Amid the festivities during the opening ceremony of the 11th SA Aids Conference in Durban on Tuesday, there were also several sobering moments. Chief among these was when co-chair of the South African National Aids Council and chair of the Civil Society Forum, Steve Letsike – flanked by several representatives of civil society – told a fully packed plenary hall at the Durban International Convention Centre about a visit earlier on Tuesday to the Hillcrest Aids Trust Centre – a hospice where 80% of the admitted people (living with HIV) are in their end stage of life.

Letsike told delegates that the youngest were 14 and 25 years. “We should be concerned. We should be angry,” he told delegates.

“If our ARV (antiretroviral) programme has no efficient psychosocial support system extended to care and support, we are a ticking time bomb,” Letsike said. “Our people are dying. We should not allow them to die when we have a successful ARV programme. We can’t. Let’s not lose this investment where we can live longer.”

‘With ARVs, everyone should be alive’

South Africa has the world’s largest ARV treatment programme. According to estimates from Thembisa, the leading mathematical model of HIV in South Africa, about 5.7 million of the estimated 7.8 million people living with HIV in the country in 2022 were on ARV treatment.

If our ARV programme has no efficient psychosocial support system extended to care and support, we are a ticking time bomb.

Later on Tuesday evening, Health Minister Dr Joe Phaahla, in his keynote address, reminded delegates that the clock is ticking for 2025 – the date set to reach the Unaids target of having 95% of all people living with HIV diagnosed, 95% of all people diagnosed with HIV on sustained ARV treatment, and 95% of all people receiving treatment to have viral suppression.

“In the remaining two years,” Phaahla said, “we have to accelerate our efforts to meet the targets. Though we have made great strides towards achieving the first 95%, we still have a long way [to go] with the second and the third 95%.”

According to him, we are currently at “94% of people living with HIV who know their status, 77% of those who know their status and are on antiretroviral treatment, and 92% of those on treatment who have a suppressed viral load”. 

“More effort is needed to place and retain more people with HIV on treatment,” Phaahla said. “To achieve the 95-95-95 targets, we must initiate an additional 1.4 million people on treatment.”

Dr Sandile Buthelezi, director-general of the National Department of Health. (Photo: Wits University)

After the opening ceremony, Spotlight caught up with the director-general of health, Dr Sandile Buthelezi, who said he would determine the exact circumstances around the people at the hospice Letsike referred to. “But in this day and age – whether you are 15 or 50 years – no one should be dying of AIDS or getting to that end stage,” he said. “With ARVs, everyone should be alive. We will need to see what are the circumstances around that. Why are they at that stage? Were they put on treatment? Did they default? So we just need to get information, but it is worrying and not acceptable.”

Although not directly speaking to the cases Letsike referred to, Phaahla said in his address that certain interventions will have to be scaled up, including “social behaviour change communication, treatment literacy and adequate resourcing” to get the country to 95 on the second and third targets.

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“We also need to improve access to treatment and prevention commodities such as pre-exposure prophylaxis (PrEP), especially for key and vulnerable populations inclusive of sex workers, the LGBTQI+ populations and young people, particularly adolescent girls and young women,” he said.

Young people and HIV

Before Phaahla took the podium (he delivered the keynote address on behalf of Deputy President Paul Mashatile) it was KwaZulu-Natal’s health MEC, Nomagugu Simelane-Zulu, who lamented the quality of social behaviour communication, especially for young people. In her address she said it looks like HIV messaging is not reaching young people. “It looks like our messaging on HIV is stale. It is the same message as when I was a teenager. We need to change that,” she said.

How to target young people and adolescents is among the key themes in several sessions throughout the three-day conference. For example, some sessions will explore PrEP uptake and barriers for adolescent girls and young women in Tshwane. In other sessions, the benefits and acceptability of technology such as using WhatsApp groups as a platform for health education among adolescent girls and young women in South Africa, will be explored, along with a session on how to address child and teenage pregnancies in KZN, which can be a key contributory factor in bringing down new HIV infections. 

Simelane-Zulu stressed the worrying number of teenage pregnancies in her province. From April to December 2022, KZN recorded 26,515 pregnancies among girls between the ages of 10 and 19, of whom 1,254 were in the 10-to-14-year bracket.

Health Minister Dr Joe Phaahla at the TAC’s 7th National Congress earlier. (Photo: TAC / Twitter)

Gogo Silungile, from the organisation SA Positive Women Ambassadors, told Spotlight that what stood out for her from the opening ceremony is Simelane-Zulu’s recognition of the high rate of teenage pregnancies and high rate of HIV among young people. 

“We hope in future they’ll engage young people themselves because it looks like we as adults are deciding for the young people. We need to sit down and listen to them and let them lead,” she said.

Silungile said her organisation works with young people in and out of school and provides information and trains young people as peer educators. In some sessions they also include boys and older men. “Because, whether we like it or not, there are girls dating older men. We need to create an environment where these two parties can come together and discuss sexual issues because girls say they don’t discuss sex with their partners – they just do it. So we try to capacitate both partners to talk about sex before they do it,” she said.

If we are talking about young girls, aged 14 to 24, who are being infected with HIV but continue talking about them without them being here, I think we are still missing the point.

