Talking to teens about sex and protection

By Nomatter Ndebele

It was business as usual at the International Aids conference in Durban in July 2016. The South African Minister of Health was about to address a plenary session when two young girls took to the stage. One made a beeline for the Minister and the microphone, while another stood with a placard about the effects of a lack of sanitary towels. Together, the Treatment Action Campaign’s (TAC) Ntombizodwa Maphosa and Tina Power set the agenda for young people at the international aids conference.

It was not a new conversation. For years, health activists have called for condoms and sanitary wear to be available in schools but their pleas have fallen on deaf ears. The only thing that changed were the numbers, and as the saying goes, numbers don’t lie.

The government’s National Strategic Plan (NSP) for 2012-2016 had envisaged an increase in male condom distribution from 492 million in 2010-11 to 1 billion, and 5.1 million female condoms in 2010-2011 to 25 million by 2016. Despite having set these goals four years ago, new infections are still on the rise.

Providing condoms in school has been a contentious issue within South African communities for a long time. Some argue that giving condoms to schoolchildren will only encourage them to become sexually active and therefore put learners at risk of teenage pregnancy as well as the transmission of diseases. Others have argued that creating easier access to condoms while including more in-depth sexual education within the life orientation curriculum, will help to curb the incidence of teenage pregnancy and HIV/AIDS infection rates among the youth.

The TAC has been at the forefront of the call for condoms and a comprehensive sexual education programme in schools. The TAC’s biggest concern, as explained by the National Women’s representative, Portia Serote, is that the law pertaining to the sexual rights of children is so contradictory that it is difficult to implement an effective plan to address the needs of learners for sexual education and access to contraception. One section of the Constitution, for example, defines a minor as being anyone under the age of 18, but another section states that having any sexual relations with anyone under the age of 16 is statutory rape.

The policy on condoms in schools gives power to school governing bodies (SGBs) to decide on whether or not they want condoms to be made accessible to learners. St Enda’s Secondary School in Johannesburg is one of those that has decided not to do so.

When interviewed by Spotlight, the principal, Moti, is somewhat dismissive of the idea, believing that it would be inappropriate, and should not even be promoted to children under the age of 18: ‛We wouldn’t want that,’ he says. ‛We are already dealing with a lot of external factors.’ The school is situated in the heart of Hillbrow and students and teachers are surrounded by drug dens and easy access to alcohol. For the principal, the last thing they want to do as a school is add to the long list of issues they battle with daily.

Although this is the official policy of the school, there are teachers who think providing access to condoms to pupils would not be a bad idea. One such educator is Afrikaans teacher Lenshur Abdul, who has also become the unofficial life orientation teacher.

‛At grade 11, there is no sexual education covered in the curriculum,’ she says. When students come knocking on her door, Abdul does her best to answer questions around sexuality, and sometimes refers them to the biology teacher.

According to Moti, the school also has the services of counsellors who engage with the learners in a general forum, to identify any issues that they may have. If necessary, children are referred to a social worker. The principal points out that although these programmes are available, he is not always privy to the information due to patient/counsellor confidentiality.

This year, reportedly, four girls have had babies, and two are currently pregnant. These numbers are, however, disputed by Moti, who believes that two girls fell pregnant this year and that one is currently pregnant. The principal confirms that learners who become pregnant are allowed to return to school.

‛How can we not talk to the children about these issues?’ asks Abdul. ‛In school we are trying to prepare them for the world ,which has HIV/AIDS, accidents and cancer,’ says Abdul.

Although debates continue about the morality and in some instances the feasibility of providing condoms in schools, the statistics continue to paint a worrying a picture. In South Africa, 2,000 schoolgirl pregnancies a week are reported – there is clearly a problem.

The MEC of Education, Panyaza Lesufi, says that recent statistics are enough to convince him that it is time to overhaul the entire approach to sexual education and access to contraceptives in schools. ‛We need to radically change whatever policy we had before, the statistics show that we are losing the battle, if 2,000 girls are newly impregnated, we cannot glorify such a policy,’ he says.

‛Pregnancy is not a scary thing anymore’

Sanele Zwane and his grade 11 friends, Lerato Ndlovu and Eva Malie, speak freely about pregnancy. Earlier this year a classmate of theirs fell pregnant. Zwane tells us, when she discovered she was pregnant, she started telling all the people in her grade not to be surprised if they didn’t see her later in the year, as she was going to having a baby. ‛She literally told everyone, even people she isn’t close to,’ Zwane recalls.

It is a reality they all face, and they are well aware of the various forms of contraception. ‛I think the Government just wants to cut down on the levels of teenage pregnancy, all they are really worried about is getting pregnant, but there is no counselling around sex,’ says Ndlovu.

‛Not talking about it (sex) is not helping us,’ adds Malie.

For these learners, what matters most is counselling that will provide them with emotional support, to prepare them to engage in sexual intercourse.

‛Nobody speaks to us about what it actually means [to have sex] with someone,’ says Ndlovu. Her beliefs around sex and abstinence are anchored in her religion. She believes that sex is sacred: ‛You can’t just go around giving everyone a piece of your soul,’ she explains.

Despite having different reasons for wanting to abstain from sex, the group is united in their view that a lot more should be done to provide social and emotional support about sex and teenage pregnancy. For most children, it is not easy to have a conversation about sex with their parents, there are questions that cannot be asked.

‛You know how our parents are, if you even try and bring these issues up, you are shut down immediately,’ says Zwane.

The generational gap between youngsters and parents is also evident between learners and the creators of the educational curriculum. ‛Our ministers and the MEC are from the 80s – they actually need to connect more with the youth,’ says Zwane.

