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Who should be the new head of UNAIDS?

Earlier this week it was reported that a short list of five people is still in the running for the Joint United Nations Programme on HIV/AIDS (UNAIDS) top job. They are South African Professor Salim Abdool Karim, Winnie Byanyima, Professor Chris Beyrer, Dr Bernard Haufiku, and Dr Sani Aliyu.

The appointment of a new Executive Director comes at a difficult time for UNAIDS. In December last year an independent inquiry was deeply critical of leadership at the UN agency, and particularly of the way in which allegations of sexual harassment was handled. As a result, the previous head of UNAIDS Michel Sidibé had to step down. Currently Gunilla Carlsson is acting in the role.

Questions have also increasingly been asked about whether we still need a UN agency focussed on HIV and AIDS. Spotlight previously reported on alleged covert plans to collapse the agency into the World Health Organisation. Whatever may or may not have become of those plans, real questions can and should be asked about what role UNAIDS should play in future, if any. The answer to this question should then inform the choice of the Executive Director, UNAIDS’ third one (excluding the acting ED). Professor Peter Piot was the first UNAIDS Executive Director, followed by Sidibé.

At a most fundamental level, UNAIDS should be an internationalist entity aimed at ensuring that HIV is eliminated as a public health threat as soon as possible. This implies a role in coordination, fundraising and diplomacy, but maybe most fundamentally in the framing of the global AIDS response.

One of the biggest blunders of the Sidibé years was the premature rhetoric about the “end of AIDS” – at a time when even UNAIDS’s own modelling suggested that we were not nearly on a trajectory to end AIDS by 2030. It seems plausible that the over-optimistic rhetoric contributed to a sense of complacency and a general perception that HIV no longer requires urgent action. The “end of AIDS” rhetoric was eventually scaled down, but not before significant damage was done.

One of the most important tasks for the new UNAIDS Executive Director would be to reframe the discourse on AIDS. This does not mean we need new spin – it means that we need a new sense of realism and seriousness. It means building a new narrative around AIDS that is firmly rooted in scientific evidence, human rights, and common decency and understanding. This will require an Executive Director who knows and understands both the dynamics of the epidemic and that of the AIDS community.

At last year’s international AIDS conference in Amsterdam much was said about what it would take to reinvigorate AIDS activism, something most seem to agree is needed. One lesson from the global AIDS response around the turn of the century is that doctors, researchers, lawyers and policymakers were all part of the AIDS movement. UNAIDS itself started as a uniquely activist UN agency – but over the years the urgency and animation has waned. For UNAIDS to justify its continued existence, as opposed to being collapsed into the WHO, it has to again become an activist agency.

Ideally, the new UNAIDS Executive Director will be someone who can bring the urgency and shared sense of activism back to the HIV response. While it is easy for candidates to say they will do this – actually doing it is another matter. While the head of UNAIDS has to be politically astute, he or she also has to be willing to step on toes when needed and to once again make HIV and AIDS a political crisis (it never stopped being a humanitarian crisis).

The new Executive Director would also have to address the very serious leadership and organisational culture problems identified in the inquiry into how allegations of sexual harassment were handled at the agency. It should go without saying that UNAIDS needs to ensure that all UNAIDS employees can safely report sexual harassment and have their allegations properly and fairly investigated by people who are independent and impartial. Given the links between gender-based violence and HIV, UNAIDS should be setting the example in this regard.

We are not in a position to definitively say which of the five candidates best meet the above criteria – and being based in South Africa we obviously know Karim better than we know the other candidates. That said, we have asked various experts and members of the AIDS community from around the world about their views on the five candidates. We have by no means conducted a scientific  survey, but we have at least some sense of sentiment in the AIDS community. With those caveats out of the way, here are some observations on the five candidates:

  • Winnie Byanyima, an aeronautical engineer, diplomat, freedom fighter and human rights activist, is currently heading up Oxfam and worked previously with the United Nations Development Programme. She  is the only woman on the short list. She handled sexual harassment allegations at Oxfam much better than Sidibé did at UNAIDS. She has no high-level experience in HIV, and is not that well-known in the AIDS world, especially among researchers and scientists. She could potentially be a hard sell to some in the AIDS world, but is a popular choice among activists who feels she is just the person for the job – and in the current atmosphere that makes her a front-runner alongside Karim.
  • Professor Salim Abdool Karim is internationally recognised to be a leading HIV researcher and clearly knows the epidemic and the HIV community well. Less well known is the role he played in strengthening and dramatically increasing funding for the South African Medical Research Council when he headed it from 2012 to 2014. Karim does not specifically have a human rights or gender record, but much of the research conducted at CAPRISA, the research organisation he heads in KwaZulu-Natal, is aimed at finding ways to help young women stay HIV negative. Based on the various conversations we’ve had, he seems to be one of the front-runners for the position.
  • Professor Chris Beyrer comes with excellent HIV pedigree having previously headed up the International AIDS Society and he has both a strong biomedical and human rights background. He is a Professor of Epidemiology and like Karim, he knows and understands the HIV epidemic and AIDS community very well. Beyrer is openly gay, well-liked among most people we spoke to – but fairly or unfairly (unfairly in our view) it will probably count against him that he is North American (he was born in Switzerland to American parents, but grew up in the US). Had it not been for that, his chances would have been very good.
  • Dr Bernard Haufiku, a medical doctor, is a former Minister of Health and Social Services of Namibia. He is currently the health advisor to Namibia’s deputy president. He does not have the international HIV experience and profile that Karim and Beyrer has, but is well-spoken of by those who know him. They specifically mention his record in promoting human rights and is viewed as someone who understands the need for a community-led response to HIV. His lack of experience on an international platform makes him an outsider for the position.
  • Dr Sani Aliyu, a medical doctor and microbiologist, is the director general of Nigeria’s National Agency for the Control of AIDS (NACA). NACA is the country’s agency which leads and co-ordinates the response to HIV. There are estimated to be about 1,9-million people living with HIV in Nigeria. The epidemic is most prevalent among women in Nigeria. Like Bernard Haufiku, he is an outsider for the UNAIDS top job given his relative lack of international HIV experience and his limited profile in the AIDS world.

 

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Assessing the Motsoaledi years

Dr Aaron Motsoaledi became South Africa’s Minister of Health 10 years ago, in

Former SA Minister of Health, Dr Aaron Motsoaledi.
Photo: David Harrison

May 2009. For most of the past decade, Motsoaledi and the Director-General of Health Malebona Precious Matsoso (appointed in 2010) have been tasked with ensuring people in South Africa have access to quality healthcare services. This week the Motsoaledi era came to an end with the appointment of Dr Zweli Mkhize as South Africa’s new Minister of Health. It is not known whether Matsoso will stay on.

The Motsoaledi years can broadly be judged on two fronts: The response to the HIV epidemic and the functioning of the public healthcare system and its related institutions. The verdicts in these two instances are quite different.

