectors involved in HIV, TB and STIs: they must promote partnerships across sectors and at all levels of society.
HIV and TB co-infection in South Africa
South Africa has experienced both TB and HIV epidemics in alarming proportions. It has the third highest incidence of TB in the world, after India and China. Approximately 1% of the South African population develops TB every year. New TB infections have shot up by 400% over the last 15 years, reaching 970 new infections per 100,000 people in 2015. The HIV epidemic is driving the TB epidemic as 73% of the 450,000 TB patients in South Africa, are also co-infected with HIV, said Mr France K Morule.
The highest prevalence of TB infection is in people who are in the age group 30–39 years, and living in townships and informal settlements. This confirms the fact that TB is a disease that affects poor communities disproportionately. Groups that are more likely to be exposed to HIV and TB, or to transmit them are called key populations and special efforts have to be made to reach out to these groups with services for prevention, treatment and care said Mr France K Morule.
Key populations for HIV services include young women in the age group of 15-24 years; people living close to national roads and in informal settlements; young people not attending school; people with low socio-economic status; uncircumcised men; people with disabilities; sex workers and their clients; substance abusers; men who have sex with men; and transgenders.
Mr France K Morule added that key populations for TB services include people who share the same living space with confirmed TB cases; mine workers; correctional services staff and inmates; people living with HIV; people with diabetes; malnourished people; users of drugs tobacco and alcohol; mobile, migrant and refugee populations; and people living and working in poorly ventilated and overcrowded environments (including informal settlements).
Many of the obstacles that impeded effective HIV prevention and treatment programs in 2000 still exist today. More than 60% of people living with HIV remain without antiretroviral therapy, including women and girls, men who have sex with men, transgender people, sex workers, young people, and people who use drugs and other marginalised groups remain under-prioritised in the response; investments in HIV prevention research appear to have flattened; and widespread violations of human rights including criminalisation continue to undermine effective responses, said Mr France K Morule.
Research needed for shorter regimens, reducing pill burden
In an exclusive media webinar on 11th July 2016 in lead up to TB 2016 and AIDS 2016 (watch webinar recording: http://www.bit.ly/jul16-recording), Nomampondo Barnabas was on the panel of experts. Nomampondo is presently the Civil Society Liaison Officer for International Union Against Tuberculosis and Lung Disease (The Union) based in Johannesburg, South Africa. She presented her patient's perspective in this webinar, sharing her experience of living with both diseases: HIV and TB.
"I was diagnosed with HIV in 1997. We know that with HIV advancing one of the leading opportunistic infections is TB. I was diagnosed with TB in 2006. Dr Fuad Mirzayev of WHO Global TB Programme has highlighted the importance of shorter, cheaper drugs. Back then in 2006 I had to take (because of my weight) 5 TB drugs, 5 antiretroviral (ARV) drugs, 2 antibiotics to prevent further infections, and other medications to prevent side effects. I want to emphasize on importance of accelerating research for shorter TB regimens and also for decreasing pill burdens. Longer regimens and huge pill burden are also responsible for those who are forced to interrupt treatment midway. Shorter regimens and reducing pill burdens are a major priority for researchers. Today I am on just one pill a day - this needs to become a reality for others too who deal with co-infections or co-morbidities."
The magnitude of the HIV and TB epidemics reduced South Africa’s chances of achieving the MDG goals related to reversing the epidemics of HIV and TB and reducing maternal and child deaths. Therefore the implementation of the NSP must assist South Africa to reach these goals. HIV and TB management must be mainstreamed into the core strategies of all relevant government departments in all spheres of governance, as many interventions lie outside the domain of health. The mainstreaming of HIV and TB into the core mandate of all government departments will lead to a streamlining of work, allowing them to make relevant policy decisions and interventions.
With a view to eradicate these diseases in future, a long term plan that seeks to address social, economic and behavioural drivers of HIV, STIs and TB is being rolled out as part of the countries National Development Plan. This includes (i) addressing challenges affecting access to social services in informal settlements, and rural and hard-to-reach areas; (ii) strategies to address the vulnerability of migrant and mobile populations and substance abuse; (iii) interventions to address harmful gender norms and gender based violence; (iv) lessening the impact of HIV, TB and STIs on orphans/children/youth ensuring that they have access to the social services they need, including basic education. It is also trying to reduce the vulnerability of young people to HIV infection by ensuring that they stay in school until Grade 12. Besides this, a Stigma Reduction Framework and the People Living with HIV Stigma Index is also proposed to be implemented nationally.
(Shobha Shukla is the Managing Editor of CNS (Citizen News Service) who is leading CNS onsite Correspondents Team at XXI International AIDS Conference (AIDS 2016) and International TB Conference (TB 2016) in Durban, South Africa, with kind support from Lilly MDR TB Partnership. Follow her on Twitter: @shobha1shukla)