‛I feel like the people who create these textbooks don’t even consult the youth,’ Malie adds.

Although Zwane and his peers are well aware of contraceptive methods, they have not thought as far ahead as the prevention of HIV/AIDS. For these 16-year-olds, pregnancy is a bigger scandal and an even bigger shame. ‛People can see your tummy, but nobody will ever know you have HIV/AIDS.’

A focus on HIV/AIDS advocacy is an issue that Health MEC Panyaza Lesufi has also identified. ‛We cannot wait until the 1st of December to start talking about HIV/AIDS; no schools should go without having posters about HIV/AIDS,’ he observes.

For Lesufi, the question of condoms in schools is not a moral question. ‛This has nothing to do with morals, it’s about taking collective responsibility,’ he says. We need to discuss the use of alcohol, we need to discuss drugs and sexual intercourse as being channels through which our children find themselves faced with issues of teenage pregnancy and being infected with HIV/AIDS.


Hearing a problem, and solving it

By Ntsiki Mpulo

Nombulelo Sojina* cradles her baby close to her chest in a kangaroo mothering-style of skin-to-skin

Air Mercy Services has provided doctors with essential transport and support to deliver specialist outreach services to remote regions in Kwa-Zulu Natal and through-out the country for over 50 years.
Air Mercy Services has provided doctors with essential transport and support to deliver specialist outreach services to remote regions in Kwa-Zulu Natal and through-out the country for over 50 years.

contact. The child’s tiny head is barely visible under the blanket in which she is swaddled. Two nursing sisters, tasked with conducting hearing screening tests on newborns, enter the maternity ward in which Sojina and her baby are resting. They explain that they need to insert a scope into the baby’s ears to determine whether she has any impairments.

‛Sojina’s baby was born prematurely, at just 30 weeks, and so the screening for hearing impairments is all the more crucial,’ says Ayanda Gina, an audiologist who is pioneering the newborn hearing screening programme at the Newcastle Mother and Child Hospital. The programme, which will help to identify hearing defects in children at birth, is part of Gina’s research towards her doctoral thesis.

She is working with Doctor Yougan Saman, Head of Discipline: Otorhinolaryngology and Head & Neck Surgery at Nelson R Mandela School of Medicine, University of KwaZulu-Natal. Although her training is in audiology, Gina dreams of following in her mentor’s footsteps and becoming an ear, nose and throat specialist.

Dr Saman has been involved with the KwaZulu-Natal Department of Health outreach programme since its inception. He regularly flies with Air Mercy Services (AMS) from Durban to support the doctors based at regional and district hospitals throughout the province. As head of the department, his main focus is to develop the services at these hospitals in order to alleviate congestion at tertiary hospital level.

‛When we started the outreach programme, I travelled to Newcastle Hospital by car,’ says Saman. ‛The three-hour journey was arduous and time consuming. I would drive up in the evening stay overnight, see patients for the day and drive back the following day, taking three days out of my schedule.
‛Now I’m able to make the trip in one day,’ he says. ‛With the support of AMS, we are able to give specialists the ability to work immediately and to develop skills in local doctors.
‛Essentially, this is what I have done with Ayanda. She has assumed more and more responsibility not only because she is keen to learn but because I have been able to impart on her the skills to enable her to drive this programme,’ says Dr Saman.

Gina supervises two enrolled nurses, three in-service personnel and a community service therapist within the hospital’s premises, and conducts outreach missions into the surrounding villages regarding hearing health for children. The World Health Organisation (WHO) estimates that there are 360 million people (328 million adults and 32 million children) worldwide with disabling hearing loss.

The WHO makes a distinction between congenital and acquired causes of hearing loss and describes congenital causes as those that may lead to hearing loss being present at or acquired soon after birth. These include maternal rubella, syphilis or certain other infections during pregnancy (low birth weight or a lack of oxygen at the time of birth) and severe jaundice in the neonatal period, which can damage the hearing nerve in a new-born infant.

In its latest fact sheet, the WHO states that half of all cases of hearing loss are avoidable with primary intervention. It is at this level that the teams hope to make an impact. The aim of the research is not only to identify potential hearing loss at an early stage but also to provide support for families whose children are identified to have hearing disabilities, including psychologist support and school assessment options.

‛If children are screened early enough, they may not need special schools,’ explains Gina. ‛With the right treatment, which may include hearing aids and speech therapy, we are essentially giving children the ability to communicate, which is crucial for their development.’
*Not her real name

Towards a workable plan

By Vuyokazi Gonyela, SECTION27

A key ingredient to ensuring our response to the AIDS and TB epidemics is effective, is having a workable plan. To that end, consultants and experts are working furiously to make sure South Africa has a new National Strategic Plan (NSP) to take us through to 2022.

But we know what is said about South Africa and our plans and policies: Full marks for great plans and policies; fail for implementation. The involvement of civil society is a critical component of a

The involvement of civil society is a critical component of a workable plan.
The involvement of civil society is a critical component of a workable plan.

workable plan. Established civil society structures already exist within the various AIDS councils at national, provincial and municipal (local or community) level but there is an unequal distribution of resources from the councils to these structures, which, in turn, means they struggle to get work done and to participate meaningfully in processes.

South Africa’s response to the HIV/AIDS, TB and Sexually Transmitted Infections (STI) epidemics requires coordination and leadership from various accountability structures, including the South African National AIDS Council (SANAC). This body hosts the National Civil Society Forum (CSF), which monitors progress on the implementation of the NSP and holds government accountable on behalf of the users and practitioners in the health-care system.