Turning the page on Aids denialism

Until September 2008 Thabo Mbeki was President of South Africa and Manto Tshabalala-Msimang Minister of Health. The Mbeki and Tshabalala-Msimang years were years of state-sponsored Aids denialism. The details of those terrible years will not be recounted here, except to say that South Africa needed to make a clean break from it. That clean break started with the appointment of Barbara Hogan as Minister of Health in September 2008.

Building on years of resistance and the hard work of many principled activists, lawyers, healthcare workers, and some politicians, Hogan spoke clearly about HIV and Aids and ended the policy madness of the Mbeki and Manto years. Hogan was in the position for only eight months before she was replaced by Motsoaledi.

Arguably the biggest job facing Motsoaledi when he took office in May 2009 was to accelerate the provision of antiretroviral treatment. Motsoaledi had some credibility owing to his time in the Limpopo provincial government and the fact that he is a medical doctor. He was also energetic, passionate and outspoken. All of this made him a great figurehead for the establishment of the world’s biggest antiretroviral treatment programme.

The numbers are worth looking at carefully. In 1994 an estimated 15,000 people died of Aids in South Africa. Deaths increased rapidly during the worst years of Aids denialism to a peak of around 273,000 in 2005. When Motsoaledi took office in 2009, Aids deaths had already dropped somewhat from the 2005 peak to around 195,000. By 2017 (eight years into Motsoaledi’s time in office) it had dropped much further to around 89,000. (In 2019 it is estimated at around 80,000 — but it is better to emphasise the 2017 figures given that they are more reliable.)

The decrease in Aids deaths over the past decade is particularly impressive given that the absolute number of people living with HIV has been increasing over the same time period. People are still contracting HIV, but antiretroviral treatment has clearly kept hundreds of thousands, or even a few million, people alive who would otherwise be dead by now. When Motsoaledi took office in 2009 about 792,000 people were receiving antiretroviral treatment. Today that number is estimated to be more than 4.7 million.

Important context to the Motsoaledi years is also to be found in changes in life expectancy. In 1994 life expectancy at birth was about 63.1. In 2017 it is estimated to have been about 65.2 (about 66 in 2019). The increase over the 1994 level is thus marginal and does not suggest massive improvements in public healthcare in the post-apartheid era. Between 1994 and now, however, things first got very bad and then better again.

Life expectancy declined to an incredibly low 53.8 in 2004, driven mostly by Aids deaths. As with Aids deaths, the recovery in life expectancy was already underway when Motsoaledi was appointed in 2009 (with life expectancy having risen to around 58.3 by then).

Either way, the increases in life expectancy in the Motsoaledi years are better thought of as a recovery from the specific disaster of Aids denialism than a general improvement in the quality of healthcare services.

Ultimately, the HIV epidemic would probably have been bad no matter what, but government intransigence in the early 2000s undoubtedly made it much, much worse than it would have been otherwise. Similarly, while things had already started to turn by the time Motsoaledi was appointed in 2009, he used what positive momentum there was to accelerate the provision of treatment, saving many, many lives in the process. For this, he deserves immense credit.

But what happened to the healthcare system?

If Motsoaledi took the baton from Hogan regarding HIV, he seems to have dropped the baton when it came to the healthcare system. In her short stint as Health Minister Hogan commissioned a series of reports into the public healthcare system in various problems. These so-called Integrated Support Team reports still stand as some of the best diagnoses of the problems in our public healthcare system. Ten years later, it seems these reports are still gathering dust and most of the problems they identify remain or have become worse.

Generalising about the public healthcare system is not always fair. There is significant variation between provinces, between districts and between individual facilities. There are undoubtedly many qualified and committed people out there putting in the hours for the communities they serve. But there are also persistent reports of under-staffing, long waiting times, patients sleeping on the floor and worse.

While much information is anecdotal, and while the media tends to focus on some of the worst cases, there are objective reasons to be very worried. So, for example, it is hard to argue against the deeply depressing picture painted by the reports of the office of Health Standards Compliance.

It is also hard to look at tragedies such as Life Esidimeni in Gauteng, the oncology crisis in KwaZulu-Natal, and the persistent problems with emergency medical services in multiple provinces without concluding that these are symptoms of deep-seated dysfunction in provincial health departments. The president himself talks of a “crisis”.

There was a sense in the Motsoaledi years that there was always a new crisis, always a new fire to put out, and that there was just never enough capacity in the National Department to deal with it all. Often short-term interventions were found.

After our Death and Dying report exposed serious problems in the Eastern Cape healthcare system in 2014, the Minister moved swiftly to intervene. Emergency plans were made and announced at a press conference. But then the Minister and the media moved on and things slowly reverted to the way they were.

After the PharmaGate scandal of 2014, Motsoaledi made headlines by describing the pharmaceutical industry plot to derail law reform efforts in South Africa as “genocide”, but strident as his public statements were at the time, he never used his powers to issue a compulsory licence on an overpriced medicine, nor did he expend much political capital on reform of South Africa’s outdated patent laws.

Similarly, while Motsoaledi was an outspoken critic of the private healthcare sector in South Africa, the draft report of the Competition Commission’s Health Market Inquiry leaves little doubt that he failed to use the levers he had at his disposal to regulate the private sector.

How to make sense of all this?

One version of the past 10 years would see Motsoaledi as a victim of the politics of State Capture. As good as his intentions may have been, unruly provincial health departments, often beset with corruption, made it impossible for him to implement.

For example, various Free State MECs for Health and the head of the Provincial Health Department were essentially untouchable, given that they were protected by Ace Magashule, Free State Premier for much of the Motsoaledi years. It could be argued that if Motsoaledi stuck his head out too far, Zuma would have fired him, and that he was therefore justified in playing the long game, much like Ramaphosa. There is definitely something to this excuse, but it only takes you so far.

As an aside, while Motsoaledi, like Ramaphosa, could and should arguably have done more to arrest the institutionalisation of corruption in the state, it is important to recognise that he was one of a small number of ministers who stood up against former President Jacob Zuma when the political crunch came in 2017. He was brave and right to do this and, quite apart from what he may or may not have done in healthcare, deserves credit for it.

A second version of the last 10 years would hold Motsoaledi and those close to him at the National Department responsible for much of the systemic failures in the healthcare system. It could be argued that the National Health Act gives the Minister much greater powers to interfere in provinces than Motsoaledi was ever willing to use. It could also be argued that what influence he did have in provinces, was not always used particularly well.

For example, the National Department of Health has relative control over the HIV conditional grant (having to approve business plans submitted by provinces), yet the grant was grossly misused in the North West to pay a private ambulance company. In addition, rather than allowing dysfunction in provinces to be exposed, Motsoaledi’s instinct was often to spin his way out of it — take the specific problem seriously, deny that it is systemic, protect your ANC comrades in the provinces.

