South Africa has become one of the world’s first countries to begin rolling out pre-exposure prophylaxis as well as “test and treat” to sex workers as it launches Africa’s first plan to prevent and treat HIV among sex workers.
Health-e News reports that South Africa will soon begin providing HIV treatment to HIV-positive sex workers upon diagnosis as part of a new national plan announced late last week. Currently, most people living with HIV must wait until their CD4 counts – a measure of the immune system’s strength – fall to 500 before they can start treatment. At least 3,000 HIV-negative sex workers will also receive the combination ARV Truvada to prevent contracting HIV. When taken daily as pre-exposure prophylaxis, Truvada can reduce a person’s risk of contracting HIV by about 90%. In December, South Africa became the first country in southern Africa to register Truvada, which combines the ARVs emtricitabine and tenofovir, for use as prevention in December.
South African National AIDS Council (SANAC) CEO Dr Fareed Abdullah credited Health Minister Dr Aaron Motsoaledi for driving the plan’s creation. “It’s rare for a country to have such high-level leadership dealing with HIV among sex workers,” Abdullah said. “It’s a sign that government is taking this very seriously and working with non-governmental organisations and the community to make sure that the right thing is done and done properly.”
The report says the plan comes on the heels of research that found about 72% of sex Johannesburg sex workers surveyed were living with HIV. “The good news is that sex workers are showing a lot of responsibility and about three-fourths of sex workers are using condoms with their clients,” said Abdullah.
The bad news is although more than 90% of sex workers surveyed had tested for HIV, less than a third of those who were living with HIV had received treatment – far less than the national average, Abdullah added.
Globally, UNAIDS estimates that 50m women are engaged in sex work and HIV prevalence rates among sex workers is often almost 14 percentage points higher than among the general population due to the inability to negotiate condom use, stigma and barriers to healthcare. Sex work is estimated to account for as much as 20% of new HIV infections in South Africa, according to Deputy Health Minister Joe Phaahla.
The three-year national plan also aims to reach 70,000 sex workers with a standardised package of services, including PrEP adherence support, delivered in part via a network of 1,000 of their peers. Deputy President and SANAC Chair Cyril Ramaphosa called the plan a chance for South Africans to affirm their rights. “This plan is about the human rights, about the rights of ordinary people,” he is quoted in the report as saying. “It affirms the right of all South Africans to life, dignity and health regardless of their occupation and sexual orientation and regardless of their circumstance.”
Ramaphosa also cautioned against that moral arguments against sex works could not trump workers’ inalienable human rights. “We cannot reclaim the morality of society by excluding the most vulnerable whatever views we might have about sex workers, whatever beliefs we have about sex workers, whatever statures are on our law books about the legality of sex work,” he said. “We cannot deny the human and unalienable rights of people who engage in sex work. Sex work is essentially work,” said Ramaphosa, who ended his address by embracing national leader of the Sisonke sex worker movement Kholi Buthelezi.
To combat low uptake of treatment, sex workers will now be able to start HIV treatment as soon as they are diagnosed with HIV – a model of care known as “test and treat”. Currently, most people living with HIV must wait until their CD4 counts – a measure of the immune system’s strength – fall to 500 before they starting treatment.
Health-e News reports that the changes in HIV treatment policies for sex workers are part of South Africa’s first national plan to address the HIV epidemic among sex workers and is a first in Africa. It also heralds the most significant move to address HIV in South Africa since the introduction of ARV treatment in 2004.
The report says South Africa’s decision to provide PrEP to sex workers is part of a growing international trend to address high HIV prevalence rates in high-risk and often marginalised populations. International donors like the Global Fund to Fight AIDS, Tuberculosis and Malaria is increasingly pushing countries to address groups like sex workers, injecting drug users and young women in national programmes not only because it promotes human rights but because it’s just good science.
“What the epidemiology is telling us is that… if you succeed in national (HIV) programmes and scale ups, you begin to push the epidemic into corners,” said Global Fund executive director Mark Dybul in a 2013 interview. “In those corners, there is not a lot of light and people are living in the shadows still with darkness and death. Those are usually the people most marginalized in society, and who don’t have access to care.” “Just building clinics and making healthcare available gets to a lot of people, but it doesn’t get to the people who are beyond the reach of clinics – that really means getting to the most vulnerable,” Dybul added.
The report says, PrEP for sex workers may be just the beginning. Prior to the announcement, both the Wits Reproductive Health and HIV Institute (WRHI) and the Anova Health Institute had started small demonstration projects aimed at learning how best PrEP might be rolled out. While WRHI focused on Hillbrow sex workers, Anova Health nurses have been providing PrEP to about 100 men who have sex with men (MSM) from its Woodstock clinic in Cape Town.
Previous 2009 studies conducted in Johannesburg and Durban, as many as about 38% of MSM surveyed were living with HIV – a figure almost double the national adult HIV prevalence rate. With a growing body of data on the country’s MSM, as well as new lessons being learned in Woodstock, MSMs may be the next group to receive PrEP if South Africa continues rolling out the once-a-day pill for prevention.
The report says the real test for PrEP in South Africa may eventually be whether the country can figure out how to provide it to one of the country’s highest risk groups: Young women – young women between the ages of 15 and 24 years old are more than four times more likely than men in their age group to be living with HIV and women in this age bracket also account for about a quarter of all new infections in South Africa.