Theoretically, national structures that manage the HIV/AIDS TB and STI response should function in a manner that provides both leadership and support to provincial and local structures. But, provincial and local bodies need to be just as empowered to hold the government accountable – even more so – on behalf of the health-care users on the ground.

Despite this theoretical commitment to the development and strengthening of provincial structures, little has been done to provide these structures with the resources and authority that they need.

In provinces like the Eastern Cape, the struggles and difficulties are clearly visible. The province has struggled to implement strategies to respond to HIV/AIDS, which has left the community at a great disadvantage. Among the factors that impact negatively on the work to be done, is poor leadership. In the Eastern Cape, for example, the former elected CSF chairperson was last seen in 2015. This critical position was left unattended because the leader had other interests that compromised, not only the forum, but the entire provincial mandate.

The intervention campaign and strategies also need to adapt and respond to new data. Recent statistics indicate that the prevalence of HIV/AIDS has shifted from adolescents to young women and girls: the stats show about 2,363 new infections weekly in South Africa, with AYWG accounting for almost 1,750 of these infections.

The goal to end HIV/AIDS by 2030 is far from being realised, particularly because there is little investment in developing young leaders and creating more active citizens. They have a big role to pay and are central in our response to HIV if we truly want to deliver on the rhetoric of ending AIDS.

A further concern is that women are grossly under-represented within provincial leadership sectors tackling HIV. Across the nine provinces, the leadership is mainly dominated by men. Provincial CSF chairpersons sit on the Provincial Councils on AIDS as co-chairpersons; seven of the nine provincial chairs are male. The Eastern Cape took a bold stand in September 2016 and elected the first woman as a CSF chairperson. No attention is paid to this.

The voices of many women are suppressed in their households, communities and in leadership structures. Provincial AIDS structures need to take the lead, transform themselves, and support capacity-building female leadership as a critical investment, not only for the provinces but for the country. Nothing less will do.

Communities in crisis

By Treatment Action Campaign

The Treatment Action Campaign has shared the following stories with Spotlight from their provincial operations in KwaZulu-Natal, Limpopo, Mpumalanga and the Free State. Elsewhere in this issue of Spotlight we take an in-depth look at Gauteng – which is therefore not included here.

France, KwaZulu-Natal

Branch members go door to door in France to find out how people in the community cope without a clinic.

The community of France in KwaZulu-Natal does not have a clinic. A mobile clinic comes to the community just once a month. But most people don’t use it; some don’t even know about it. Instead they travel by taxi to other clinics – if they can find the money. Sometimes they must lie about where they live in order to see a nurse, or they simply go without medicines and health services altogether. Only certain community caregivers can deliver medicines to patients, if they have an ID, and if the patient is being treated at the mobile clinic. The rest, however ill, have to collect medicines themselves. It seems people are defaulting on ARVs, TB treatment and other chronic medicines as a result. We can never have #treatment4all – or #EndTB – when people can’t even get to the clinic. TAC members have asked the people of France how only having a mobile clinic affects them. The resounding response is that once a month is not enough. To resolve service deficiencies such as this one, which keep the dual epidemics burning, health system challenges must be addressed in the National Health Department’s test-and-treat plan and within the new National Strategic Plan on HIV, TB and STIs. Otherwise we are doomed.  #FranceNeedsAClinic.

Khujwana, Limpopo

Within a few hours of walking door to door through the streets of Khujwana it is clear there is a major problem. Every home has a story to tell – a story of frustration and suffering, a story of failure.

While the local clinic looks functional, even ‘pleasant’, from the outside with its solid infrastructure and garden, inside it s a totally different matter. Many patients report ongoing stockouts and shortages of their medicines. They wait for hours before being seen by anyone – there is a shortage of nurses and no doctors ever come. Some go to other clinics altogether. People report incidences of nurses treating them badly, being rude or, worse, negligent. Mothers report the indignity of having been mistreated, or unattended to, in the midst of labour. Khujwana Clinic is failing the people and the community it is meant to serve. Tired of this situation, the community is mobilising. Testimonies from community members who try to use the clinic are being gathered. Local stakeholders are coming together to draw attention to the major shortcomings. All they want is a clinic that can give them the health-care services they need. They are clear: They will continue to escalate this issue until they #FixKhujwanaClinic.

Boekenhouthoek, Mpumalanga

The local TAC branch in Boekenhouthoek receives ongoing complaints about the local clinic. People

In Boekhouthoek a TAC branch member takes testimony from a community member struggling to access health services.
In Boekhouthoek a TAC branch member takes testimony from a community member struggling to access health services.

report waiting for long periods of time, with or without being seen. There aren’t enough nurses stationed in the clinic exacerbating this issue. The clinic is too small, and people wait outside while waiting to be seen. The clinic is faced with regular stockouts and shortages of medicines meaning people are often sent home empty handed. Some community members choose to go to different clinics altogether. A luxury that many of those unemployed people who live in the area cannot afford. Traditional leaders confirm these conditions, from personal experience. One woman spoke of never receiving a TB diagnosis, months after taking a test. One man spoke of misdiagnosis. Another had never been told he had HIV, yet had been prescribed ARVs for more than four years with serious side effects. People reported of nurses being rude to them in moments of severe vulnerability. The TAC Boekenhouthoek branch is monitoring the clinic and gathering information from residents about the challenges they face. How can we reach #treatment4all if clinics run out of medicines? Or if people don’t want to use them because of the lengthy waits and poor service? The reality is that the dysfunction in our health-care system will stop the new HIV guidelines on test-and-treat from being a success. We need significant investment into stronger systems in order to respond to the HIV and TB epidemics. #BetterBoekenClinic

Phuthaditjhaba, Free State

Members of the TAC in Phuthaditjhaba have reported serious problems at Manapo Hospital that are putting people’s right to access health care in serious jeopardy. This report followed a strike by frustrated, overburdened staff members, including doctors, nurses, physiotherapists, porters, cleaners, and kitchen staff, who claimed to have not received pay for significant amounts of overtime since 2015. TAC members investigated the hospital and spoke to many patients entering and exiting the facility. Reports of long waiting times, a lack of nurses, doctors, and other staff being stretched beyond their capacity, and medicine shortages, were common.