While unruly provinces are one thing, there are various national level processes and institutions that Motsoaledi had significant influence over in his decade in office. Today the Special Investigating Unit (SIU) is looking into alleged corruption at the Health Professions Council, the National Health Laboratory Service and the ongoing problem of fraudulent medico-legal claims against the state.

Motsoaledi both supported the appointment of persons now suspected of corruption and failed to intervene effectively when the extent of some of these problems became apparent. That the SIU has now been asked to mop up, does not reflect well on Motsoaledi’s leadership – although the politicised Hawks and National Prosecuting Authority did not make things easy for him.

Some critically important policies were allowed to expire, such as the Human Resources for Health Policy in 2017, which has not yet been replaced. The need for a single electronic health records system for the public healthcare system has been a priority for years, but progress has been painfully slow. National Health Insurance has been on the cards for ages, but when a draft bill was published in 2018 it was half-baked and lacked clarity in various key areas, such as the role of provinces.

State Capture or unruly provinces cannot be blamed for these policy and leadership failings. Something else has clearly gone wrong.

Even so, while the healthcare system and many of the institutions meant to support it have struggled in the Motsoaledi years, these failings are arguably outweighed by the tremendous growth of the HIV treatment programme and the many lives that have been saved through this programme. The numbers do not lie.

In the final analysis then, Motsoaledi is likely to be remembered primarily as the minister who definitively closed the book on Aids denialism and made sure that millions of people living with HIV received life-saving antiretroviral therapy.

Note: Figures quoted in this article are taken from the Thembisa model outputs version 4.1.

 

 

 

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AIDS2018: UNAIDS LEAKS! Will Amsterdam Be UNAIDS’ Last Stand?

According to leaked information about UNAIDS Executive Director Michel Sidibe’s correspondence with McKinsey and Company, 2018 will mark the beginning of the end of UNAIDS: the embattled leader has hatched a plot to begin dismantling the agency as soon as this year, writes Paula Donovan.

It’s no secret that the 2018 international AIDS conference this week in

Amsterdam is Michel Sidibe’s last with UNAIDS. His second and final term as

Michel Sidibé. Credit:Wikimedia

Executive Director is officially due to end in January 2020. But according to leaked information about his correspondence with McKinsey and Company, 2018 will also mark the beginning of the end of UNAIDS: the embattled leader has hatched a plot to begin dismantling the agency as soon as this year.

Many people may never have heard of the influential United States-based management consulting firm McKinsey until the company brought itself into disrepute by bilking the South African government of R1.028 billion through an illegal contract with the public utility Eskom. When caught, McKinsey apologized and did penance by repaying some of the funds. But that scandal may never have come to light if South Africa were not a sophisticated democracy, with a Constitution that guarantees the right of access to information “to everyone when that information is required for the exercise or protection of any rights.”

The United Nations is uniquely different. For anyone seeking truth from the United Nations, there is no right to freedom of information. Just the opposite: UN immunity gives the Organisation the right to withhold records and information, releasing them only at the Secretary-General’s discretion. From the deadly cholera epidemic in Haiti, to the sexual assault of children and women in the Central African Republic, to impunity for abuse of authority and sexual harassment enjoyed since the 1940s by countless, mostly male officials throughout the UN system, leaks can be the only hope of justice where freedom of information is denied.

Am I positively sure that what I’m divulging here is 100 per cent accurate? No. Does my experience with UN leaks cause me to believe that this particular information is true? Yes. And do I think that it’s worth taking the risk, given the likelihood that history will repeat itself, that the UN will deny all accusations, that Member States will have no “appetite” to investigate, that there will be ample time to destroy any evidence, and ultimately, that proof may be impossible to authenticate? Yes, it’s worth it; change doesn’t happen unless we take risks.

The distressing leaked information begins with advice given to Michel Sidibe by McKinsey and a very few, very high-level UN officials in New York, just after an internal WHO investigation closed a case of alleged sexual assault made against then-UNAIDS Deputy Executive Director Luiz Loures, and a claim against Sidibe himself, who was accused of interfering and trying to halt the ongoing investigation. The UN officials involved in dispensing advice were none other than Deputy Secretary-General Amina Mohammed and Jan Beagle. Ms Beagle served alongside Sidibe’s dear friend and accused serial sex abuser Luiz Loures as the second Deputy Executive Director of UNAIDS. While she herself was under investigation for harassing staff at UNAIDS, she was promoted by the Secretary-General to the top management and human resource position in the UN system. Not long after, United Nations Secretary General Antonio Gutteres chose her to lead the UN’s task force on—you guessed it—sexual harassment. All three UN officials are savvy enough to use private email accounts that can’t be tracked by UN investigators.

The transcripts of investigators’ interviews in the Loures case and the final reports had been sent to the Code Blue campaign, and under the pressure we caused by exposing the whole process for the sham that it was, the Secretary-General announced his intention to re-open the case — after Loures retired, and without asking the claimant if she wanted to start all over again. She doesn’t.

I share the view that the UN’s internal, hidden “judicial” processes are haphazard, unprofessional, and firmly biased in favor of the accused. For instance, WHO Director-General Tedros, whose investigators did such an appalling job the first time around, has been given the role of judge in round two. In the leaked correspondence, Sidibe asks the Deputy SG to keep him updated about the re-opened investigation. She says yes, I’ll phone you this evening, and he reassures her that he’s spoken with Tedros, who’s in the loop.

As hopeless as it seems, even one future UN leader might behave differently if 0105, the Office of Internal Oversight Services, were to ask just a few questions about the damage-control collusion among Sidibe, McKinsey, and UN headquarters. But will 010S ever ask senior UN officials why they used private email accounts to discuss highly sensitive UN business, knowing that only UN emails can be inspected by 010S? Will Under-Secretary-General for Management Jan Beagle be questioned about her advice to Michel (whom he addresses as “my dear sister”) that he clear the house? Will investigators ever dig into McKinsey’s concurrence—”I agree with Jan”—and their guidance that the problem with a Guardian newspaper partial exposé of the Loures case was “not how to remove the external perception but how to manage your reputation and the impact of the news on you”? Will the Deputy-Secretary-General be asked by 0105 whether, in reference to plans for an expert panel, she’d ever have said to Sidibe, “I would suggest that we make the recommendations of the commission look like they will achieve the way forward” if she’d been using her official UN email? Will anyone be asked how much the UN is paying for advice from McKinsey such as, “Michel, if everything stays as it is, please do not expose yourself further and let the dust settle, including with the SG,” or who prompted Mr Gutteres to play his part by announcing, months ago now, that the Loures case would be reopened — never to be mentioned again?

The leaks jump several weeks ahead to that plan to shut down UNAIDS, which Mr. Sidibe devised with McKinsey for the Secretary-General’s approval, via Amina Mohammed. They show that while he was threatening staff that they must unite behind him and mobilize women living with HIV to do the same, or else UNAIDS would come crashing down, he was simultaneously carving out a role for himself as grand marshal of the demolition. The plan: slash 40 per cent of UNAIDS staff, shovel the remainder into a newly designed “global public health” unit located somewhere within the UN, and —the cherry on top for wealthy, fatigued donor governments — end the AIDS exceptionalism that UNAIDS has championed vocally for over a decade. (After such a cold-blooded betrayal, can tears work again to persuade loyalists that it’s all the fault of others?)

