We turn the spotlight on people living or working on the margins in South Africa. Referred to some as key populations, these folk – sex workers, trans people, MSMs, injecting drug users, LGBTQIA+ people – are at more risk of HIV and are often forgotten. Read about them here and then go to our website to read the longer stories.
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.
By Anele Yawa
Two years ago, we welcomed the world to the International AIDS Conference
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.
By Ngqabutho Mpofu
Dressed in a Robert Sobukwe Dashiki and trendy shoes, Thando Jack draws
gazes from the mainly white upper middle-class folk in Cape Town who can afford to be taking a stroll in the Company Gardens during a week day. They obviously try not to but there is something about him that captivates them.
When we start engaging, it becomes clear that it Is a genuine sense of love and concern about members of a community that embraced him that makes Thando do the work he does. It is alarming figures such as those released by UNAIDS that spur him on. According to UNAIDS, Men who have sex with Men (MSM) globally are a staggering 24 times more likely to be living with HIV than the general population. A 2015 study in South Africa found that 33.9% of gay-identified men in a research sample of 378 black MSM in the historic township of Soweto were found to be HIV positive. This is compounded by the finding that between 88% and 94% of MSM in South Africa were reported to not know their HIV status, in a context where high levels of concurrent sexual partners among the Soweto cohort, for instance, was reported by 73% of respondents.
It is these figures and his own lived experience as an MSM that led 28-year-old Thando Jack to becoming an activist since his late teens. His extreme passion for ensuring that MSM access affordable, quality health care services is clear from the moment he starts engaging.
Working as a data capturer at a prominent men’s health non-governmental organisation (NGO) in Cape Town, South Africa, Thando is at the coalface of clinical consultations focusing on ensuring that data involving HIV tests results, on the treatment programme, including the rate of defaulting, and on the outcomes of TB test results are meticulously captured. The organisation runs programmes in Cape Town and Johannesburg, as a result of the high MSM populations and the corresponding high risk of infections in these two cities.
Despite many gains, including a progressive Constitution and law reform that allows the LGBTI+ community to enjoy the same rights as heterosexual people, Thando is worried about numerous factors that continue to affect MSM’s access to healthcare services in South Africa, including stigma. “Many health workers are still not informed or sensitive about MSM issues when providing healthcare despite the numerous interventions of organisations such as Anova Health and Health4Men, who conduct sensitization trainings in health facilities across South Africa”, says Thando. “Just from engaging with a clinician in history taking and explaining how you got anal warts or Gonorrhea, you can see from the reaction that you are being discriminated against. It’s sad. You would hope that someone who has the courage to get out of bed to seek medical health care is not treated that way”, he says.
Sensitisation trainings occur for health practitioners in both public and private practice. The programme has a website that directs MSM to health practitioners who are MSM friendly. These are services that do involve greater awareness, tolerance of others and less stigmatization of health seekers on the basis of their sexual orientation. For Thando, it is imperative that programmes such as these are amplified to reach areas beyond just Johannesburg and Cape Town, as MSM in other areas will be better placed to seek health care services knowing they won’t face the discrimination they often still face. “There is still a need for more public and private health care workers to undergo this MSM sensitization training throughout the country, as only a certain portion have gone through this programme”, he says.
Ivan Toms clinic in Cape Town, which Thando highlights as an essential health care facility in improving the fight against HIV amongst MSM and the site from which they work has about 13 000 patients who leave their own communities and local clinics from areas as far flung as Paarl, Atlantis, Fish Hoek, Wellington, as well as nearby areas such as Khayelitsha, Phillipi, Gugulethu and Kraaifontein in order to access critical health care services from practitioners who are MSM friendly. They acknowledge the importance of the right to food through providing food and/or energy drinks to underweight patients in their road to health.
Having been born and raised in Gugulethu, and realizing the continued stigma faced by MSMs in his community when attempting to access healthcare, a critical worry of Thando’s is that safe spaces such as the health facility he works for will have to shut down their doors as a result of potential funding cuts from prominent international donor organisations. This could quite conceivably result in many defaulting and in an increase in avoidable deaths of many people, some of whom make up his close community.
The external stigma; continued fear of help seeking among men and the potential funding crisis form a deadly cocktail that would effectively place the gains made among MSM through the ‘universal test and treat’ policy from the national Department of Health in jeopardy.
For Thando, “when it comes to the needs of the MSM population and significantly reducing the rate of infections, it is important to find innovative ways and systems to help in fighting HIV. We need to keep up with new technologies and knowledge to do so, something we aren’t really doing at the moment.”
This article is part of a Spotlight special series on people who form part of so-called key populations.
 UNAIDS (2017), “Blind Spot: Reaching out to Men and Boys – Addressing a Blind Spot in the Response to HIV”, PDF.