After being stabbed in the forehead, one teenager reported not seeing a doctor after seven days of waiting. Another teenager had been stabbed in the upper chest four days earlier. He was also still waiting to see a doctor. A woman with a homemade sling and swollen wrist left the hospital in pain to return to the clinic. One man, falling in and out of consciousness, was told to return to casualty with a referral letter. Outside the hospital, visibly injured patients could be seen wandering the grounds in their pyjamas. After taking a rest on the grass, one young man with bandages across his face struggled to stand up and had to be assisted by two other patients to get onto his feet before limping back inside. Portable toilets remain outside the hospital after a water crisis the month before. It is unclear whether the water shortages continue. A TAC member helped a man with crutches who struggled to climb up the metal steps to enter the toilet. If urgent action is not taken to turn around this crisis, the TAC will be forced yet again to embark on a campaign of civil disobedience in order to save the lives of those reliant on the failing public health-care system. #FSHealthCrisis





Behind the headlines

By Marcus Low

Medical research findings are often sensationalised and overstated in the mainstream media. We debunk three cases of HIV-related misreporting that caught our eye in recent months.

Reports of HIV cure are misleading

In October, a number of mainly British newspapers and websites reported that we are on the brink of finding a cure for HIV. The reports were based on a trial called the RIVER (Research in Viral Eradication of HIV Reservoirs) trial – currently being conducted by the CHERUB Collaboration in the United Kingdom.

All 52 study participants in the RIVER trial are receiving antiretroviral therapy. Half of them are also receiving a vaccine and an extra drug called vorinostat. The hope is that vorinostat will ‘wake up’ dormant HIV hiding in the body that the immune system (primed by the vaccine) would then kill. The trial is one of a number of trials exploring potential strategies to cure HIV.

In reaction to the RIVER trial, the media made much of the fact that HIV was undetectable in one study participant’s blood. However, HIV becomes undetectable in the blood of most people who are stable on antiretroviral treatment. The researchers don’t know yet whether HIV is hiding elsewhere in the specific person’s body and whether it will remain undetectable when that person stops taking ARVs. The researchers were quick to issue a clarification stating, ‘Our study will report in 2018, and until then we will not know if the intervention has had an effect.’

‘An important clarification is that all participants involved in the study will be expected to have no HIV in their blood because they are receiving antiretroviral therapy – these are the standard drugs we use to treat HIV.

This does not mean they have been cured as some headlines have suggested. This does mean that their immune systems will recover and that they will not transmit the virus. We look forward to reviewing the final results of this ground-breaking study, but until then should emphasise that we cannot yet state whether any individual has responded to the intervention or been cured.’ – Researchers conducting the RIVER trial,

What is really happening with tenofovir resistance?

In January 2016, it was widely reported that people, especially in sub-Saharan Africa, are becoming resistant to the key antiretroviral drug tenofovir. Tenofovir is part of the standard first-line antiretroviral combination used to treat HIV in South Africa and many other countries.

An alarmist article on the BBC website reported, ‘HIV was resistant to the drug Tenofovir in 60% of selected cases in some African countries.’

The BBC – and other media houses – didn’t do enough to place the 60 percent figure in its proper context. In fact, the study (called TeNoRes) only looked at a very limited sub-set of people living with HIV – people who failed first-line antiretroviral treatment. Among this sub-group, 60 percent were resistant to tenofovir. This number is high, but not all that unexpected since people who fail first-line treatment almost by definition have some level of drug resistance. The study excluded the many people who are currently taking first-line treatment or who have not yet started taking treatment.

‘Although this study is important in providing data for the nature of acquired drug resistance, the choice of first-line regimens should be based on levels of drug resistance among individuals who have yet to start ART, known as pre-treatment drug resistance,’ Nathan Ford and colleagues wrote in The Lancet, commenting on the TeNoRes study. ‘Although updated data are needed, available data up to 2013 suggest that rates of transmitted tenofovir resistance remain low, at 0.4% in sub-Saharan Africa.’ (emphasis added)

Efavirenz liver side effects in context

In August, media widely reported a University of Cape Town study showing that the first-line antiretroviral drug efavirenz has been associated with severe liver damage in some very rare cases. While we do not object to the study being reported in the media, it is extremely important that reporting should be properly contextualised given South Africa’s history of AIDS denialism and fear-mongering about the side effects of life-saving antiretroviral therapy. Alarmist reporting could lead to people living with HIV endangering their lives by stopping, or not starting, antiretroviral therapy.

The study, published in the highly respected journal AIDS, described 81 cases of efavirenz-related liver injury. As a description of these liver injuries, the study makes an important contribution to our understanding of efavirenz. It is important to note, though, that this was not a study aimed at establishing how prevlalent such efavirenz-related injuries are.

Even so, newspapers in the Independent group reported: ‘About 4 million HIV-positive South Africans who rely on the states [sic] single dose antiretroviral treatment (ART) are at risk of grave liver damage and death due to elements contained in one of the drugs.’