The scheme has Sidibe heading up the “transition” with the aid of an external management consulting firm. McKinsey seems the obvious candidate. And as noted, without leaks, the protective shield of immunity allows the UN to hide the expense of the company’s exorbitantly priced advice. I wish I were surprised by the UN’s lack of concern about the role their crisis-management gurus played in the Eskom scandal in South Africa, or about the public exposure that forced McKinsey to end its $20 million contract with the federal US Immigration and Customs Enforcement agency, ICE, which is now famous for separating undocumented families crossing the US-Mexico border and locking up their children. In words reminiscent of the UN’s mantra of “zero tolerance for sexual exploitation and abuse,” the company’s Managing Director promised staff that the firm won’t do any more work that “advances or assists policies that are at odds with our values.” McKinsey and UNAIDS may be a perfect match.

It seems that at this point, there are two possible scenarios in play: perhaps UNAIDS and McKinsey consider it a triumph to have waged the world’s single most expensive and far-reaching damage-control campaign ever attempted by one man to discredit the MeToo movement. The student faithfully followed his coaches’ strategies: stay busy; phrase any apology as “if anyone misunderstood or was offended” in order to remain fully in charge; travel the world, whatever the cost, cooking up awards to give out as magnets to draw important people into your personal photographer’s range; meet, greet, and tweet about your one-on-ones with as many world leaders as humanly possible (and in a pinch, tweeting a selfie of yourself with a photo of Queen Elizabeth is second-best); terrorize staff into believing that if the captain goes down, the ship goes with it. At the Amsterdam AIDS conference, scatter employees throughout your audience who’ll jump to their feet and start the applause as soon as their leader takes the stage. Don’t worry unduly about Member States; they don’t want or expect change. As Amina Mohammed knows, the Programme Coordinating Board will be satisfied with a low-energy “review” culminating in easily implemented recommendations, all drawn up by UNAIDS in advance: a survey, a hotline, a series of meetings (same script, different titles: town halls, focus groups, civil society consultations…), a series of posters, a voluntary compact, and a pledge to redouble your efforts to ensure zero tolerance. Of course, two times zero is often the simplest “way forward.”

If one possibility is that McKinsey is declaring Sidibe victorious, another is that the Secretary-General struck a grand bargain: he may have offered a guarantee that he’d offer his full support without a shred of evidence if Sidibe would just devise a “game-changing solution” for the SG’s funding woes. They may have come to a gentleman’s agreement that if sacrificing the UN’s joint programme on AIDS is what it will take to show the US a leaner budget, well, you win some, you lose some.

As reasonable people, we should probably all be depressed about what these leaks reveal, and about the near-certain knowledge that like so many revelations before them, they’ll be repudiated and then ignored. But for the first time since we launched our Code Blue Campaign to end impunity for sexual abuse by UN personnel, we can see women (feminists, that is; not female replicas of the most ruthless male leaders) all over the world calling the shots where sexual conduct is concerned. So I’m actually feeling hopeful. The UN thinks that it’s beating the MeToo movement, but they’re always a generation behind. Everyone else’s day of reckoning is arriving; the UN’s day will come. – The views expressed in this opinion piece are the author’s own and not that of Spotlight or the Daily Maverick.

On 24 July, UNAIDS sent the following response via email:
Your article of July 22 on UNAIDS is based on false and fabricated
information. The UNAIDS leadership has not engaged in any
consultations with Mckinsey or United Nations senior staff on the
future of UNAIDS. The value of UNAIDS is clear. The dedicated staff of
UNAIDS are our greatest asset. We have unfinished business as
demonstrated by our recent report “Miles to go”. Together with our
partners, we are focused on delivering on our goals.
Yours sincerely,
Sophie Barton-Knott
Communications Manager
  • Paula Donovan is Co-Director of AIDS-Free World and its Code Blue Campaign. Donovan has served as senior advisor to the UN Special Envoy for HIV/AIDS in Africa from 2003 to 2006.   Between 2000 and 2003, she was posted in Nairobi as UNICEF regional advisor on HIV/AIDS for eastern and southern Africa, and then as UNIFEM’s Africa-wide gender and AIDS advisor.  Donovan worked for UNICEF at its international headquarters throughout the 1990s; she started her work in international relations as director of communications at the US Committee for UNICEF in the late 1980s. Donovan was the first to call for a UN agency devoted to women. UN Women was ultimately established in 2011. Among her accomplishments with AIDS-Free World, Paula Donovan forced the World Health Organization to re-examine the connection between contraceptive injections and the transmission of HIV; forced UNICEF to abandon a dangerous and ill-conceived HIV scheme called “The Mother-Baby Pack”;  successfully demanded UNAIDS, WHO, and UNICEF stop the use of single-dose Nevirapine; championed the quest for justice for Zimbabwean women raped during the elections of 2008; joined the fight to overcome child marriage by making it an issue of child labour; and initiated and led the campaign of eliminating immunity for sexual violence committed by UN peacekeeping personnel.  Donovan co-direct AIDS-Free World with Stephen Lewis.

Editorial note: The views expressed in this article are that of Donovan and does not necessarily reflect the views of Spotlight. The editors of Spotlight are conscious of the seriousness of the allegations made in this article. We are also conscious of the risks taken by those who leaked documents and the need to protect whistle-blowers. While we are not in a position to verify all allegations made in this article, we nevertheless consider the allegations to be credible and the publication of these allegations to be in the public interest. Should Mr Sidibe wish to submit a response to these allegations, we undertake to publish his response on Spotlight.

 

 

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AIDS2018 Breaking News: Zero HIV transmissions in PARTNER study after gay couples had sex 77,000 times without condoms – an undetectable viral load stops HIV

By Simon Collins, HIV i-Base

On Tuesday 24 July, the results from the extension to the PARTNER study were presented by Alison Rodger at a press conference at AIDS 2018, ahead of the main conference presentation. [1, 2]

After eight years the study was unable to find a single linked HIV transmission when viral load was undetectable, even after 783 couples had sex without condoms 77,000 times.

The results show that ART is as effective for gay men at preventing HIV transmission as it is for heterosexuals. They actually provide an even greater level of evidence for gay men as the first PARTNER results provided for heterosexual couples in 2014.

PARTNER extended to include more gay couples

The second phase of the PARTNER study included some participants from the first phase (which started in 2010) but was expanded from 2014 to 2018 to just enrol gay men.

PARTNER 2 included 972 gay couples where one partner was HIV positive and on effective treatment (ART) and one partner was HIV negative. Before joining the study, couples were already not using condoms. Participants also completed routine confidential questionnaires on their sex life.

