Almost four decades on and despite having benefited as favoured child of global health funding, the HIV/Aids epidemic is far from over, writes Professor Linda-Gail Bekker, president of the International AIDS Society, in Spotlight.
The 22nd International AIDS conference is being held in Amsterdam, as we move through the 37th year of the Aids epidemic, writes Professor Linda-Gail Bekker, president of the International AIDS Society and deputy director of the Desmond Tutu HIV Centre at the University of Cape Town.
Bekker writes: “The first Aids conference was held in 1985 in Atlanta, US at a time when the world was still grappling with what this virus is, what its impact might be, and how to even begin helping those affected.
“The immense strength of the HIV response has meant that in quite a short period of time the HIV/Aids community has moved leaps and bounds to achieve both treatment and prevention. Some are even suggesting that we are near to the end – however, there are many reasons why the end is not yet in sight and why this conference still matters.
“The Aids conference remains an anomaly in the health world, being both the first and one of the only health conferences to cater to the full range of people involved and affected: basic scientists, doctors, programme implementers, social scientists, lawyers, policy-makers, activists and the patients themselves. All coming together in one place to hear each other and share their ideas.
“This is a manifestation of what the Aids epidemic has driven home to the world: nothing can be done or achieved without involving everyone, including those who are often isolated, stigmatised, or voiceless. In a slogan, this is ‘nothing about us without us’, but in practice this is what the Aids conference enables. It works to connect people and form networks across tracks, population groups, and country borders. At every point in the HIV epidemic this has mattered, but potentially now as we face an ever more hostile and nationalist world, this is critical.
“HIV/Aids is not over – nor are we fast approaching an end. In terms of new infections, while some generalised epidemics have seen success, infections in key populations such as people who inject drugs and sex workers in Eastern Europe and Central Asia are increasing and in South Africa alone 2,000 young women are infected every week. A primary prevention revolution is desperately needed. In terms of mortality, we have also had huge success; however, we now have an ageing population of people living with HIV who will need to combat a range of co-morbidities. There is much work still needed to prepare for this.
“Ultimately, until we have a vaccine or a cure, until we can reach all marginalised populations affected, until we prevent all new infections and know how to best support those living with HIV, we need to keep this conversation going.
“We are reaching a new era in the HIV response where considerations need to be made on how to integrate HIV care and prevention programmes with other disease programmes and within a universal healthcare model.
“HIV/Aids has benefited as a favoured child of global health that receives a high level of funding, focus and pooling of global resources. How do we now continue to sustain these gains while also integrating HIV/Aids with other global health issues? The IAS-Lancet commission will aim to tackle these questions and lay out some recommendations. The Aids conference provides an ideal opportunity to launch this and other new conversations and allow everyone to hit the ground running.
“The Aids epidemic broke in 1981. Many of the researchers, activists and movers leading the response were there to witness it and thus strategically placed to lead the response. However, as time has passed the baton needs to be handed to the younger generation. We need them to lead, we need their passion and new ideas, and we need them to make it relevant and accessible for generations to come. The Aids conference, with its youth focus, scholarship programmes and inclusive agenda, provides the platform to achieve this. The conference co-ordinating committee includes a youth representative, the global village hosts many youth-lead organisations, and at Aids 2018 an entire plenary session is to be dedicated to the youth.
“The Aids conference still matters as long as it provides an opportunity for everyone involved and affected by this epidemic to congregate, feel included, get involved and be inspired to move the HIV response forward – because we are not there yet!”
The 600 new HIV infections in South Africa every day should constitute a health emergency. City Press reports that this is according to the Treatment Action Campaign, commenting on the latest results from the fifth South African national HIV prevalence, incidence, behaviour and communication survey conducted by the Health Science Research Council.
“While the politicians celebrate, we cannot afford to do so while the epidemic is still raging in our communities and the healthcare systems that are supposed to help us are falling apart. You don’t celebrate while your house is still burning,” Anele Yawa, the TAC’s general secretary said in the report.