 Lane T, Raymond HF, Dladla S, Rasethe J, Struthers H, McFarland W, et al. “High HIV prevalence among men who have sex with men in Soweto, South Africa: Results from the Soweto Men’s Study” in AIDS Behav. 2011;15(3):626–634.
 Ibid and Burrell E, Mark D, Grant R, Wood R, Bekker LG, “Sexual risk behaviours and HIV-1 prevalence among urban men who have sex with men in Cape Town, South Africa” in Sexual Health. 2010; 7 (2):149–153.
 Ivan Toms Clinic (2018), http://search.info4africa.org.za/Organisation?Id=83901., accessed 10 July 2018.
 Department of Health, “Re: Implementation of the Universal Test and Treat Strategy for HIV Positive Patients and Differentiated Care for Stable Patients”, http://www.sahivsoc.org/Files/22%208%2016%20Circular%20UTT%20%20%20Decongestion%20CCMT%20Directorate.pdf, accessed 10 July 2018.
By Nomatter Ndebele
Zizipho has flaming red hair that matches her clutch bag. Her demure pink
manicure matches her soft pink top. Initially, Zizipho gives nothing away, she doesn’t smile much, but when she does, she reveals a dazzling, disarming white smile, picture perfect teeth.
Zizipho has lived in South Africa for 10 years. In 2008 she ran away from Zimbabwe to start a new life in South Africa where she believed she could be free. Ten years later, Zimbabwe remains a country that has high levels of intolerance towards men who have sex with men. Zizipho recalls being called ugly names on the streets, as well as being beaten up by police officers for being gay. “You know how they are there,” she says.
One afternoon, tired of living on the margins of Zimbabwean society, Zizipho made her way to what she believes is the land of the free, South Africa. “I had heard that In South Africa, Gay people were free, they lived without anyone bothering them.” With nothing other than the clothes on her back and the idea of being free, Zizipho boarded a bus, to chase freedom.
South Africa is one of the first African countries to legalize same sex marriage. The country’s Civil Union Act was passed in 2006, following a 2005 Constitutional Court judgment instructing Parliament to pass legislation allowing same-sex couples to get married.
Almost 12 hours after boarding that bus Zizipho set foot in the so-called promised land. Her first mission was to pursue her life-long dream of Gender reassignment “I had always known that I wanted to be a woman, and when I started seeing adverts about it, I was even more convinced, so I started searching for someone who could help me,” she said.
In the beginning, Zizipho struggled. She could not find any reliable sources of information about the process of transitioning. For at least three years, Zizipho hit walls in her quest for useful information, but eventually she found her way to a doctor’s room in Hillbrow, Johannesburg. Desperate to speed the transitioning process up, Zizipho hardly bothered with all the pre-counselling. She told the doctor she knew everything there was to know about the process, and was ready to begin.
Today Zizipho is taking female hormones as part of her transitioning process. She knows very little about them and what they are doing to her body. “I’ve just noticed that I’ve started gaining weight and I don’t have to shave as often,” she says.
Zizipho has also decided that she will not go for voice training. “I love my voice, and I don’t want it to change,” she says decisively. So far during her transitioning, her voice is the one thing that gives it all away. “When I am walking in the street, men see a woman, but they are taken aback when they hear my booming voice.”
One of Zizipho’s challenges is that at first glance, most of her clients believe she is a woman, but when they see her penis, they are taken aback and become confused. “That’s very hard for people to understand, but I am very open, and when I explain what I’m going through, they often understand.”
Zizipho says that she has not met any hostility while living in South Africa, “I don’t have to hide, everyone in my neighborhood knows who I am, and they respect me, they never call me names.”
Despite the fact that her community has welcomed her with open arms, Zizipho is not ignorant about the groups of people who do not understand or accept what she is going through. Like other people we spoke to, she feels there is not enough support for people like her.
“You’ll never even find a support group or anything like that for people like us, they often Just mix us up, but we need to talk about our issues specifically,” says Zizipho.
This article is part of a Spotlight special series on people who form part of so-called key populations.
By Nomatter Ndebele
Carmen is impossible to miss. She comes sauntering down the road with her luscious black locks bouncing gently behind her, as she moves closer she casually drops her arms and reveals her toned abdomen, sporting a tattoo that rises to the side of her midriff.
Carmen is a transgender person who does sex work. Yesterday we met her as Clinton.
You wouldn’t say this was the same fidgety man we met in the blistering cold yesterday, trying to make his way to the drug dealer to calm his morning nerves. Today, Clinton is no more, and we are greeted by the beautiful Carmen.
Today, her face is softer, she is visibly more gentle and her voice has a softer tone to it. Her face is meticulously done up, highlighted and contoured to absolute perfection. She is a beautiful woman, with piercing hazel eyes and once they settle on you, she’s got you.