To be included in the analysis, only periods when couples had sex without condoms (and without PEP or PrEP) were included, and when the positive partner had undetectable viral load (defined as being less than 200 copies/mL).

Overall, this led to data from 783 couples contributing 1596 couple years of follow up (CYFU). The main reasons for follow-up time not being included in the analysis (477 CYFU), was not having sex without condoms during that period (33%), use of PrEP or PEP (24%) viral load not available (18%) or other missing data. Less than 5% (only ~25 CYFU) were due to viral load being >200 copies/mL.

Median age was 43 (IQR: 31-46) and couples had already been having sex without condoms for a median of 1.0 years (IQR: 0.4 to 2.9). The positive partners had been on ART for a median of 4.0 years (IQR: 2.0 to 9.0), with high adherence (98% participants took >90% of meds), and 93% self-reported having an undetectable viral load.

Result: zero linked HIV transmissions after having sex 77,000 times without condoms

During median 1.6 years of follow-up (IQR: 0.9 to 2.9), couples had sex without condoms about once a week. The average (median) was 43 times a year (IQR: 19 to 74). And during the study this added up to almost 77,000 times.

Many of these couples were in open relationships and 37% of the HIV negative partners reported having other sexual partners. During follow-up, 24% of the negative partners and 27% of the positive partners reported at least one STI.

Over eight years, 15 HIV negative partners did become HIV positive. Importantly, all the new infections were with HIV that was structurally too different to be linked to their main partner. Phylogenetic analysis compared was the pol region of HIV in 15/15 paired cases and for env region in 13/15, with differences that were sufficiently distinct to rule out linked transmissions.

Range of theoretical risk – allowing for chance

An important aspect of the PARTNER study was to quantify risk. So even when no transmissions occurred, the study also reported an upper range of risk that might be possible, given that data is always limited. This is the 95% confidence interval (95%CI).

The initial PARTNER study produced an upper 95%CI of 0.46/100 CYFU overall, which is equivalent to a worst case of a couple needing to have sex for about 200 years for a transmission to occur. This is the highest level – in reality, this would be more likely to take thousands of years. Because two-thirds of participants were heterosexual, this figure was higher for gay men at 0.84/100 CYFU.

The new results from PARTNER2 are able to reduce the upper 95%CI to 0.23/100 CYFU for overall risk in gay couples: equivalent to a worst case when a couple would need to have sex for 400 years – if the true risk is at the upper 95%CI level.

The 95%CI was calculated using the 77,000 times that couples had sex without condoms. As this is a factor of number of CYFU, by definition, this figure becomes higher for sub-groups of risk. For example, the upper 95%CI for insertive anal sex was 0.27 (based on more than 52,000 times), 0.43 for receptive anal sex without ejaculation (>23,000 times), and 0.57 for receptive anal sex with ejaculation (based on 20,000 times). In the subgroup that included sex with a recent STI, the upper 95%CI was 2.9/100.

Note that these events add up to more than 77,000, as individuals could report more than one type of activity when they had sex.

Conclusion: PARTNER2 supports U=U

The PARTNER study was designed to provide a careful dataset that individuals could use as a basis for their own personal decisions. In doing this, even with extensive follow-up over eight years, the study has not been able to find a single case where HIV transmission occurred when viral load was undetectable (defined as less than 200 copies/mL).

The results provide the largest dataset to show how effectively HIV treatment prevents sexual HIV transmission. They support the U=U campaign that an undetectable viral load makes HIV untransmittable.

The research group have also produced a non-technical Q&A resource to cover additional questions. [3]

Note: this report has been published before the main conference presentation because of the IAS policy of choosing to hold press conferences before rather than after the researchers have presented their full results.

The report is based on early press access to the presentation slides. The embargo was lifted at the start of the related press conference but this report will be updated, if appropriate, after the full presentation.

Simon Collins is a community representative on the PARTNER study.

COMMENT

After eight years of trying to find a case of transmission with undetectable viral load, we have a dataset that covers both gay and straight sex – without a single linked transmission.

The PARTNER researchers should be acknowledged for extending the initial PARTNER study for another four years to produce an equitable level of confidence for gay men as for heterosexual couples.

Enrolling, following and retaining couples over eight years has been a considerable achievement. The complexity and the rigour of the phylogenetic analysis prove that none of the transmissions were linked.

As receptive anal sex carries a higher HIV risk than vaginal sex, these data can also reasonably be used to inform the risk from heterosexual anal sex.

This shows the risk of HIV transmission with an undetectable viral load to be effectively zero.

References

  1. Press conference. PARTNER study results. Tuesday 24 July 2018. 9.00 am.
    http://www.aids2018.org/Media-Centre/Resources/Press-programme
  2. Rodger A et al. Risk of HIV transmission through condomless sex in MSM couples with suppressive ART: The PARTNER2 Study extended results in gay men. AIDS 2018, 23-27 July 2018, Amsterdam. Late breaker oral abstract WEAX0104LB.
    http://programme.aids2018.org/Abstract/Abstract/13470
  3. PARTNER study Q&A.
    https://chip.dk/Studies/PARTNER

THIS ARTICLE IS REPRODUCED WITH THE KIND PERMISSION OF i-base.

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AIDS2018: Reduction in price of bedaquiline welcome, but is it enough?

This week the price of bedaquiline in the public sector in South Africa was cut in half. What does this mean for the increased uptake of this critically important TB drug across the world?

This week at the International AIDS Conference South Africa’s Minister of Health Dr Aaron Motsoaledi announced that the South African government had negotiated a much-reduced price for the multi-drug resistant tuberculosis (MDR-TB) drug bedaquiline.

Bedaquiline is something of a break-through drug being one of only two new TB drugs approved in the last half-a-century. The South African government recently announced that bedaquiline will replace kanamycin injections in the country’s standard treatment for MDR-TB. This decision has been widely welcomed given the serious side-effects, such as irreversible hearing-loss, related to the painful injections. It is expected that the World Health Organization and other high-TB-burden countries will follow South Africa’s lead.

The new price announced by Minister Motsoaledi is $400 (around R5400) for a six-month treatment course. This is down from a price of $750 according to Motsoaledi. The figure quoted to Spotlight by the Department of Health last month was $820. Either way, the South African government has managed to negotiate a price drop of around 50%. For this they deserve credit.

More good news is that the new price will also be available to countries purchasing bedaquiline through the Global Drug Facility and to countries that benefited from the soon-to-end bedaquiline donation programme. It is now up to these countries to update their MDR-TB treatment guidelines and to ensure that all people who can benefit from the drug has access to it. So far, uptake of bedaquiline outside of South Africa has been depressingly poor and many people are still being exposed to hearing-loss causing injections of doubtful efficacy.