The TAC maintained that in order for South Africa to bring down the infection rate, the priority should be for everyone to know their HIV status and have access to treatment. “When someone is stable on antiretroviral therapy and the virus is suppressed in their body, they are no longer infectious. In this way, getting more people on to treatment is actually one of the most effective ways of preventing new HIV infections,” Yawa said.
The report says he also pointed out that the ailing healthcare system in the country needed to be fixed. “To make all of this possible, however, we will have to fix our broken and corrupted provincial healthcare systems and turn our clinics into places everyone is comfortable visiting and where only high quality treatment and care is provided,” Yawa said.
A key campaign run by the TAC is to monitor the HIV and tuberculosis response in South Africa, and Yawa said that its members worked closely with poor people who live with HIV and rely on the public health system for treatment and care, “so they are the first who notice when it is not working”.
UNAIDS set a target, to hit by 2020, for 90% of people living with HIV to know their status, 90% of people who know their status to be on antiretroviral therapy and 90% of people living with HIV on ART viral suppression. “If the government delivers on its promise of an ambitious new HIV testing campaign then it is likely that we will reach the first 90 by 2020.
“However, given the widespread crisis in our public healthcare system it will be very hard to ensure that 90% of people diagnosed with HIV be receiving sustained antiretroviral therapy by 2020 as required by the second 90. At our current trajectory we will fail the second 90,” Yawa said.
Two years ago, we welcomed the world to the International AIDS Conference in Durban, South Africa, writes Anele Yawa, the general secretary of TAC in the Daily Maverick. He writes: “At a march of 10,000 people we held up banners proclaiming that 20m people still need treatment. At that conference we said to the world that Aids is not over – and indeed, the misguided rhetoric about the end of Aids has now given way to more sober, more realistic assessments. The reality is that we are still in the thick of it.
“In South Africa, as in many other countries, the first phase of the global Aids response was a fight for policy. It was a fight for the idea that governments have a responsibility to do whatever they need to do to get HIV treatment to the people who need it. In our country it involved various court cases and a fight against Aids denialism. Around the world it required a massive effort by activists, researchers, diplomats, progressive business persons and willing governments. Our shared success is something to be celebrated.
“That said, the victories of this first phase of our struggle against HIV has to be won again and again. We cannot take the recognition of the human rights of all people for granted nor can we take the affordability of medicines for granted. As we hear reports of plans to shut down UNAIDS without any public consultation, we can’t take even UN support for granted. As we know too well, we can’t take continued political will or funding from our governments for the Aids response for granted either. All this work from the first phase of the Aids response must continue and we must support each other in it. 1
“Almost everyone agrees today that we need to provide prevention, treatment and care to all who need it. The wide adoption of the 90-90-90 targets are testimony to that consensus. We have reached a point in the Aids response where the question is not so much what to do, but rather how to actually get it done given the state of our health care systems.
“We now know that policy victories and innovative technical interventions can only take us so far. In South Africa, and in many other countries, the Aids response has come up against a wall. This wall is the widespread dysfunction in our health care systems. It doesn’t matter how good our donor-written policies are if they are never implemented. It is no use if we have medicines in depots, but the medicines never reach the people in the clinics. Beautiful guidelines for treatment and care mean little if we refuse to employ health care workers to actually provide the treatment and care.
“As TAC we are very clear: Our struggle against HIV is now in a new phase, a phase where our fundamental struggle is against dysfunction, mismanagement and corruption in our public health care system.
“This new phase of our struggle is, in its way, much harder than the struggles against Aids denialism and profiteering pharmaceutical companies. There are fewer victories to be had in laws or in policies. The problems we face are much more diffuse and harder to influence. Meetings in board rooms in Geneva, New York or Amsterdam matter less in this phase of our struggle, while community meetings in Lusikisiki and Khayelitsha matter more and more.
