In what might be construed as a renewed commitment to the fight against HIV, Western Cape Premier Alan Winde is co-chairing the newly reformed provincial AIDS council. This is particularly notable since his predecessor, former Premier Helen Zille, declined to chair the council.
In February last year, the Western Cape was still one of the few provinces where premiers were not chairing provincial AIDS councils. These provincial AIDS councils are important platforms for government, civil society, labour and the business sector to work together in the fight against HIV/AIDS.
Activists have for some time called on premiers to chair AIDS councils in their respective provinces to ensure that the AIDS response has high-level political support and is not left only to the provincial departments of health. Deputy President of South Africa and chair of the South African National AIDS Council, David Mabuza, echoed this idea in his 2019 World AIDS Day speech when he said that “political leadership and commitment is required from our premiers and mayors”.
Man of action
Winde recently told Spotlight in an interview his decision followed a request by Western Cape Health MEC Nomafrench Mbombo that he chairs the council to ensure that HIV/AIDS gets the spotlight it needs. Winde said it was also the fact that HIV/AIDS contributes to 8% of deaths in the province, that made him realise a strong approach is needed. “So, I’ve chaired the first meeting (in December last year).”
When probed on how he intends to strengthen the provincial AIDS council and improve the work it does, Winde was frank. “Honestly, I don’t know yet. I’ve only chaired one meeting so far. I have also raised a whole lot of questions during the meeting. Even when I saw the minutes of the meeting after, I still had questions. Yes, the minutes were done but I want to know who is going to do what and by when because when you don’t have an action to this minute we will only end up talking about it at the next meeting,” he explained.
“And I don’t want to just talk about it – I want to know what happened after we talked about it.”“It is about action plans for me. As soon as I see indicators going the wrong way we have to deal with it and ask different questions,” he explained. “One thing government does a lot is to keep doing the same thing and hoping it changes. I don’t believe in that. If the report back shows we keep getting the same thing we must have a different discussion.”
Change in tone
During her term as Premier relationships between Zille and some HIV/AIDS activists were acrimonious at times. She once compared some AIDS activists to an “AIDS Gestapo” and came under fire for public statements in support of criminalising HIV transmission by people who transmit HIV knowing that they themselves are living with HIV.
Winde however hopes to find common ground with AIDS activists and others represented in the province’s AIDS council. “I do think I really try to work on tone,” he said in response to a question on how he will rebuild relationships with HIV/AIDS partners. “I believe that if you have the right tone you will find common ground and agreement that what we are doing is to make things better for tomorrow,” Winde explained.
“Whether it is in the Aids council or whether it’s in my safety plan or whether it’s in (provincial) parliament - that is what I’ll work on. That is what I’ve been trying to do from day one –maybe trying things from a slightly different relationship point of view.”
According to Winde this however, does not mean there should not be dissenting voices. “You can’t just have a room full of people that are all just in a choir – otherwise you not going to get anywhere either. We do need people that challenge, that asks the question and push for strong debate. So, I do think that it (the AIDS council) can be one of those spaces,” he said.
“It is important to get the right people around the table and ensure that what is discussed is communicated back to communities. I did get the feeling that we have the right people in the room and that they’re representative of our communities. So, let’s see what we can do with it. It is only the first quarter.”
Choice and personal responsibility
But there are also certain things on which Winde is sticking to his guns concurring with some positions taken by the former Premier. One such issue is on individual responsibility. In 2011 Zille said the state has limited resources and spreading HIV through unprotected sex place additional strain on state coffers. In a Twitter thread on the issue in the same year she was more forthright stating in response to a tweet that if people do not want to use a condom, “pay for your own ARVs”.
AIDS activists slammed this and her other comments on criminalising HIV transmission and argued her stance on personal responsibility leans toward blaming people living with HIV for contracting the virus and fuel stigma and discrimination.On World AIDS Day last year Winde had himself gone for an HIV test and also stressed the importance of personal responsibility. “You cannot blame someone if unbeknown to them they contract HIV/AIDS - absolutely not,” Winde conceded.
“But of course, there is a responsibility. They got it somewhere. Where is that responsibility? And people need to step up. I mean, I think in our country – and let’s not talk about this (HIV/AIDS) space only but in general – each one of us as citizens must play our part. I always ask the question why and what are the causes, and then that’s when we get to the stage where government should step in. But citizens need to take responsibility here too.
”He gave another example reminiscent of Zille’s comments on this issue a few years ago. “Say you have a sick child who contracted HIV and it is not their fault. We will have to help him - absolutely. But say you have a child who needs education and I now only have R1 million to spend. This child is waiting for a school; waiting to be educated and then we have this person (now HIV positive) who knew what they were doing - what do I do?” he asked. “See that is the conundrum because we only have so much money. That’s the hard choice. And that’s what Helen (Zille) was always talking about. That’s why I think Helen just left it to the (provincial) department (of health).” According to Winde these are still “massive conundrums”. “So, there are no easy answers.”
Criminalising HIV transmission
Another issue the former premier often got criticised for was her call to criminalise HIV-transmission by those who are aware of their positive status. Zille said people who knowingly infect others with HIV, should be charged with attempted murder. This statement also caused a stir as AIDS activists slammed her views as, among others, unscientific.