The four million figure is wrong on two counts. Firstly, it is not true that four million people in the public sector are taking efavirenz. While the total number of people taking treatment in the public sector may be heading toward four million, a substantial number of them are taking second-line treatment, which does not contain efavirenz. Secondly, and more importantly, saying that everyone taking efavirenz is at risk, is sensationalist fear-mongering. It fails to place the very small risk associated with efavirenz in the context of its life-saving benefits. While only a minute percentage of people taking efavirenz will experience these liver side effects, close to 100 percent will experience the life-saving benefits of the drug.

Hoer! Magosha! Prossie! Doxy! – Why has the law on sex work not changed?

By Marlise Richter

Sex work is fully criminalised in South Africa.

This means that anyone who buys sex, who sells sex, or who helps facilitate a sex-work transaction can be prosecuted.

An installation by SWEAT highlighting the delays of the South African Law Reform Commission and the Department of Justice in transforming apartheid-era sex work laws.
An installation by SWEAT highlighting the delays of the South African Law Reform Commission and the Department of Justice in transforming apartheid-era sex work laws.

For years, advocates and sex workers have asked that the law on sex work be changed, and that all criminal elements are removed (the ‘decriminalisation’ of sex work).  Research has shown that this will reduce HIV, will make societies safer, and will respect the human rights of sex workers.

Yet, very little has happened. Why?

People do not like to think or talk about sex work (or prostitution). Except when they are rude or insulting towards other people, or when cracking ‘dirty jokes’ – mostly about women.

Many people associate sex with love, intimacy and perhaps even long-term relationships.  The idea of having sex with a stranger for money, and therefore selling sex as a job, is something that many people feel deeply uncomfortable with. They think selling sex is a ‘sin’, is ‘wrong’ or an insult to women, and want the criminal law to stamp it out. They don’t think about the fact that people have sex for many different reasons, and that adult, consensual sex is a private decision and should be free from state interference.

This prejudiced thinking is a form of sexual moralism – that is, making judgements about another person’s morality based on their sexual behaviour or preferences. Sexual moralism forms the core of homophobia and transphobia, and was the basis for outlawing sex across the colour bar in apartheid South Africa. Fortunately, our laws on sexual orientation and race have changed for the better and reflect our Constitutional values.

It is time that people challenge their own sexual moralism, and that we do the same on sex work!

Did Durban listen to sex workers?

By Ishtar Lakhani

This year marked the 21st International AIDS Conference (AIC) held in Durban – 16 years since this conference was last held on South African soil in 2000. So it was an apt time to ask what has

Richter and Steve Lambert ask plenary speakers at the 2016 AIDS Conference how long it will take before they mention sex work in their speeches
Richter and Steve Lambert ask plenary speakers at the 2016 AIDS Conference how long it will take before they mention sex work in their speeches

changed for sex workers in the last 16 years? The answer is, very little.

In those 16 years: the apartheid-era law that criminalises sex work remains unchanged; sex workers are still on the frontline in the battle against HIV/AIDS; violence against sex workers continues to occur with impunity, and sex workers are still stigmatised and discriminated against based on their occupation.

Undeterred by this lack of change, the Sex Workers Education and Advocacy Taskforce and the Sisonke Movement of Sex Workers in South Africa mobilised to put sex workers’ issues on the agenda at the IAC. We were there to make our struggle visible. We were there not only to occupy civil society spaces but to claim a space at the table that is usually reserved for the ‘professionals’ – doctors, scientists, politicians, policy makers. We were there as human rights’ activists, experts, and academics, to ensure there was ‘nothing about us, without us’.

Many of the conference sessions focused on sex work and sex workers are acknowledged globally as a ‘key affected population’ in HIV prevention, treatment and care, yet sex workers were barred from the conference – the very platforms that were created to ‘help us’. Two of our delegates were refused access to the conference because the accreditation process revealed they had previous criminal records and a number of our contingent experienced severe transphobia from conference organisers and security. The process was humiliating and a clear example of how criminalisation results in bizarre double-speak.

But these hurdles did not stop us. We arrived in our numbers determined not to be left outside. We were unrelenting and unapologetic in our calls to decriminalise sex work, and we can say with certainty that our voices were heard. Our voices were heard by our politicians (the Deputy Minister of the Department of Social Development wore our bright orange ‛This is what a sex worker looks like’ t-shirt), celebrities (Charlize Theron and Sir Elton John both showed their support for decriminalisation), and Constitutional Court Judge Edwin Cameron invited us to share the stage.

The question is now is not whether we were heard, but whether our voices are still ringing in the heads and hearts of South Africans. Will the Department of Justice finally release the South African Law Reform Report, whose process started 17 years ago? Will policy makers listen to the overwhelming evidence that decriminalisation is the best legal model to ensure that sex workers can access their rights? Will we be able to attend the next conference and not be criminals?


How PEPFAR’s anti-prostitution pledge impedes sex worker health

By Marlise Richter[1]
The US President’s Emergency Plan for AIDS Relief (PEPFAR) should end its anti-prostitution pledge. It prevents organisations that received PEPFAR money from advocating for law reform on sex work, which not only harms sex workers but is bad for health, especially HIV prevention and treatment.
PEPFAR is an initiative to diminish the impact of the global AIDS epidemic. During the 2016 International AIDS conference in Durban, PEPFAR pledged R5.7 billion ($410 million) towards the AIDS response in South Africa[2].