And yet, even the $400 price is far from ideal. Researchers from the University of Liverpool have estimated that bedaquline could be produced and sold at a profit for under $100. The researchers did however assume much larger volumes than current demand – so that price might not be realistic right away. It is with this in mind that activists recently demanded that bedaquiline should be priced no higher than $200 for a six-month course. Whether this demand played a role in the price-cut is not known.

For some perspective, a year’s supply of first line antiretrovirals costs the South African government about $100. Six months of drug susceptible TB treatment (a full course) costs less than $30. It should also be kept in mind that bedaquiline is just one of multiple drugs used for MDR-TB and the entire MDR-TB drug regimen will thus cost much more than $400.

It seems likely that for bedaquline to become available to all people who need it across the world the price will have to be dropped further. Then said, this week’s price-cuts is a firm step in the right direction. It is now up to countries to start scaling up use of this drug and over time to negotiate further price cuts.

Low is both an editor of Spotlight and a member of the Global TB Community Advisory Board, one of the organisations that demanded a reduction in the price of bedaquiline. The views expressed in this article are his own.

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AIDS2018: Delegates walk out on Sidibe

Hundreds of delegates walked out of the opening of the International AIDS Conference in Amsterdam last night in protest when UNAIDS Executive Director Michel Sidibe took the stage.  By Kerry Cullinan, Health-e News Service

Before the walkout, a group of African women read out a statement describing Sidibe as “aider and abetter of sexual harassment” for his handling of a sexual assault case against his former deputy, Luiz Loures.

The women called for Sidibe to step down, then walked out, followed by a large number of delegates.

Before Sidibe took to the stage, the celebrity-studded opening event had focused on young people and people marginalized and at particular risk of HIV, including sex workers and injecting drug users.

Dutch Princess Mabel warned that, unless the real needs of girls and young women were addressed, “we could lose an entire generation to HIV”.

Focus on youth

Two 20-year-olds who were born with HIV, Mercy Ngulube and Ukranian Yana Panfilova, urged governments to do more to reach young people with sex education to protect them against HIV.

Professor Linda-Gail Bekker, AIDS 2018 International Chair and University of Cape Town scientist, said that HIV infections had increased by 30 % in Eastern Europe and Central Asia since 2010.

“They are the only region in the world to show an increase in HIV, largely because of injecting drug use,” said Bekker.

Actress Dame Elizabeth Taylor addressed the last AIDs conference held in Amsterdam 26 years ago, and last night her grandson, Quinn Tivey, and granddaughters Naomi and Laela Wilding continued the family tradition.

Tivey described the fight against HIV as a fight for human rights and social justice, while his cousin Naomi called for lesbian and gay rights to be recognized.

Dinah, a transgender sex worker activist living with HIV welcomed the 15,000 delegates to Amsterdam with a sober message: “Trans sex workers face exclusion, discrimination and violence and we have the highest rates of murder and suicide.”

Tedros Adhanom Gebreheyesus, Director General, World Health Organisation, warned that there are still too many people who cannot get HIV treatment as it is not available in their country, they can’t afford it or they can’t get access to it.

“We cannot be complacent about the end of HIV,” warned Tedros.

The conference, which lasts until Friday, will also be addressed by Prince Harry, Charlize Theron, Bill Clinton and Elton John. – Health-e News.

 

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AIDS2018: G23 women draw a line in the sand

This is a statement read out by the group of 23 women as Michel Sidibe took to the stage at the opening plenary.

“…a political struggle that does not have women at the heart of it, above it, below it, and within it is not struggle at all.” – Arundhati Roy

We are the group of 23 women who dared to step into the light, to place ourselves at the heart of it, below it and within it. We dared to put pen to paper and say we will not keep quiet, that we will speak for those who have spoken and were silenced and for those who were too afraid to go public.

We have continued to speak out, we have met, written, consulted, spoken, begged, asked and spoken some more…everything we do is in solidarity with women, women who have for too long been forced to stay in the dark. We have stepped into the light.

We have been disappointed many, many times, but we have been in the struggle long enough to know this is a marathon, not a sprint and that victory is certain.

We feel strongly that there is a lack of respect, that individuals such as UNAIDS Chief Michel Sidibe, who has been an enabler and protector of sexual harassment, continues to be invited into women’s spaces, into spaces we occupy and fought hard to be in. That him being given platforms, is a secondary violation.

We hold no brief, we have no political ambitions, there is no monetary reward, we are simply a group of individual women who are speaking for ourselves, our daughters, our sisters, our mothers, our Comrades…who have for too long been silenced because we know we are up against a patriarchy machine which is well oiled and well-funded.

We refuse to hide behind structures and organisations to symbolically show other women we can show up for each other without asking for permission or a mandate.

We have been stripped of our dignity and power, but again we rise!

We do not ask for much:

  1. We call on donors to continue supporting us and our struggle. We have heard too many stories of donors and those who sign the cheques using their power to bully and threaten those who dare challenge the power and position of people like Michel Sidibe.
  2. We appeal to Michel Sidibe to step away from his scripted, spun, rehearsed propaganda machine and for once to look us in the eye and speak the truth. No more tears, let’s speak honestly and let’s make the difficult decisions.

Today we draw a panty line…not to be sensational, but because we have drawn a symbolic line in the sand. The panties symbolize the continuous violence against women and our struggles. They violate us daily, we continue to bleed.

We also note the information revealed by our sister at AIDS-Free World Paula Donovan, showing that we are up against a big, well paid machine. That we are the cannon fodder as big men and their women battle to cover their tracks. We will not be silenced, the AIDS struggle will not be sacrificed.

AIDS 2018 in Amsterdam will be remembered as a moment where women drew a line in the sand. It will be our #MeToo #UsToo moment.

We invite all allies of women, all believers that women rights are human rights to show your support at this conference, to add your voice. Each time you speak or present in a session, say one thing, beam it on the screen: “I Believe Her! Silence is violence! Time for change is now!”

An attack on women’s bodies is an attack on the AIDS struggle.

Signed by Group of 23 Women:

Vuyiseka Dubula, Activist, former TAC Secretary General, South Africa

Nomfundo Eland, Feminist Activist, South Africa

Shereen Essof, Feminist Activist, International

Dr Tlaleng Mofokeng, SHRR Expert, South Africa

Sisonke Msimang, Writer, South Africa & Australia

Sipho Mthati, Activist, Former TAC Secretary General, South Africa

Dr Lydia Buzaalirwa, Activist, Uganda

Aisha Kangere, Activist, Uganda

Martha Tholanah, Feminist, Zimbabwe

Seehaam Samaai, African Feminist Lawyer, South Africa

Alice Kayongo, Feminist Activist, Uganda

Lucinda van den Heever, African Feminist and Queer activist, South Africa

Winnie Muiisa, Activist, Uganda

Prima Kwangala, Advocate, Uganda

Polly Clayden, United Kingdom

Dr Francoise Louis, Activist, South Africa

Irene Omoding, Activist, Uganda

Oluwakemi Gbadamosi, Activist, Uganda

Peace Nyangoma, Activist, Uganda

Vuyokazi Matiso-Gonyela, Feminist, South Africa

Yvette Raphael, Feminist, South Africa

Dr Cecilia Natembo, Activist, Uganda

Salome Ssekakoni, Activist, USA

Lebo Ramofoko, Activist, South Africa

Steve Letsike, Activist, South Africa

Sharon Ekambaram, Feminist, South Africa

For interviews, pls contact via Whatsapp:

