Healthcare systems around the world faced an unprecedented health crisis as the Covid-19 pandemic swept from country to country, leaving lives, livelihoods and economies in its wake. The intense focus on Covid-19 has resulted in other widespread diseases being relegated, with services and resources directed away from them. HIV is one such disease, where the infection rate among adolescent girls and young women in South Africa versus the rest of the population remains alarmingly high, with this demographic being disproportionately affected. 

According to the UNAids report for 2022, In Danger, in 2021 there were more than 165,000 new HIV infections among adolescents and young girls in East and southern Africa. Have we been ignoring HIV prevention to the detriment of the population group most affected? What’s more, are we too late?

There is no doubt that Covid-19 had to be prioritised in South Africa, with one key consequence being that community health workers were no longer able to fulfil their HIV and TB responsibilities. Part of their job, essentially, is to go into households and screen for HIV and TB, refer patients to clinics and provide sound healthcare advice and education. However, the global pandemic had the unintended consequence of Covid-19 preventative measures becoming a barrier for communities’ access to lifesaving healthcare services. 

People avoided visiting healthcare facilities for regular HIV testing due to the perceived risk of potentially contracting Covid-19 there. As interventions to prevent Covid-19 were initiated, such as physical distancing and personal protective equipment, access to clinics became more challenging. This was particularly true for vulnerable key populations, adolescent girls and young women, who were seemingly forgotten. 

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Already stretched thin, community healthcare workers were directed to prioritise Covid-19 to the detriment of people requiring HIV prevention and testing services. This led people to look for more innovative solutions to access healthcare, such as HIV self-testing, online healthcare support and home drug delivery. Ideally, we need to develop partnerships encouraging HIV service providers to prioritise Covid-19 prevention and testing while still focusing on providing innovative HIV prevention interventions.  

Vulnerable groups 

While the world has had its eye on the spread of Covid-19, HIV is still as prevalent as it was before. According to the Joint United Nations Programme on HIV/Aids (UNAids) women and girls account for more than half of the 37.7 million people living with HIV. Closer to home, the stats, disappointingly, are very similar. 

Adolescent girls are more prone to contracting sexually transmitted infections (STIs), not only because of biological factors but also socioeconomic circumstances and cultural norms. These result in many not being encouraged to complete their schooling, for instance, or being kept home by their families who don’t see the need for them to be educated. 

This marginalisation, in the context of HIV, increases their susceptibility on many levels – biologically, economically and socioculturally, girls are at a disadvantage. As a direct consequence they are more likely to participate in risky sexual behaviours and are at a disadvantage when it comes to negotiating safer sex practices. For example, some may be exposed to physical abuse if they ask their partners to use a condom, highlighting the intersection between economic vulnerability and gender-based/intimate partner violence.

What now?

First, it is critical that any interventions that are implemented to address these issues are holistic. One-off or siloed approaches are doomed to fail. Many studies have demonstrated that if economic empowerment is enhanced, HIV vulnerability is reduced. This encompasses finishing school, obtaining a tertiary qualification and entering the workforce. This also means sexual actions are not born out of economic necessity, enabling women to be firmer around condom use and more able to leave abusive relationships.

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One such intervention was developed through a public-private partnership between the global pharmaceutical company, Gilead, the Wits Business School, Reckitt Benckiser and UNAids to launch the “Aspire, Higher” sexual health innovation competition. Entrants were tasked to think about new ways of empowering girls and young women so that they can take control of not only their sexual health but also their lives.

It is imperative that programmes not only encourage girls to stay in school but also equip them with entrepreneurial skills to start their own businesses or carve out a prosperous career. As such, interventions need to be cohesive and integrated from start to finish. 

“Aspire, Higher” winners, Imbokodo Launchpad, offer an out-of-school programme that seeks to change the prevalent negative mindset among young people in South Africa and includes creative, sports and adventure opportunities for youngsters and a business hub to help women entrepreneurs transform their communities. The Gratitude Project, also selected as one of the top three contenders in the competition, offers a digital leadership academy focused on starting and accelerating businesses through inspiring content and access to entrepreneurs and financial education.

Six graphs that tell the HIV story in South Africa

Critical programme components need to include peer-to-peer support mechanisms, ensuring that participants are given a safe space to talk about issues that are relevant and pertinent to them. While facilitators can be used to guide the discussion, girls should also be able to provide support for each other in the form of relevant coping skills. 

The goal of such initiatives, combined with access to age-appropriate and context-specific healthcare services, is to ensure that adolescent girls and young women remain HIV negative, particularly through their riskiest years. Technology, of course, is an essential tool, but it is important that solutions are accessible and appropriate for target audiences, especially when looking at access to connectivity and data costs in South Africa. This has been considered by the third “Aspire Higher” finalist, Storm, which uses social media and an SMS subscription service to provide effective sexual health information. It is complemented by an in-school education service, community outreach and provision of sanitary protection and condoms through a social marketing campaign.

HIV infections decreasing in South Africa but millions at increased risk as global response falters

While we are still navigating the repercussions of the Covid-19 pandemic, it is important that we do not lose sight of our population’s vulnerability to other diseases. HIV cannot be ignored or downplayed. Programmes need to emphasise the prevention of HIV while addressing the factors that increase the risk of infection, whether sociocultural, environment or financial. And, no, we are not too late to give young women the opportunities they need to carve a life of their own without HIV. DM

Dr Michael Reid is Senior Director, Medical Affairs at Gilead Sciences.