Between 2004 and 2014, PEPFAR invested $4.2 billion (approximately R47 billion) into HIV prevention, treatment and care in South Africa, and by the end of 2015, had assisted the South African government to achieve these remarkable goals:

  • Anti-retroviral treatment for 3 million people
  • Voluntary medical male circumcision for HIV prevention for 472,047 men
  • HIV testing and counselling for more than 9.9 million people
  • Care and support for 592,260 orphaned and vulnerable children affected by HIV/AIDS
  • Anti-retroviral treatment for 226,369 pregnant women living with HIV to reduce the risk of parent-to-child transmission[3]

Yet, there’s a big problem with PEPFAR funding. PEPFAR recipients have to commit to a perplexing promise: to oppose sex work. According to the USA’s ‛Leadership Act’, all recipients of PEPFAR money have to sign an agreement with PEPFAR that commits them to the following[4]:

No funds … may be used to provide assistance to any group or organisation that does not have a policy explicitly opposing prostitution and sex trafficking.

No funds … may be used to promote or advocate the legalisation or practice of prostitution or sex trafficking.

There are two problems with this ‛pledge’

(1) Muddled thinking: conflation between sex work and trafficking

Sex work relates to adult, consensual sex. It is a job, a way for people to make a living. Trafficking on the other hand is similar to sexual slavery and is a gross human rights violation.

The United Nations is clear that for a person to have been the victim of trafficking these conditions must be met:

(a) The person must have been moved.

(b) There must have been deception or coercion for the purposes of exploitation.

Trafficking and sex work are not the same thing, and conflating them is disrespectful to sex workers and minimises the severity of the crime of victims of human trafficking.

(2) Direct and ‘chilling’ effects on organisations working with sex workers

Some PEPFAR recipients have documented how the pledge has limited the access of sex workers to health care and increased their vulnerability. This following extract is from an interview with a representative of a PEPFAR-funded organisation in southern Africa:

‛Our organisation is committed to combination HIV prevention. Evidence shows that biomedical, behavioural and structural interventions are all important for HIV prevention. The PEPFAR agreement our organisation has signed inhibits our efforts in structural HIV prevention in the following three ways:

  1. Public health evidence is clear that that structural interventions, such as the decriminalisation of sex work, can be important to improving sex worker health outcomes and yet we are not allowed to talk about this in our work nor advocate for this.
  2. Governments are increasingly recognising that the criminalisation of sex work can be a structural driver of HIV and seeking ways to address it through law reform. PEPFAR requirements mean that we may not participate in these discussions during government-convened meetings on sex worker health; and
  3. One of the key problems we encounter in our direct health-care provision to sex workers is mitigating the effects of violence, rape and abuse that sex workers experience from clients and the general public. Evidence shows that the high levels of violence sex workers experience are directly related to the on-going criminalisation of sex work. We are prohibited from advocating for changes to this system, and are placed in a position where we have to only deal with the on-going consequences.’

The Global Network of Sex Work Projects criticises the pledge saying that no clear guidance has been given on what is prohibited and allowed under the pledge, that some organisations have limited their services to sex workers, have withdrawn their partnership with sex worker organisations, have suppressed information of their work with sex workers and have used vague terms like ‛women at risk’ or ‛vulnerable populations’ to disguise the fact that they work with sex workers.[5] This is bad not only for sex workers but for evidence-based medicine because, as the Global Network of Sex Projects explains, it is particularly difficult to evaluate what programmes are effective on sex work issues, and how HIV affects this population.
A case study: The Wits Reproductive Health and HIV Institute

A South African example of the implications of the PEPFAR Pledge is the Wits Reproductive Health and HIV Institute (WRHI) based in Johannesburg. This organisation has been providing health services specifically aimed at sex workers in inner-city Johannesburg since 1996. It started receiving PEPFAR funds in 2003, and was able to expand its services to a great number of sex workers. Until 2010, it was the only sex work-specific health-care service available in South Africa.

The institution has accumulated a wealth of information on sex worker health problems. The staff have vital first-hand knowledge of the detrimental impact of the criminal law on sex workers. The voices of WRHI staff would carry particular authority on the public health implications of the criminalisation of sex work, and the urgent need to decriminalise sex work in South Africa. But their voices are effectively silenced by the PEPFAR Pledge. Indeed, in 2002, one of the Institution’s doctors provided expert testimony in a Constitutional Court case in which the criminal law on sex work was challenged (St vs. Jordan 2002 (6) SA 642 (CC)). Under PEPFAR obligations, this likely would no longer be possible. In the context of current debates on law reform of sex work – and those looming in future – WRHI may not be able to present input or take a particular view on the matter.

PEPFAR has direct funding agreements with approximately 120 organisations in South Africa[6] and other organisations are in a similar position as the WRHI. The medical anthropologist Paul Farmer and his colleagues have argued that health-care workers are the ‛natural attorneys of the poor’. PEPFAR funding agreements effectively stop these ‛attorneys’ from PEPFAR-supported organisation from speaking out about the cruelty and human rights abuses of the current criminal system.

Various courts in the United States have ruled that the PEPFAR Pledge violates the right to free speech of organisations bound by it. Regrettably, the judgements only apply to USA NGOs and their foreign affiliates[7]. This creates the astonishing paradox that countries outside of the USA are bound by the Pledge, but not those working within the USA. Fortunately, the Pledge does not apply to the Global Fund to Fight AIDS, Tuberculosis and Malaria, the International AIDS Vaccine Initiative, or any United Nations agency.[8]

The PEPFAR Pledge was drafted under the leadership of George W Bush and the laws that authorise PEPFAR funding included a number of other provisions based on right-wing, religious approaches to HIV/AIDS. Since the election of Barack Obama as President of the USA, most of these ideology-based provisions have been changed to reflect current evidence on HIV/AIDS. The PEPFAR Anti-Prostitution Pledge, however, has not.

