Motsoaledi and the devil’s alternative
By Ntsiki Mpulo
Health minister Dr Aaron Motsoaledi sat down with Spotlight in an exclusive interview. He shares details on how the department plans to target vulnerable groups in efforts to stem the incidence of HIV. He speaks passionately on plans to target adolescents, a little less forceful on decriminalizing sex work and is thin on detail when it comes to men who have sex with men.
The Health Department’s plan to decrease the HIV-infection rates in adolescents aims to challenge the taboos surrounding sex and HIV, says South African Minister of Health, Aaron Motsoaledi.
In an interview with Spotlight ahead of the International AIDS Conference in Durban in July this year, the Minister outlined a wide-ranging programme for dealing with the groups most vulnerable to contracting HIV in South Africa, with a particular focus on adolescents.
“We have turned a corner on HIV and there are signs that a vaccine is imminent but, according to World Health Organisation research, we still face 5 000 new HIV infections in adolescents per week in Sub-Saharan African and half of those are in South Africa,” says Motsoaledi.
Following the dark period of AIDS denialism, which resulted in the deaths of at least 330 000 people whose lives could have been saved with ARV treatment, the South African government implemented a number of significant programmes that have yielded good results.
“We started an HIV Counselling and Testing programme (HCT) in 2010 and within 18 months had raised the number of facilities offering HCT from 40 to 3 500,” says Motsoaledi.
“In 2009, there were only 250 nurses trained to initiate ARV treatment without the presence of a doctor and now there are 23 000.
“Over 3.5 million people are now on antiretroviral therapy and we continue to expand the programme,” he said. “We have now turned our focus to vulnerable groups such as sex workers, men who have sex with men (MSM) and adolescents.”
According to the Minister, the R3-billion programme, which will span three-years, is aimed at reducing infection rates, bringing down teenage pregnancy and abortions rates, and addressing gender-based violence. This is in addition to keep girls in school and linking them to economic opportunities.
He explains that this is part of a broader government- and society-wide programme, which includes the school health programme in which learners’ eyesight, hearing and speech are screened, and during which immunisation, alcohol and drug education, reproductive health education and HIV Counselling and Testing are addressed.
The Minister says the programme will drill down to individual school level and allow the department to profile high-risk schools, with specific programmes tailored to the requirements of that school.
“We have prevalence statistics from each municipality and each district in the country based on the ante-natal survey, so we’ve been able to identify the hardest-hit districts,” says Motsoaledi. “Where we find girls who are positive, we will immediately put them on ARVs in line with our test and treat programme.
“They will receive HIV counselling and testing and, if they are negative, we will continue to monitor and counsel them to limit the possibility of contracting HIV, and even administrating pre-exposure prophylaxis if necessary.”
Responding to criticism that the programme places an unfair burden on girls, Motsoaledi says: “We will not only focus on girls but on men as well. Of the 18 million South Africans on our HCT programme, 65 percent are women, five percent adolescent, and only 30 percent are men. We are insisting that men know their status and we are promoting male circumcision.”
He says the media focused too much attention on the part of the programme dealing with encouraging girls to stay away from so called “sugar daddies” whereas the success of this programme depended on support from parents and the community.
“Parents tell me not to worry about consulting them about screening, immunisation and alcohol and drug education but with respect to reproductive health and HCT, they do not even want to engage,” he says. “They say if you give children condoms, you’re asking them to have sex. But the fact that girls are falling pregnant and contracting STIs means they are having sex anyway.
“I call this the devil’s alternative,” says Motsoaledi. “Parents must make a difficult choice. In one corner are condoms but in the other corner is HIV, teenage pregnancy and abortions. The difficulty is that this choice is not really a choice.”
In addition to school-based programmes, Motsoaledi envisages creating a safe environment for young people in clinics.
“We have received reports where children have been turned away and told to bring their parent when they requested contraception at some of our clinics,” says Motsoaledi. “That is not acceptable.”
The Minister speaks of an instance in 2011 when he visited Umkhanyakude district in KwaZulu-Natal, which is reported to have a high HIV prevalence among young women.
“Women came into the clinics asking for contraception and there was none,” he says. “We just didn’t provide contraception in the public health system at the time. It was the result of some poor policy choices.”
According to the Minister, literacy about contraception somehow fell off the agenda at one point in the 1990s.
“In our panic to address the alarming rates of HIV infection, we abandoned education programmes around contraception and focused our energies on the ABC programme and, as a result, the contraception programme collapsed.”
But this has changed with the introduction of the dual-protection programme in 2014. This programme encourages women to use two contraceptive methods, one that protects them from sexually transmitted diseases and HIV as well as from pregnancy. Since then, the department has provided about 800 000 women with sub-dermal implants.
Decriminalising sex work
In addition to the programme for adolescents, the Minister outlined the National Sex Work Sector Plan announced by Deputy President Cyril Ramaphosa, in his capacity as chair of the South African National AIDS Council (SANAC), in March 2016.
In his speech, Ramaphosa said South Africa was one of the first countries in the world to take a decision to provide pre-exposure prophylaxis to sex workers. In addition, government will roll out its test and treat programme in which anyone who tests positive for HIV will be offered treatment regardless of CD4 count.
Beyond providing health services, the plan for sex workers is expected to address the difficult issues of violence, stigma, alcohol and drug abuse, depression, social isolation, forced migration and lack of economic opportunities.
Responding to the question of decriminalising sex work, Motsoaledi says it is not something that he as health minister can tackle alone. It has implications for the whole of society and so must be tackled by the different stakeholders together. To this end, the Minister has consulted with organisations that represent sex workers, including SWEAT, to understand the challenges faced by this sector.
“One of the major issues they highlighted was harassment by police officers,” says Motsoaledi. “They said police confiscated their condoms thus putting them at great risk for HIV infection. This is something we are addressing with the South African Police Service. Some things can be achieved without having to decriminalise sex work.”
On programmes addressing men having sex with men (MSM), the Minister says there is a need to fully interrogate the issues before plans are rolled out.
Ntsiki Mpulo is a Spotlight Journalist