What happens to HIV prevention programmes during the coronavirus pandemic? Take a look at how South African projects went from performing medical male circumcisions to Covid-19 testing and screening in just days - and what they learned.
Nompulelelo Magagula shuts the door with a quiet click as she unhooks the elastic of her mask from behind her ears.
She has come home from a long day of screening people for Covid-19 in Isipingo, KwaZulu-Natal. It's a far cry from her usual day job, where she spends a lot of time talking about another virus, HIV, and a fair amount of time focused on foreskins.
Before South Africa's Covid-19 outbreak hit, Magagula's job at the Centre for HIV-AidsPrevention Studies (Chaps was to help train healthcare workers on how to provide voluntary medical male circumcision (VMMC). Medical male circumcision can reduce a man's risk of contracting HIV via vaginal sex by up to 60%, according to international studies.
But as South Africa went into its coronavirus lockdown in March, non-emergency procedures such as medical circumcisions were stopped. And Chaps teams - like many organisations providing VMMC around the world - pivoted to begin supporting the fight against Covid-19, specifically South Africa's massive Covid-19 screening and testing campaign.
Early in the outbreak, the global HIV community knew that some services such as VMMC might need to pivot during the Covid-19 pandemic, halting normal operations to contribute, for instance, staff and supplies to the emergency response.
So Magagula's job changed from focusing on VMMC to Covid-19.
So what does it take to transform a brick and mortar HIV prevention medical male circumcision programme into a roving Covid-19 community screening and testing programme?
The answer is more than just nurses or gloves.
Within days of South Africa's national coronavirus lockdown, our teams were in the field conducting large-scaled Covid-19 screening and, to a lesser extent testing. Our experiences revealed that time-tested lessons from the fight against HIV about building community trust and battling misinformation are just as important in today's Covid-19 response as they have been to us in the HIV field for the past two decades.
Lesson one: Don’t show up unannounced
As other Chaps teams in Gauteng and the North West embarked on community screening campaigns, Magagula formed part of a special team deployed to KwaZulu-Natal that would do Covid-19 screening and testing.
“I didn’t expect I'd move from VMMC to the Covid frontline so quickly,” she says.
But our teams in KwaZulu-Natal didn't always get a warm welcome despite having the provincial health department's backing. In two communities, leaders told us to pack up our mobile testing units and go. They were deeply suspicious about Covid-19 and us - in large part because no one had consulted them prior to our arrival.
And it's not surprising. What we've learned through our prior public health responses, which also includes HIV testing and access to antiretrovirals, is that you can't just parachute in teams to go and provide services to the community.
You have to start with the leadership structures, with the community themselves, and ask them how they feel about what you're offering and what they'd like those services to look like.
This is a rapid consultative process and doesn't take days to complete. But it is also a matter of courtesy to the community.
The more people trust you, the more likely they are to sign up for health services whether that's Covid-19 screening, HIV testing or medical male circumcision.
After KwaZulu-Natal communities initially turned our Covid-19 screeners away, we met with the local ward councillor to explain that we were working on behalf of the Durban Covid-19 Command Council. We also outlined what services would be provided and how they would work.
Two days later, the community allowed us to come back and begin screening and testing.
Lesson two: Stock up or lose out
But building trust doesn't stop there.
When you start a new public health project or, in this case, pivot an existing one, what often catches organisations is the fact that they haven't worked out all the kinks yet.
For example, with Covid-19, when our teams went out into the field we thought we'd anticipated how many testing swabs, for instance, we'd need and we put in orders to cover that. However, we didn't expect how rapidly the number of tests done daily would rise, so we ran out of testing swabs for two days.
What does that mean for public health programmes? You've engaged with the community and created demand for your service; you've made that investment and you've made a promise that you'll do what you say.
Now you can't deliver because your supply chain doesn't match the demand - immediately you are breaking the trust that you've created in the community. And that hampers your credibility, so when you come to them again offering Covid-19 testing or any other service, people may be skeptical that you have the supplies to do what you say you will.
In the time of Covid-19, something as logistical as making sure your supply chains are streamlined to ensure you have a continuous supply of the resources you need is important, but there are real limitations.
Delivery delays for personal protective equipment such as masks and gloves, and also testing kits, remain a looming possibility given global shortages. Additionally, teams struggled to meet earlier testing targets of close to 2 000 tests a day, managing to do only between 1 000 and 1 500 daily tests.
The queues at the testing sites are long, but the community is coming to know the Chaps team and rely on them for rapid, reliable Covid-19 testing results. And partnering with a private lab, led by Global Health Innovations and the University of KwaZulu-Natal, means that results are being processed within 48 hours.
Lesson three: Get out ahead of the myths and the stigma
But the biggest lesson South Africa could learn from Covid-19, is something we also saw with past efforts to increase the uptake of VMMC and antiretrovirals for HIV-positive clients: Don’t roll out a public health response without adequate knowledge, or information dissemination, to communities.
We make the mistake time and time again of thinking that we send information out that everybody in the country has access to - and that's not always the case in a country where many don't have television sets or internet data.
And when people don't have access to good public health information tailored for them and in ways they can access, myths take hold that are difficult to dispel later. For example, when VMMC programmes were rolled out, people didn't sign up for the procedure because they didn't trust that it could help protect men from HIV infection via vaginal sex.
So the lesson that we've learned is that a public health response should always be focused on those most at risk with associated and relevant communication channels.
This is especially important as we become increasingly aware of the stigma associated with Covid-19. Recently, we ran a small online survey in some of the areas in which we work.
Many people knew about Covid-19, although a few reported that they didn't believe it actually existed. But many people said they were fearful to test, some because they were afraid if they tested positive for Covid-19 they would suffer interpersonal violence and community backlash - something we also heard during the early days of the HIV response in South Africa.
In VMMC, we've used community champions - or men who have undergone medical male circumcision - to help disseminate information in the community and recruit others.
They have great credibility because they are trusted by the community and that's something South Africa can capitalise on for Covid-19: Finding local leaders, training and teaching them, and getting them out to spread the message about Covid-19 in their communities.