Now, years later there is a new Premier at the helm of the province who echoes the sentiment albeit more measured. Winde told Spotlight that once someone knows their positive HIV-status and “purposefully” go and have unprotected sex with someone – it is “totally unacceptable”.
But is it just “totally unacceptable” or should it be criminalised?
In responding to the question Winde reached for hypotheticals. “Well I don’t know. Has anyone ever been criminally charged? It would be interesting if I’m a female and I meet this guy and I then find out I have HIV and he knew he had HIV – I would probably go and lay a charge, yes. It is totally unacceptable.”
In a report published in 2001 the South African Law Reform Commission concluded that current legislation is sufficient to deal with intentional transmission of HIV and that no further criminalisation is required. Similarly, in a landmark 2012 report the United Nations Development Programme’s Global Commission on HIV and the Law also advised against enacting any laws that “explicitly criminalise HIV transmission, exposure on non-disclosure of HIV status, which are counterproductive.”
Winde reiterated the need to take personal responsibility and getting tested for HIV. “And then once you know your status you have to behave differently,” he said. “It’s treatable. It’s like getting diabetes. I have diabetes and I manage it. So, because I have diabetes I have a responsibility to manage it through exercise and eating properly. The exact same thing is applicable to someone living with HIV/AIDS."
According to Winde he does not believe in a ‘nanny state’ approach where “government says don’t worry I will give you a grant, build you a house – you don’t have to get a job”. “No ways! Citizens must take responsibility to develop themselves, to play a meaningful part in society. So, if we narrow it down, each one of us have a responsibility. I need to be responsible in a HIV/AIDS space and get myself tested. It’s not that difficult to get yourself tested – so surely that is a basic responsibility that society should take.”
Hits and misses
Although the Western Cape performs well with its HIV/AIDS programme there has been some hits and misses under the previous administration. In terms of strategies to get people tested and on treatment the province a few years ago tried offering cash prizes as an incentive for HIV testing.Spokesperson for the Western Cape Health Department Mark van der Heever told Spotlight in response to a media query there were two campaigns, one in 2011, which was incentivised and one in 2013 which was not incentivised.
“Data was collected to determine the impact of both campaigns and to ensure those who tested positive received counselling and treatment required,” Van der Heever said. “The uptake between the two campaigns could not conclusively confirm that the lottery campaign of 2011 yielded better results as the incentivised campaign of 2013.”The First Test & Win campaign in 2011 was initiated to boost HIV testing in the Western Cape and enabled more than 15 000 people to get tested.
Van der Heever said that was three times the average testing rate at that time. “Short term incentives do not lead to better health outcomes in the long term but can be good for initial boosting of a particular campaign,” he said. The campaign has since ended.Although there are currently no such incentivised campaigns in the Department as confirmed by Van der Heever, Winde supports the idea.
“What’s the alternative? Do you force people to go into testing? I mean it is hard enough for us as government to make sure we have our inoculation processes in place to support mothers. But we must continually put the message out there to be a responsible citizen and to understand that if you’re in a risk environment the right thing to do is to get yourself tested,” he said.
Western Cape and the 90-90-90 targets
The so-called UNAIDS 90-90-90 strategy aims to have 90% of people living with HIV tested and knowing their status, 90% of people living with HIV receiving treatment, and for 90% of people on treatment to have a suppressed viral load – all by 2020. These targets have also been endorsed in South Africa’s National Strategic Plan on HIV, TB and Malaria 2017 – 2022.
According to estimates from the Thembisa mathematical model, around 89% of People living with HIV in the Western Cape knew their HIV status in 2018. Of those who had tested positive for HIV in the province, only around 66% of people were receiving treatment and of those on treatment around 90% had achieved viral suppression. (See this article for more detail on how the Western Cape compares with other provinces on these and other indicators.)
In response to a question on how his government plans to fast track plans to meet these targets, Winde could not immediately say.
“One has to apply your mind to these things. At the moment I’m applying my mind to the provincial safety plan and thereafter the economic plan for the province. And to be honest I’m almost spending 80% of my day in getting the safety plan right,” he said.
“So, I’m getting there still.” He explained to Spotlight how crime in the province impacts how the health system operates and described some of the tough decisions that have to be made daily. “In Red Cross (Children’s Hospital) there were two boys. They were 11 years old and admitted with gunshot wounds. They belong to rival gangs, so we could not have them on one floor in one ward because people will come to visit these boys and we cannot afford to have a gang war in the middle of the hospital. These are tough decisions being made daily.”
At around 6.8%, the Western Cape has the lowest HIV prevalence of South Africa’s nine provinces. In absolute terms, the province has the third smallest number of people living with HIV at around 450 000 – only the Northern Cape and the Free State have fewer. The Western Cape also has a very serious tuberculosis epidemic. The soon to be published National TB Prevalence Survey should provide useful information on how the province’s TB epidemic compares with other provinces.The Western Cape AIDS Council is expected to meet again in February.
* This article was produced by Spotlight – health journalism in the public interest.
Image credit: Nasief Manie, Spotlight