Treatment Action Campaign (TAC) chairperson Sibongile Tshabalala told Spotlight that young people, particularly women, need to be given a voice and allowed to communicate what their problems are around HIV and how they can be supported.

“What we need to do as a country now is to give young women their space. We need to give them skills, we need to allow them to take charge of their struggles,” she said. “If we are talking about young girls, aged 14 to 24, who are being infected with HIV but continue talking about them without them being here, I think we are still missing the point.”

South Africa’s National Strategic Plan for HIV, TB and STIs (2023-2028) was launched at Tlhabane Stadium in Rustenburg, North West, as the world commemorated World TB Day on 24 March. (Photo: Denvor de Wee / Spotlight)

According to SA Aids Conference chairperson Dr Gloria Maimela, a Youth HIV track is being launched at this year’s conference that “is run by youth, for youth who will set the tone and agenda on how we end the epidemic, for their sake”. There will also be updates on what is new in paediatric and adolescent HIV with respect to long-acting injectables, among other things.

Legislation undermining the HIV response

Another issue that permeated the speeches during the opening ceremony was the condemnation of Uganda’s recently passed anti-homosexuality legislation. 

Letsike lashed out at people who “have become bystanders when countries such as Uganda, Ghana, Kenya, Tanzania and even Namibia introduced anti-homosexuality laws that seek to erase LGBTI people”. 

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“They undermine the health agenda,” Letsike said, “and they undermine human rights of citizens in those countries. Injustice there means injustice everywhere. For all of us.” 

Maimela also took a swipe, saying the latest developments in Uganda are “making a mockery of the gains made in the fight against HIV”. 

“There is no place for stigma and discrimination in our modern society. We, therefore, condemn the passing of the Ugandan anti-LGBTQIA+ law in the strongest terms. It is inhumane.”

A TAC activist addresses attendees at a World Aids Day event. (Photo: Denvor De Wee / Spotlight)

While many of the speakers condemned the law passed by Uganda, Phaahla, however, stopped short of outrightly condemning Uganda but rather focused on South Africa. 

“I would want to stress again that the South African Constitution forbids any form of discrimination on the basis of a person’s sex, gender or sexual orientation, whether on the part of the state or a private citizen.

“Because of our firm belief that LGBTQIA+ (lesbian, gay, bisexual, transgender, intersex, queer/questioning, asexual) rights are human rights, our government will continue to defend and advance these rights,” he said.

Speaking to Spotlight after the opening ceremony, Tshabalala expressed her disappointment: “It’s a bit disappointing and we were expecting our government to speak out [against Uganda’s bill]… the minister [of health], he didn’t say much, because they are afraid to speak about it. We don’t know why.”

Decriminalising sex work

Phaahla was not the only minister who came in for criticism. Kholi Buthelezi, the activist who founded Sisonke – a South African movement for sex workers of all diversities – was among those who used the platform to call for the urgent decriminalisation of sex work. 

The first time Maimela called for “the speedy passing of the Amended Sexual Offences and Related Matters Bill that decriminalise sex work”, a sex worker activist shouted “yes” from their seat and skipped joyfully under an orange umbrella across the hall.

The stigma and discrimination against sex workers also make it difficult to access PEP and PrEP from healthcare services even when they have experienced sexual violence. (Photo: SG ZA / https://commons.wikimedia.org)

Buthelezi said in her speech: “Criminalisation of sex work leads to stigma, discrimination and violence against sex workers, and enables an environment for law enforcement officials to abuse their power. 

“It creates an environment where sex workers are at high risk for acquiring HIV and STIs. The stigma and discrimination against sex workers also make it difficult to access PEP and PrEP from healthcare services even when they have experienced sexual violence.” 

She referred to Justice Minister Ronald Lamola who, this month, “without consultation, halt[ed] progress to decriminalise sex work”. 

“This, “Buthelezi said, “proves the lack of commitment to address gender-based violence and femicide, equal access to healthcare and justice, economic freedom and freedom of choice and association for sex workers by our ruling party and its Cabinet. This is how far yet near we are to decriminalising sex work,” she said.

‘A diversity of voices’

After the opening ceremony, health director-general Buthelezi told Spotlight in an interview that he welcomed a successful opening ceremony, and appreciated the “diversity of voices”. 

“It is good to also have people from the community with lived experiences so that it’s not just scientists. We also want to hear some new stories and developments because we haven’t had this conference since 2019, especially new developments on long-acting PrEP, injectables, and all of that. So it [the conference] will be interesting.

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When Spotlight asked about the expected pilots for the HIV prevention injections, he said their team “is still working on some protocols”. 

“I will have to follow up on that. With the dapivirine ring, I know we are quite advanced. It’s the CAB-LA where we just need to finalise the protocols. We hope it will start early next year – if we are able to sort out a number of issues.” 

Buthelezi could not immediately provide more details and said he will have to follow up with his team. Spotlight reported earlier that South Africa was expected to begin piloting the CAB-LA HIV prevention shot early this year. New modelling released in November 2022 showed that the injection could prevent as many as 52,000 new HIV infections in the next two decades if rolled out nationally. DM

NOTE: The TAC is mentioned in this article. Spotlight is published by SECTION27 and the TAC, but is editorially independent, an independence that the editors guard jealously. Spotlight is a member of the South African Press Council.

This article was produced by Spotlight – health journalism in the public interest.