Carmen is about as key population as you can get: A transgender person who has been taking drugs from the age of 14 and who has been involved in sex work from the age of 18. If all the talk in the HIV world about serving key populations were being implemented, Carmen would have all the support she needs. However, this is not the reality.
Brixton Cemetery next to Vrededorp where we initially met Clinton is a hive of constant activity. While some rest, injecting drug users mill about to find spaces to take their hits. Sex workers look for spaces where they can provide services to their clients. In the evenings the cemetery comes alive with hundreds of destitute night dwellers.
Carmen has been a sex worker for 14 years now. She has gone from working in surreptitious establishments to picking up clients on the side of the road. Within her first year and a half of doing sex work Carmen calculates that she has provided sexual services to over 100 men. Most of these men are married and straight, she explains, all of them trying to live out their fantasies, in such a way that they never intersect with their daily realities.
Carmen has been dating her partner, Justin, for three years now. Justin has a job as a carpenter, he has dark brown hair, that match his eyes, and he too is addicted to heroin.
The two had to figure out how they were going to maintain their relationship, while Carmen continued with her sex work. “It was really hard in the beginning, but I guess I have got used to it by now and it doesn’t bother me as much,” says Justin. Out of respect for her partner, Carmen says she no longer “picks up” men on the side of the road and doesn’t wear feminine clothing as often, despite the fact that she can make a lot more money when she is dressed up.
On evenings where Carmen goes to meet clients, Justin waits patiently at home. “I wait for her and I pray that nothing bad happens to her out there, because you never know what could happen”, says Justin.
When Carmen is working her biggest priority is being safe. She never shares needles, not even with Justin and she never takes a client who refuses to use a condom. All of this however, Carmen had to learn on her own. She had to learn for herself that she did not have to have unprotected sex with anyone. It was her own knowledge of HIV that led to her making the firm decision to not share needles with other users. In Carmen’s case it was not even that services failed her, they simply don’t exist.
This article is part of a Spotlight special series on people who form part of so-called key populations.
Melusi Dlamini, AIDS Foundation South Africa
Melusi Dlamini shares his take on the state of play when it comes to the Sexual
and Reproductive Health Rights (SRHR) of the LGBTQIA+ community.
The overlaps between our progressive constitution and SRHR policies should enable a more effective realisation of SRHR rights for LGBTQIA+ persons; however, we are far from achieving this. There remain glaring gaps between policy and the lived realities of homosexual, bisexual and gender-nonconforming persons. While more than half (51%) of South Africans agree that human rights and inherent protections should be for all, seven out of 10 (72%) still believe that same-sex relations are ‘wrong’.
This is according to a survey by The Other Foundation titled Progessive Prudes – A survey of attitudes towards homosexuality & gender nonconformity in South Africa. South Africa remains a divided society on many fronts, and these divisions are reflected in the treatment and quality of services most queer persons receive. I use the word ‘queer’ here as an inclusive term, to signify the sexual orientations and gender identities that are normally encompassed by LGBTQIA+.
Instances of queer folk being victimised in public institutions are a dime a dozen. The trauma and humiliation suffered by queer persons demonstrates that accessing services is not a given. As a result, most of the queer persons I have encountered through my work usually have to think of all these possibilities before even approaching any public institution. This can have very serious repercussions if it relates to one’s health.
The National Strategic Plan and Accessing SRHR
Sexual and reproductive health rights (SRHR) are about the intersecting issues and concerns that affect the lives of all individuals. Most importantly, these rights – like any others – are legally recognised and protected.
Many queer persons depend on the public healthcare system; even so, access is not automatic. Factors such as gender and income inequality, unemployment, and living in a rural or urban setting have a profound effect on how or whether queer persons are able to access SRHR.
In addition, many queer persons struggle with issues such as mental wellness, owing to the internal and external pressures they experience. For queer persons, SRHR means having service providers who are not only ‘sensitised’, but also able to competently provide access to comprehensive services.
As a result, the role of public institutions is important, and the implementation of the National LGBTQIA+ HIV Plan is central.
The LGBTQIA+ plan is a great example of how South Africa is showing the intention to realise SRHR for queer persons. While the plan acknowledges the importance of reducing HIV infections among ‘key populations’, it is also important to expand psychosocial support and empowerment. The experiences of queer persons are not limited to sexual and reproductive concerns, and the range of services that offer inclusive and comprehensive information should reflect this.
Melusi Dlamini is the Sexual and Reproductive Health Rights Training Officer at the AIDS Foundation of South Africa. His interests include improving access to sexual and reproductive health rights for young people, as well as issues of social justice. Melusi has also worked with queer youth in Durban on creating safe spaces and access to healthcare. He is also a PhD candidate at the University of KwaZulu-Natal, with a specific interest in young masculinities in South Africa.