Vuyiseka Dubula +27 82 763 3005

Vuyokazi Gonyela +27 73 636 1373

Yvette Raphael +27 76 612 7704

 

 

 

 

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AIDS2018: Time to make AIDS political again

By Anele Yawa

Two years ago, we welcomed the world to the International AIDS Conference

Anele Yawa at the Durban2016 march

in Durban, South Africa. At a march of ten thousand people we held up banners proclaiming that 20 million people still need treatment. At that conference we said to the world that AIDS is not over – and indeed, the misguided rhetoric about the end of AIDS have now given way to more sober, more realistic assessments. The reality is that we are still in the thick of it.

In South Africa, as in many other countries, the first phase of the global AIDS response was a fight for policy. It was a fight for the idea that governments have a responsibility to do whatever they need to do to get HIV treatment to the people who need it. In our country it involved various court cases and a fight against AIDS denialism. Around the world it required a massive effort by activists, researchers, diplomats, progressive business persons and willing governments. Our shared success is something to be celebrated.

That said, the victories of this first phase of our struggle against HIV has to be won again and again. We cannot take the recognition of the human rights of all people for granted nor can we take the affordability of medicines for granted. As we hear reports of plans to shut down UNAIDS without any public consultation, we can’t take even United Nations support for granted. As we know too well, we can’t take continued political will or funding from our governments for the AIDS response for granted either. All this work from the first phase of the AIDS response must continue and we must support each other in it.

Almost everyone agrees today that we need to provide prevention, treatment and care to all who need it. The wide adoption of the 90-90-90 targets are testimony to that consensus. We have reached a point in the AIDS response where the question is not so much what to do, but rather how to actually get it done given the state of our healthcare systems.

We now know that policy victories and innovative technical interventions can only take us so far. In South Africa, and in many other countries, the AIDS response has come up against a wall. This wall is the widespread dysfunction in our healthcare systems. It doesn’t matter how good our donor-written policies are if they are never implemented. It is no use if we have medicines in depots, but the medicines never reach the people in the clinics. Beautiful guidelines for treatment and care mean little if we refuse to employ healthcare workers to actually provide the treatment and care.

As TAC we we are very clear: Our struggle against HIV is now in a new phase, a phase where our fundamental struggle is against dysfunction, mismanagement and corruption in our public healthcare system.

This new phase of our struggle is, in its way, much harder than the struggles against AIDS denialism and profiteering pharmaceutical companies. There are fewer victories to be had in laws or in policies. The problems we face are much more diffuse and harder to influence. Meetings in board rooms in Geneva, New York or Amsterdam matter less in this phase of our struggle, while community meetings in Lusikisiki and Khayelitsha matter more and more.

As TAC we have in recent years attempted to create accountability across the public healthcare system in South Africa. Our 200 branches spread across the country have each adopted a clinic – where our members, all users of the public healthcare system, both monitor and provide support where possible. Where issues persist, we escalate them to district or provincial level, and if needs be to the National Department of Health. Let me be clear, the more we monitor, and the more systematically we monitor, the more disturbed we get about the near collapse of our public healthcare system.

Our recent monitoring reports on seven of South Africa’s nine provinces paint a very bleak picture. In these and in our previous reports, it has become clear that TB infection control measures are grossly deficient in many facilities – turning many clinic waiting areas into likely transmission areas. Our diagnosis of widespread dysfunction in public sector facilities is confirmed by devastating reports from the Office of Health Standards Compliance (a statutory health inspection body that reports to parliament).

The crisis in many of our public facilities does not come from nowhere. Over the last decade, on the watch of former President Jacob Zuma, corruption has flourished in South Africa and the public service has been systematically hollowed out. This has directly impacted the healthcare system and the AIDS response.

It is worth recounting some details. Recently in emerged that millions ear-marked for HIV in the North West province was looted to pay overinflated prices to a controversial ambulance company that is now the subject of police investigations. This is while over 200 000 HIV treatment eligible people in that province are not yet on treatment.

In the same province strikes resulted in the shutdown of the public healthcare system, a shutdown that meant medicines distribution had stopped completely for weeks on end. Some shared treatment with others, others paid high prices in private pharmacies, many simply defaulted. These strikes, and a similarly disruptive strike at a Gauteng hospital, suggest that more healthcare workers are now prepared to strike in ways that place patients at risk. It tells us that the ethos of public service has dangerously eroded.

Of course, there are still many good people trying to do their best within a failing system. The tragedy though is that there is so little help for them. While some politicians come when there is a strike or a protest, they generally show little interest in fixing the underlying problems plaguing the system. Indeed, many officials in provincial departments of health have been appointed for political reasons or with corrupt motives and have neither the inclination or the ability to start turning the system around. And even with Jacob Zuma gone, the balance of powers in the ANC is such that many corrupt and underperforming persons remain firmly in place.

Part of why Cyril Ramaphosa is now President of South Africa is a deal he made with David Mabuza, the former Premier of Mpumalanga province and now Deputy President of South Africa. Mabuza has generally been associated with some of the more unsavoury characters in the ruling party and on his watch Mpumlanga politics was mired in alleged corruption. As Deputy President Mabuza is also now the new head of the South African National AIDS Council, a body already ridden in controversy over the way it removed its former CEO and its failure to deal decisively with conflicts of interest. While Premier in Mpumlanga and chairing that province’s provincial AIDS council, Mabuza failed completely to address that province’s severe HIV crisis, not to mention the general corruption of that province’s government.

That Mabuza is now making some of the right noises on HIV and TB is of course welcome and we will hold him to his words. That our government has finally approved a progressive new policy on patents and medicines 17 years after the Doha Declaration is also welcome. That our Department of Health has shown urgency in introducing new medicines such as bedaquiline for MDR-TB and dolutegravir for HIV is to be applauded.

But, as Minister Aaron Motsoaledi recently admitted, South Africa’s healthcare system is in crisis. From our national department he has tried to stop the crisis, but in South Africa the healthcare system is run by provinces and Motsoaledi has been powerless to get the provinces into line. The underlying reality is that inside the borders of South Africa, our internationally popular Minister is severely hamstrung by his lack of political power.

Ultimately, as with all the issues we faced in the first phase of our struggle, the second phase is also fundamentally political. And as we have to address the patronage networks within our ruling party in South Africa, we call on our international allies to address the distorted values of the current United States administration and to seek out again the international solidarity that made our movement as successful as it once was.