But, the report says, Dr Kevin Rebe, a specialist medical consultant for the Anova Health Institute in Cape Town, worries that how we talk about PrEP now, may affect how young women see the prevention option tomorrow. With initial rollouts focused on highly stigmatised populations like sex workers and perhaps later MSM, Rebe cautions that there may be a risk that PrEP itself becomes stigmatised. “We may be creating a social construct that PrEP is for these ‘bad people’ who are disorganised and are thought to be having a lot of sex,” he said. “If this happens, we may get a backlash against PrEP. How do we prevent shaming people who are actually doing something responsible for their health?” he asked. “That’s a real danger. What we should be doing is targeting anyone who is at high risk of HIV,” said Rebe, adding that following Truvadas 2015 Medicines Control Council approval for use as prevention there is nothing stopping private sector patients from asking doctors if PrEP is right for them.
Medical aid Fedhealth has already said it will cover at least six months of PrEP for medical scheme members who are at a high risk of HIV as well those who are in relationships with HIV-positive partners.
For the SA Medical Research Council’s head of AIDS Research Dr Gita Ramjee, the first step in talking about young women and PrEP is understanding young women. “In all the bio-medial interventions we’ve tried and tested with young women, the main reason for them not working was because of low adherence in this group,” said Ramjee, who added small demonstration projects conducted among young women – like those already being conducted with sex workers and MSM – would be needed to understand everything from women’s desires and emotions to how they perceive their HIV risk.
“Emotion and desire are very important drivers of decision-making process for this group,” Ramjee is quoted in the report as saying.”Once we understand the social, cultural and economic context and the emotions underneath what these young women are feeling and believing… what their need for HIV prevention is then we’d be ready to send a message out to young people.”
Sex workers and advocates praised the plan as a turning point in the recognition of sex workers as humans who deserve to do their jobs with dignity and safety, reports The Times. But Ramaphosa said: “We are moving ahead in terms of arresting new HIV infections. This effort we have embarked on will not be successful if sex workers are disempowered, ignored, neglected, forgotten, disregarded or stigmatised.”
Deputy Minister of Social Development Hendrietta Bogopane conceded that sex workers were harassed, arrested and abused by policemen. And, the report says, the plan concedes that criminal sanction affects the provision of health services to sex workers. “While services for sex workers are available in some areas, there is limited reach and treatment is a challenge given that sex work is criminalised.”
At the launch of the plan not one speaker from government mentioned decriminalisation, the report says. Sex worker Nosipho Vidima, who works for advocacy group Sweat, said: “The health plan without decriminalisation is limited in effectiveness.” Even Ramaphosa said government worked against itself.
Up to 45% of infections of sex workers and clients could be averted if sex work was decriminalised, the report says. The Law Reform Commission – which investigated whether the law that makes prostitution illegal has to be changed – heard hearings on decriminalisation in 2001 and accepted written submissions in 2012. “The process, taking 15 years, has been too long,” said Sally Shackelton, director of Sweat. “The Department of Justice said it is still considering the commission’s report on adult prostitution,” said Marlise Richter, researcher at the University of Cape Town’s department of public health.
The report says Department of Justice was notably absent at the launch of the plan. Deputy Minister John Jeffery who was expected to attend was ill.
Richter said: “While the plan is ambitious and far-reaching, it is doubtful if it will truly be able to reach its own stated targets if the criminal law in any form still applies to sex work.
“If the criminal law applies to sex work even when it is in the formal, legalised or partially criminalised framework, the state sends a symbolic and practical message that sex workers and their clients are not worthy of protection or dignity.
“It diverts important resources away from supporting sex workers and providing the necessary services,” she said.
South Africa’s latest antenatal survey, conducted in 2013, finds an HIV prevalence rate of about 30% among pregnant women. Health-e News reports that the survey was conducted among about 33,000 first time antenatal clinic attendees in about 1,500 clinics. About 30 percent of pregnant women surveyed were living with HIV. The report notes that while this is a slight increase from HIV prevalence rates recorded in 2011 and 2012, this increase was not statistically significant.
The report notes that continued disparities in HIV prevalence rates among pregnant women persist. KwaZulu-Natal had an antenatal HIV prevalence rate of about 40%, which showed a three percentage point increase from the province’s 2012 antenatal survey.
Results for other provinces are as follows rounded to the nearest whole number:
Eastern Cape: 31%; Mpumalanga: 38%; North West: 28%; Free State: 30%; Northern Cape: 18%; Western Cape: 19%; Limpopo: 20%; and Gauteng: 29%.
In 2013, there were six districts in the country – five in KwaZulu-Natal and one in Mpumalanga – that recorded HIV prevalence rates above 40%. The highest prevalence in the country was recorded in iLembe, KwaZulu-Natal (45.9%). The other five districts recording HIV prevalence above 40.0% were as follows rounded to the nearest whole number: UMkhanyakude, KwaZulu-Natal: 44%; eThekwini, KwaZulu-Natal: 41%; UMgungundlovu, KwaZulu-Natal: 43%; Ugu, KwaZulu-Natal: 41%; UThukela, KwaZulu-Natal: 40%; and Gert Sibande, Mpumalanga at 41%.