Scores of organisations and individuals in South Africa, Africa and Asia are bound by the PEPFAR Pledge and may not be able to risk speaking out against its requirements.

This places a greater responsibility on those of us who can speak out, to demand the repeal of the PEPFAR anti-Prostitution Pledge and to move to evidence-based policy on sex work and HIV.

PEPFAR Planned Funding in South Africa, 2004 – 2015 (USD in Millions) 5


Marlise works as a Policy Development & Advocacy Specialist at Sonke Gender Justice.

[2] ′PEPFAR Investing More Than $410 Million Towards an AIDS-Free Generation in South Africa′ Available:

Accessed 3 October 2016

[3] PEPFAR (2016) ′Partnering to achieve epidemic control in South Africa′, available:

[4] It also noted that ′Prostitution and other sexual victimisation are degrading to women and children and it should be the policy of the United States to eradicate such practices′ in H.R. 1298 – 108th Congress: United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003. (2003). In (database of federal legislation)

[5] Global Network of Sex Work Projects ′PEPFAR and Sex work′ Briefing Paper #01, available:


[7] Centre for Heath and Gender Equity ′Anti-Prostitution Loyalty Oath′, Fact Sheet, August 2015, available:

[8] CHANGE Centre for Health and Gender Equity ′All Women, All Rights, Sex Workers included – U.S. Foreign Assistance and the sexual and reproductive health and rights of female sex workers′, 2016



Don’t make us criminals

By Sally-Jean Shackleton[1]

Address presented at a session entitled ‛South Africa’s National Sex Worker HIV Plan: Are you coming?’ at the 2016 International AIDS Conference in Durban. For a video of sex worker rights activism at the conference, see:

After 16 years the International AIDS Conference again occupied the city of Durban.

Much has changed in the 16 years since those 12,000 researchers, policy makers, donors and activists came together for the first time in a developing country. South Africa at the time had the highest prevalence rate in the world and, under the leadership of Thabo Mbeki, was facing AIDS denialism.

The conference, under the theme Breaking the Silence, took place just six years after our first democratic elections and four years after we adopted our Constitution. At that time SWEAT (Sex Worker Education & Advocacy Taskforce) was four years old, recently registered as an independent organisation, and had begun the hard work of organising sex workers. The Sisonke Sex Workers movement was just a dream, and sex workers were idealistically waiting for change.

Law reform on sex work pre-dated the AIDS conference – it was 1999 when law reform on sex work was first mooted and in 2002 an issue paper was released by the Law Reform Commission.

Yet, criminalisation of sex work still remains on the agenda 14 years later.

The release of the last report resulting from a discussion paper in 2009 has been ‘imminent’ for three years now.
Just how serious are we about addressing the needs of sex workers?

There are four things you need to know about criminalisation of sex work: It harms sex workers; it enables corruption and abuse against sex workers; it drives stigma, and it erodes our efforts to end AIDS.

(1) Harms

  • Sex workers were at the AIDS conference [in their] numbers, although continued criminalisation meant sex workers had to wait at the doors while criminal records were checked and some, whose past records had been unearthed, had to argue to be let in. We had to explain why sex workers were here, we had to answer questions for security personnel. This is an excellent example of the barrier that criminalisation poses to sex workers.
  • Sex workers are arrested for having consensual sex while their rapists never see the inside of a jail cell.

(2) Corruption and abuse

  • The law against sex work doesn’t work – after almost 60 years of criminalisation, sex workers are still here. The only thing the law has done is enable police corruption and abuse. It allows violence against sex workers to continue unabated – crimes against sex workers go unreported and those who abuse sex workers can do so with impunity. For the most part, when a sex worker is murdered, no one faces justice.
  • Sex workers are jeered at in police stations, and told they cannot report rape because ‛sex workers can’t be raped’. Sex workers are profiled by police, fined exorbitant amounts under by-laws, and are jailed if they can’t pay. They are routinely asked for money – and for sex – in exchange for their release from custody[2].

(3) Stigma

  • Stigma is a machine oiled by criminalisation, justifying the actions of those who would shut sex workers out and refuse [them] health and other services. Stigma also means
    Members of the public are encouraged to ask the sex work questions about things they have always wanted to know.
    Members of the public are encouraged to ask the sex work questions about things they have always wanted to know.

    sex workers anticipate being treated unfairly at health-care clinics and delay seeking help, if at all, for their health problems or worries.

  • After all, sex workers are criminals. At the AIDS conference, we assumed we would be supported – but again, sex workers were pulled aside and questioned.
  • We have to ‘sensitise’ health-care workers and the police to do their jobs because sex work is stigmatised. Just like the entry to the Conference, we must answer questions before being let in.

(4) Erodes efforts to end AIDS

  • Sex workers and sex work allied organisations have a Plan, as delegates heard from the CEO of the South African National AIDS Council, Dr Abdullah. The Plan is comprehensive, it includes sex workers as peers, as partners, and sex workers collaborated in its development. It also includes the decriminalisation of sex work. It was launched in March this year, with our Deputy President affirming the urgency of its implementation.
  • We have evidence of a crisis, as heard from Prof Lane in a session at the AIDS Conference[3]. HIV prevalence in sex workers, to use the words of our Deputy President, ‛is the highest we have seen in any community’. HIV prevalence among sex workers is a judgement on South Africa’s HIV response. We have failed.

