As expected, both the Mbeki letter and Deputy President Ramaphosa’s Friday launch of the sex worker HIV prevention programme got people talking, not so much because what politicians say often grabs headlines but more so because the central subject, HIV and Aids, has been a life-and-death matter for millions of people for many years.
Moreover, it has been politicised more than any other epidemic in recent history.
Although there is merit in a discourse on the political economy of HIV and Aids in South Africa, there is much urgency to implement targeted prevention and treatment interventions to key population groups such as sex workers, pregnant women, migrant labourers and young people who continue to occupy the epicentre of the Aids epidemic in southern Africa.
Not being an expert on HIV, one must always approach this subject with great care because we are dealing with cherished, fundamental human rights issues. Our approach to the pandemic must remain informed by our local dynamics, lived experiences, and the voices of our active citizens affected or infected by HIV and Aids.
Research shows many solutions have to do with the need to address socio-economic and cultural factors shaping human behaviour and vulnerability of certain population groups, especially marginalised conditions that often drive young women into sex work.
With studies we have conducted and the interactions we have had with sex workers, we have learnt that where South Africa today — following years of difficult dialogues about science and delaying treatment — can be proud of having turned the corner, to the extent that in a neoconservative society like ours, the government is working with sex workers to reduce the burden of HIV and Aids in this sector.
With more than 3-million people on life-saving antiretroviral treatment, we have not only made up the backlog but have earned the respect of the world for providing the planet’s biggest HIV treatment.
We acknowledge the role of leadership which shaped public policy in a manner that de-escalated conflict and shifted focus to prevention, care and support for affected and infected communities.
Equally, we acknowledge the role of NGOs, business and organised labour who have come together under the banner of the South African National Aids Council (Sanac) to champion the country’s HIV-Aids response.
At every single meeting of Sanac I have observed, one issue has revealed the dark side of HIV and the harsh reality of those most at risk for HIV.
This was the issue of sex work or prostitution as some people prefer to call it. Exemplary of the unique ability of Sanac to bring together people from all walks of life and social classes, representatives of sex workers shared openly the harsh realities of working on the streets and in brothels and how the risk of HIV made their already difficult lives even bleaker.
Not only are sex workers regularly exposed to unplanned pregnancy and sexually transmitted diseases, they face social stigma, abuse from partners and violence from clients. They are hauled off the streets in the middle of the night and arrested for loitering or soliciting sex. Disheartening stories are rife of police officers confiscating condoms from sex workers claiming they constitute evidence of illegal work — prostitution.
There is brutality, exploitation and dehumanisation in these episodes that sex workers experience. They are effectively shunned by from society while meeting the demands of the same society.
Given the high degree of vulnerability of sex workers to HIV and the social and economic factors that drive new infections in this group, the government has decided, under the banner of Sanac, to comprehensively address the needs of sex workers and the high risk exposure to HIV, pregnancy, STIs and human rights violations.
In a country where constitutional rights are paramount, no group within society should be refused full rights to social services and to justice.
That is the context within which Sanac launched a comprehensive plan to tackle the burden of HIV and Aids among sex workers whose right to justice and service delivery is as equal as that of the unemployed, those in tertiary education and the elderly.
This plan will reach sex workers and their clients with education and information about safe sex, condom use, healthcare and social services, psychosocial support for alcohol and substance abuse as well as access to legal support where there are violations of their human rights through abuse and violence.
The plan is in keeping with the highest standards set by the United Nations and has been extensively canvassed with experts throughout the country. Sex workers participated in the development of the plan.
Initially, the programme will reach 70,000 sex workers out of an estimated 153,000 throughout the streets, taverns, private homes and brothels in South Africa. Available research suggests women sex workers have the highest rates of HIV in South Africa in comparison to other women. A recent survey done by Sanac in collaboration with the University of California reported that 71% of sex workers in Johannesburg had already contracted HIV but only one-third of these were receiving antiretroviral treatment.
Another study showed that sex workers on the national roads in KwaZulu-Natal and the Free State had an HIV prevalence rate of 88%.
Yet only one-quarter of HIV-positive sex workers have access to antiretroviral treatment. In a country with such high coverage for antiretroviral treatment, the low coverage for sex workers is testimony to their marginalisation in our communities — yet their exposure means we are all exposed given that they often service family men, some of whom do not use condoms with the sex workers and with their partners.
If a sex worker would feel safe and free in the privacy of a clinic consultation room to reveal his or her “occupational hazard” to the doctor or nurse, they would be prioritised for treatment, but the stigma associated with sex work creates the opposite result. Even with the statistics we have on HIV-positive sex workers, researchers have not arrived at a national, agreed HIV incidence rate because many sex workers or women involved in transactional sex prefer not to come forward.
This HIV plan for sex workers seeks to establish an accurate figure of sex workers in the country and to ensure the sector receives the health services other citizens enjoy.
For a sex worker who is HIV-positive and not on treatment there is a high likelihood of death in a few years. Untreated with antiretroviral drugs, sex workers are more likely to pass the virus on to clients, spouses or partners. On good treatment and regular care, the risk of a sex worker transmitting the virus is reduced by up to 96%.
This is the reason that the government is looking at giving immediate treatment to sex workers who test HIV-positive. If a sex worker summons the courage to visit a clinic to test for HIV, the health system should not be missing the opportunity to immediately offer her antiretroviral treatment when necessary.
This is now the global standard for the treatment of HIV-positive sex workers.
In addition to providing immediate antiretroviral treatment for HIV-positive sex workers, a novel approach to HIV prevention among sex workers called pre-exposure prophylaxis (PrEP) was announced as part of the comprehensive plan. Sex workers who test HIV-negative are offered a two-drug pill that they take daily. This reduces their risk of contracting HIV also by up to 90% if taken regularly.
This approach to antiretroviral treatment and prophylaxis for HIV-positive and HIV-negative sex workers is a world first and South Africa can be proud of another innovation in our response to HIV. Again, an evidence-based, pragmatic, necessary and humane approach trumps the political economy debate preferred by the former president whose pitiful defence of his convictions has opened wounds for many who believe lives could have been saved if his government acted differently.
Sex work is a contentious subject and there is a wide spectrum of opinion about how it should be regulated. In this regard, the work of the South African Law Reform Commission which engages on the difficult subject of the legal status of sex work is acknowledged. Eventually, a solution will be found balancing the moral arguments with objective realities. The country is known for using inclusive dialogue to find solutions to such divisive subjects.
For now, it is encouraging that while grand and sometimes inconsequential debates continue, a service-oriented response to the challenges of HIV, Aids and general healthcare facing sex workers is being championed by the state, working with social partners.
This will mean sex workers can be embraced by the broader community and address issues of exclusion and stigma. India has made great strides in reducing infection rates among sex workers. South Africa has the will and capacity to do likewise. DM
Ngcaweni works in the Presidency and Abdullah is CEO of Sanac. Ngcaweni’s forthcoming book (AISA, 2016) Sizonqoba: Outliving AIDS in Southern Africa chronicles the evolution of of South Africa’s Aids response since 1994.
Photo by Greg Nicolson from his Street Life series.
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