OPINION | Pandemics and plans: Why South Africa needs to reimagine its HIV strategy

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  • Although new HIV infections fell by an impressive percentage between 2010 and 2019, the Covid-19 pandemic has led to setbacks
  • Some of these setbacks include a reduction in HIV medication and HIV viral load testing
  • As a result, South Africa needs to start thinking about how it can re-imagine the future of its responses

This World AIDS Day will be like no other. There will be few big public speeches by politicians in front of gathered crowds. There will also be shorter queues of people waiting to be tested under those white, branded tents.

Each year on 1 December, the world reflects on the progress made in the fight against HIV. This year and with the Covid-19 outbreak, South Africa has perhaps more to reflect on than most years.

There are, of course, milestones to celebrate. New HIV infections fell by 40% between 2010 and 2019, and this year, new research from South Africa found that an injectable ARV could prevent new HIV infections with just six shots a year.

But Covid-19 has also led to setbacks. Gauteng reported an almost 20% reduction in HIV medication collection following the start of a national lockdown in March.

Allegations of corruption

There was a similar reduction in HIV viral loading testing, which measures the amount of virus in a person's blood. Writing in the South African Medical Journal, researchers largely attributed these reductions to people's fear of going to health clinics or leaving the house during the national Covid-19 lockdown.

HIV viral load testing is the only way to know if people have become resistant to their treatment or if they are virally suppressed. When people are virally suppressed, it means their ARVs have brought the level of HIV in their blood down to levels so low that they cannot transmit the virus to others.

Meanwhile, the health sector was rocked by allegations of corruption by government officials surrounding tenders for much needed personal protective equipment (PPE).

We won't know the true impacts of these disruptions to our HIV programme for months to come, but we do know that Covid-19 is here to stay with us for the foreseeable future. With just two more years under the country's current National Strategic Plan for HIV, TB and Sexually Transmitted Infections (NSP), now is the time to reflect and rethink the document set to guide the future of the world's largest HIV treatment programme to better serve as a tool to protect human rights and ensure accountability.

NSPs aren't particular to South Africa – documents like these provide the foundations for what major HIV donors such as the Global Fund to Fight AIDS, TB and Malaria and the US President's Emergency Plan For AIDS Relief will fund.

Plans have their faults

South Africa's current plan is the fourth in its history and the product of hundreds of consultations across the country. Although the plan isn't perfect, it is the product of more than a decade of activism to ensure that the plans include those most at risk of HIV infection, that strategies were costed and importantly funded and, lastly, that NSPs had implementation plans that could be monitored.  

South Africa's NSP has become a model for other sectors hoping to hold the government to account. This year, civil society and government released the country's first National Strategic Plan on Gender-based Violence and Femicide.

But the latest plan, like any, had its faults. Provinces struggled, for example, to draft provincial implementation plans. As late as 2018, the Eastern Cape, for instance, still only had a draft implementation plan. Only four provincial implementation plans were ever publicly released by the National AIDS Council and remain critical for the full mid-term review of the NSP to be made available to the public to strengthen a culture of accountability and solidarity.

The plan lacked ambitious targets on human rights and South Africa's largest stigma survey among people living with HIV found that almost four out of 10 people interviewed said they had experienced discrimination based on their HIV status. About a quarter said they had been physically assaulted because of it.

And, despite much anticipation, our current NSP stopped short of calling for the decriminalisation of sex work, despite sustained calls for this by civil society, and by President Cyril Ramaphosa, who was then Chairperson of the National AIDS Council who said: "Sex work is essentially work... we cannot deny the human and unalienable rights of people who engage in sex work."

Roadmap for our collective journey

Modelling has shown that decriminalising sex work could avert almost half of all new HIV infections among female workers and their clients between 2014 and 2024.

South Africa's latest strategy also desperately needs a publicly available accountability framework and scorecard – both propositions have enjoyed increasing civil society support in recent years. These calls for increased accountability find renewed importance in the wake of PPE corruption scandals. SANAC has stated that these tools would be subject to extensive consultation. 

This World AIDS Day, it may still be too early to count all the ways in which Covid-19 has shaped our HIV response, but it's not too early to start thinking about how it can push us to re-imagine the future of our response in South Africa.

The National Strategic Plan remains the people's plan, and South Africans must continue to engage, interrogate and demand accountability to ensure that the plan becomes what it is meant to be: a roadmap for our collective journey towards a future where HIV, TB and STIs (and now Covid-19) are no longer public health problems. 

Full disclosure: The author served as a Lead Consultant on South Africa's current National Strategic Plan on HIV, TB and STI's (2017 – 2022). 

Tian Johnson is founder and lead strategist of the African Alliance, member of the Ministerial Advisory Committee on Vaccines (Workstream 4) and convener of the Vaccine Advocacy Resource Group (VARG). They are also the International Civil Society Observer of the Robert Carr Fund – the world's leading international fund focused on funding regional and global networks led by and involving and serving inadequately served populations (ISPs). Follow them on Twitter @tianjohnson.

READ | OPINION | Millions of people are on treatment for HIV: Why are so many still dying?

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