“As TAC we have in recent years attempted to create accountability across the public health care system in South Africa. Our 200 branches spread across the country have each adopted a clinic – where our members, all users of the public health care system, both monitor and provide support where possible. Where issues persist, we escalate them to district or provincial level, and if needs be to the National Department of Health. Let me be clear, the more we monitor, and the more systematically we monitor, the more disturbed we get about the near collapse of our public health care system. 1
“Our recent monitoring reports on seven of South Africa’s nine provinces paint a very bleak picture. In these and in our previous reports, it has become clear that TB infection control measures are grossly deficient in many facilities – turning many clinic waiting areas into likely transmission areas. Our diagnosis of widespread dysfunction in public sector facilities is confirmed by devastating reports from the Office of Health Standards Compliance (a statutory health inspection body that reports to parliament).
“The crisis in many of our public facilities does not come from nowhere. Over the last decade, on the watch of former President Jacob Zuma, corruption has flourished in South Africa and the public service has been systematically hollowed out. This has directly impacted the health care system and the Aids response.
“It is worth recounting some details. Recently it emerged that millions ear-marked for HIV in the North West province was looted to pay overinflated prices to a controversial ambulance company that is now the subject of police investigations. This is while over 200,000 HIV treatment eligible people in that province are not yet on treatment.
“In the same province strikes resulted in the shut-down of the public health care system, a shut-down that meant medicines distribution stopped completely for weeks on end. Some shared treatment with others, others paid high prices in private pharmacies, many simply defaulted. These strikes, and a similarly disruptive strike at a Gauteng hospital, suggest that more health care workers are now prepared to strike in ways that place patients at risk. It tells us that the ethos of public service has dangerously eroded.
“Of course, there are still many good people trying to do their best within a failing system. The tragedy though is that there is so little help for them. While some politicians come when there is a strike or a protest, they generally show little interest in fixing the underlying problems plaguing the system. Indeed, many officials in provincial departments of health have been appointed for political reasons or with corrupt motives and have neither the inclination or the ability to start turning the system around. And even with Jacob Zuma gone, the balance of powers in the ANC is such that many corrupt and under-performing persons remain firmly in place.
“Part of why Cyril Ramaphosa is now president of South Africa is a deal he made with David Mabuza, the former premier of Mpumalanga province and now deputy president of South Africa. Mabuza has generally been associated with some of the more unsavoury characters in the ruling party and on his watch Mpumlanga politics was mired in alleged corruption. As Deputy President Mabuza is also now the new head of the South African National Aids Council, a body already ridden in controversy over the way it removed its former CEO and its failure to deal decisively with conflicts of interest. While premier in Mpumlanga and chairing that province’s provincial Aids council, Mabuza failed completely to address that province’s severe HIV crisis, not to mention the general corruption of that province’s government.
“That Mabuza is now making some of the right noises on HIV and TB is of course welcome and we will hold him to his words. That our government has finally approved a progressive new policy on patents and medicines 17 years after the Doha Declaration is also welcome. That our Department of Health has shown urgency in introducing new medicines such as bedaquiline for MDR-TB and dolutegravir for HIV is to be applauded.
“But, as Minister Aaron Motsoaledi recently admitted, South Africa’s health care system is in crisis. From our national department he has tried to stop the crisis, but in South Africa the health care system is run by provinces and Motsoaledi has been powerless to get the provinces into line. The underlying reality is that inside the borders of South Africa, our internationally popular Minister is severely hamstrung by his lack of political power.
“Ultimately, as with all the issues we faced in the first phase of our struggle, the second phase is also fundamentally political. And as we have to address the patronage networks within our ruling party in South Africa, we call on our international allies to address the distorted values of the current US administration and to seek out again the international solidarity that made our movement as successful as it once was.
“As the world gathers in Amsterdam for the 22nd International Aids Conference, my appeal to you is to once again make Aids political. Just like the gag rule and Global Fund withdrawal is political, the failure in my country to act against corrupt individuals is political. The potential shut-down of UNAIDS and the mishandling of sexual harassment at the agency is political. In recent years we have too often played nice with our elected leaders and as a result they have come to believe that Aids is almost over. We must once again take the gloves off and make Aids political. We have elected our leaders, we demand that they deliver the Aids response and the health care systems we need.”