As the world gathers in Amsterdam for the 22nd International AIDS Conference, my appeal to you is to once again make AIDS political. Just like the gag rule and Global Fund withdrawal is political, the failure in my country to act against corrupt individuals is political. The potential shutdown of UNAIDS and the mishandling of sexual harassment at the agency is political. In recent years we have too often played nice with our elected leaders and as a result they have come to believe that AIDS is almost over. We must once again take the gloves off and make AIDS political. We have elected our leaders, we demand that they deliver the AIDS response and the healthcare systems we need.

Anele Yawa is the General Secretary of the Treatment Action Campaign. The TAC is a South African membership-based organisation that advocates for the rights and interests of people living with and affected by HIV and TB.

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AIDS2018: Tangerine, a Thai transgender programme that works

Almost everyone in the HIV world is talking about providing services to key populations – a ground-breaking project in Thailand is providing an example of how to go about it. They kindly answered Spotlight’s questions.

 Q: What is the Tangerine project and how does it work?

A: The “Tangerine” Community Health Center is the first transgender-specific sexual health and wellbeing clinic in Thailand and in Asia. Launched in November 2015, Tangerine offers fee-based healthcare services that is situated in an Anonymous Clinic at the largest HIV testing facility in Bangkok at the Thai Red Cross AIDS Research Centre (TRCARC).

The transgender healthcare services include gender affirmative hormone treatment (GAHT) and other sexual health services covering HIV testing and counseling, testing and treatment for other sexually transmitted infections, vaccination for viral hepatitis A, hepatitis B and human papillomavirus (HPV). In addition, the clinic offers antiretroviral treatment (ART), post-exposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP).

Q: What practical steps do you take to create a welcoming environment for trans people?

A: TRCARC conducted a series of transgender community consultations with diverse members of transgender communities, including transgender advocates, healthcare providers, those working within the fashion industry, as well as transgender sex workers. Through the extensive consultations, TRCARC understood the barriers and the unmet health needs. The consultations revealed that transgender people faced obstacles in accessing hormone level monitoring and treatment, the most basic health services that they regularly require to affirm their gender identity. The services available in general are not transgender-friendly, or even worse are provided outside the medical profession. Hormone treatment services were identified as the entry point to make the clinic attractive to its target populations. At the end of the consultation, the name “Tangerine”, the slogan “Where transition fulfils identities” and the logo were mutually adopted.

After the consultation, TRCARC Director Professor Praphan Phanuphak supported all healthcare staff to attend the training on “gender sensitization in healthcare settings” before providing direct services to transgender clients. This created the learning platform between healthcare providers and transgender communities. At the same time, the Tangerine protocol was developed by Dr. Frits van Griensven, which was adapted from international guidelines in order to make it appropriate within the local Thai context. This included hormone supplies, hormone therapy monitoring, and interpretation of laboratory results. Data collection forms were also designed to respond to gender identity, sexual orientation and sex assigned at birth.

Tangerine officially opened in late November 2015 and became the first clinic catering specifically to the needs of transgender people in Bangkok. Funding from the United States Agency for International Development (USAID) through the LINKAGES Thailand Project covered the costs of the community consultations, certain healthcare staff, communications, trainings and research studies conducted to specifically address sexual health concerns among transgender people.

Q: What positive outcomes have you seen?

A: From November 2015 to December 2017, there were 1 184 transgender individuals receiving services from Tangerine with 4 501 visits. Of those, 972 were transgender women (TGW) and 212 were transgender men (TGM). Of those TGW, median (IQR) age was 25.4 (22.5-30) years, 55% had education below bachelor’s degree, 25% were unemployed, 56% used alcohol, and 10% used amphetamine-type stimulants. The HIV testing rate among TGW was 91%, with 12% HIV prevalence. 80% were successfully initiated on antiretroviral therapy.

Compared to clients not accessing GAHT services, GAHT service clients were more likely to re-visit the clinic (50% vs. 34%, p<0.001), had higher rates of repeat HIV testing (32% vs. 25%, p=0.019), repeat syphilis testing (14% vs. 9%, p=0.026), PrEP uptake (10% vs. 6%, p=0.015), and use of other sexual health services, including hepatitis B testing/vaccination and sexually transmitted infection treatment (50% vs. 34%, p<0.001).

Recently, Tangerine has intensively utilized transgender influencers as an online-to-offline social media strategy to better reach transgender individuals at high risk for HIV infection, including those who are young and first-time HIV testers. From October 2017-January 2018, there were 247 (60%) transgender clients from online, out of 411 clients.

Jiratchaya Sirimongkolnawin (Mo), Miss Tiffany’s Universe 2016 and Miss International Queen 2017

“Tangerine is the clinic that addressing my several health needs, including hormone treatment. The staff here were very friendly and knowledgeable. Having the HIV testing was no longer fearful for me.” Jiratchaya Sirimongkolnawin (Mo), Miss Tiffany’s Universe 2016 and Miss International Queen 2017

Q: What lessons have you learnt from the project?

A: Some lessons learned from Tangerine are:

  • Its strong foundation was built on meaningful participation of the transgender communities at the nascent stage.
  • The clinic’s transgender staff who are members of people living with HIV and who represent vulnerable community, have also proven essential to ensuring that the clinic continues to offer accessible, transgender-friendly services and remains in close contact with the needs of the community it serves.
  • Support to enhance knowledge exchange between the trans community and health professionals is necessary to increase access to and provision of transgender health services, aiming at ending AIDS in Thailand and the region.
  • The model that integrates gender affirmative hormone services and sexual health services is feasible and effective in increasing access to and retention in HIV testing and PrEP service uptake.
  • Available data from Tangerine increases visibility of transgender people in the National AIDS Program and will be further used for the development and refinement of a comprehensive health service package and policy advocacy for transgender people in Thailand.

Tangerine also provides technical assistance to community-based organizations – Sisters Foundation in Pattaya, Mplus Foundation in Chiang Mai, and Rainbow Sky Association of Thailand in Bangkok and Songkhla- in replicating the comprehensive health service model.  The community health workers were trained on GAHT and hormone dispensing in different local settings.

Q: What advice could you give to people trying to set up similar projects in other places like e.g. South Africa?

A: In establishing a transgender health project, it is essential to engage transgender communities at the beginning including planning, implementation, and evaluation. This will help you understand their needs and truly respond to the needs of the populations you serve.

Substantial involvement from healthcare providers and leadership from your organization is also fundamental as it will be translated into policy, action and resources. The combination of transgender staff and cisgender staff will help create a learning platform in the healthcare environment and will build mutual trust between transgender communities and healthcare providers.

You may not need to have a full service package at the formation, but you will need to come up with a minimum service package, based on what the communities really need such as hormone counseling, hormone level measurement integrated with other sexual health and HIV services. You can start with a gender-responsive data collection form and gender sensitisation for healthcare team. The services can be integrated in different settings such as public health facilities, MSM-focused community-based organisations or standalone health centres, depending on resources, population size and sustainability.