Can we say we are serious when our government, through the police, burns condoms provided by another arm of government?

Can we say we are serious when condoms are confiscated from sex workers as evidence of criminal activities?

Can we say we are serious about HIV when sex workers are refused access to this conference?

Can you say you are serious about the needs of sex workers when your commitment is only on paper, and not in practice?

Now that you know criminalisation harms sex workers here are some things you need to know about decriminalisation.

Based on evidence, decriminalisation will enable sex workers to address violence against them, enforce their rights and report violence against them[4].

Based on evidence, decriminalisation will not increase the number of sex workers exploited, women trafficked or children exploited[5].

Decriminalisation will not increase the demand for sex work – evidence suggests that the legal framework has little impact on the demand for sex work[6].

We have made so many gains since 2000: We changed the racist and oppressive laws that prevented progress; we progressed beyond AIDS denialism, and vastly improved the numbers of people on treatment.

The law that criminalises sex work is the last remaining apartheid era law and a significant barrier to progress in reducing infections among sex workers.

The Deputy Minister of Justice said in his address to delegates at the AIDS Conference on 18 July that his ministry had received a report from the Law Reform Commission, but Cabinet wanted to ‛form its own opinion’. He admitted that the law was not working. Deputy President Ramaphosa said in March that South Africa had ‛an inability to develop a coherent approach to the challenges facing sex workers’[7] – this is a clear indictment on criminalisation.

Courageous activists attended the AIDS Conference, and had to fight to be there. Some didn’t make it – we have lost many of our colleagues to untreated illness and violence.

Organisations delivering services to sex workers have done their work with significant funding and other challenges, and continue to do the work to ensure sex workers have access to prevention, treatment and care. Rights organisations like SWEAT, Sonke Gender Justice, Treatment Action Campaign and the Women’s Legal Centre continue to defend sex workers rights while the Sisonke Sex Workers Movement organises sex workers’ resistant to injustice.

We are asking for the same courage and commitment from our country’s leaders to make true the promise to leave no one behind, and decriminalise sex work.


[1] Director: Sex Worker Education & Advocacy Taskforce

[2] Police Abuse of Sex Workers: Data from cases reported to the Women′s Legal Centre between 2011 and 2015. Women’s Legal Centre April 2016, Cape Town.

[3] Prof Tim Lane UCSF 18 July, see South African Health Monitoring Survey: an Integrated Bio-Behavioural Survey Among Female Sex Workers

[4] The Impact of the Prostitution Reform Act on the Health and Safety Practices of Sex Workers – report to the Prostitution Law Review Committee Nov 2007, Gillian Abel, Lisa Fitzgerald Cheryl Brunton,

[5] Prostitution Law Reform in New Zealand, Prostitution Law Review Committee, New Zealand, June 2012

[6] Moving Beyond Supply and Demand Catchphrases: Assessing the uses and limitations of demand-based approaches in anti-trafficking – Global Alliance Against Traffic in Women

[7] News 24 Wim Pretorius 11 March 2016 ′Ramaphosa launches ″historic″ plan to aid sex workers′

Ambulance emergency in the Eastern Cape

By Mluleki Marongo, SECTION27 Researcher

If you call an ambulance in Johannesburg, there’s a good chance you will be in a hospital within 45 minutes; if you call an ambulance in rural Eastern Cape, you will probably die before it arrives. Sadly, that has been the case for decades.

During 2013, the community of Xhora, in the Xhora Mouth Administrative Area, lodged a complaint

Some people have told us they have never seen an ambulance before
Some people have told us they have never seen an ambulance before

with the South African Human Rights Commission (SAHRC) regarding the unavailability of ambulances in their community. In June 2014, the Eastern Cape Health Crisis Action Coalition made a submission to the SAHRC investigation into emergency medical services and planned patient transport in the Eastern Cape. The investigation by the SAHRC culminated in a provincial hearing in which it invited officials from the Eastern Cape Health Department (ECDoH), the Eastern Cape Department of Roads and Public Works, the Eastern Cape Provincial Treasury and more than seven communities, including Lusikisiki and East London. On 1 October 2015, the SAHRC issued a report in which it stated clearly that the ambulance service in the Eastern Cape did not meet the human rights obligation of the ECDoH. It then detailed ways in which the ECDoH should remedy the situation.

After the SAHRC hearing, the Coalition has been travelling to all the communities that participated in the hearing, and to other communities, to establish whether access to emergency medical services and patient transport in the Eastern cape has improved. The Coalition has spoken to and collected evidence, in the form of statements, from people living in Lusikisiki, Port St Johns, Mqanduli, Xhora mouth, Isilatsha, East London, Nier villages in Peddie, and on the outskirts of Port Elizabeth.

On the whole, the statements paint a picture of death and dying in the Eastern Cape. Families, surviving on social grants resort to hiring private vehicles when in need of emergency medical services, or die in their homes because ambulances never arrive. Those who hire vehicles sacrifice an average of R800 for a single trip to their closest hospital, giving the patient a chance of survival, but plunging the family deeper into poverty as the money used depletes funds for other household necessities, like food.

Three years into the investigation by the SAHRC, people are still living in the same conditions that existed when the investigation started, and even decades before that. Some people have told us they have never seen an ambulance before, and others have reported that it took more than five hours for an ambulance to arrive. Furthermore, because of the bad conditions of the roads leading to their homes, these patients often face a 10 to 20-minute walk to meet the ambulance that can’t reach their homes.

Where lives are at risk and human rights are at stake, how is it that in 2016 the biggest emergency many face is not having access to an ambulance?