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.

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.

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.

 

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

 

 

 

 

AIDS2018: Humans in the Age of HIV-There was no one who came to visit them at their homes

By Ngqabutho Mpofu

Ronnie came out in the early 1980s, telling his friends and sister that he was

Ronnie. Pic by Joyrene Kramer

homosexual. This was not an easy thing to do, given the traditional Xhosa culture that he is from. He credits his support network for helping him come through that period in his life. Today he works in Observatory in Cape Town as a youth programme coordinator at a child and human rights programme.

He has been closely involved in issues affecting Men who have Sex with Men (MSM) for a long time, including as a (now former) board member of the Triangle Project, which focused on health issues affecting the LGBTI community.

Over the years he has witnessed the deaths of many comrades and friends as a result of HIV/AIDS related causes. “Most of the people that were in my (age) group have passed on because there was no support from government, they had no health support, there was no one who came to visit them at their homes, so they died in isolation”, says Ronnie.

He acknowledges that much has changed in the over 30 years since he came out, including the formation of initiatives run by the State and non-governmental organisations such as the Ivan Toms clinic, with programmes specifically tailored for MSM, which have yielded great results in terms of help-seeking[1] and greater access to health care amongst MSM.

Yet, Ronnie says there is still a very long way to go. Most of these health facilities are very far from the people who need them, which is problematic given the high levels of unemployment and poverty in the country. “Government needs to bring the services closer to the people through creating satellite clinics tailored for MSM. Unfortunately, we are still struggling with stigmatization and prejudice in South Africa against the LGBTI community in public health facilities”. This critical problem, which is not only limited to health care practitioners, but includes the attitudes of front line staff such as security guards, receptionists and cleaners, continues to severely stymie the country’s fight to attain its overall goal of an AIDS free population.

Ronnie argues that the state should implement mass sensitization campaigns so that staff in health facilities can acknowledge the LGBTI community and ensure that health care spaces are not spaces that they feel they cannot enter.

Community sensitization is also important, says Ronnie, as he has been heavily involved in community dialogues, educating them about key populations. He cites the important work done by Anova Health, which rolled out workshops in shebeens, a South African colloquial term much like the American ‘speakeasy’, a place mainly frequented by men who want to drink alcohol. Anova Health has sought to increase help seeking and foster tolerance in a country where men have been notorious for their role as perpetrators of violence.

Ronnie argues that another possible way that the State could significantly broaden its reach in terms of access to healthcare is to employ MSM from within communities as community health care workers, as they have greater access to MSM specifically and the broader LGBTI community that other health care practitioners would not be afforded.

The critical right to food is also extremely important to Ronnie, having seen his comrades waste away in the past. In a country where poverty has led to about 12 million people going hungry, Ronnie harks back to the Black Consciousness strategies of community upliftment projects through the establishment of vegetable gardens in order to be able to take one’s pills with a full stomach.

Ronnie shows no signs of slowing down. He hopes to pass on his knowledge to younger activists to join the fight for access to quality, affordable and dignified health care for MSM and other key populations.

This article is part of a Spotlight special series on people who form part of so-called key populations.

[1] Avert, “Men who have Sex with Men (MSM), HIV and AIDS”, https://www.avert.org/professionals/hiv-social-issues/key-affected-populations/men-sex-men#footnote1_epqbh49, accessed 16 July 2018 and MSMGF (2013) ‘MSM in Sub-Saharan Africa: Health, Access & HIV’

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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.

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.

 

AIDS2018: Humans in the Age of HIV-There’s no one influencing me anymore

By Nomatter Ndebele

Gloria. Pic by Joyrene Kramer

Gloria lives in Vrededorp, Johannesburg with her partner and her 2-year-old son. She has been on drugs since 2013. Gloria started with Marajuana and then graduated onto harder drugs. She currently smokes Crystal Meth, which Is available in her neighborhood for R50 a hit (less than U$4).

“I used to smoke rocks (Crack cocaine), but it’s very expensive, so I settled for crystal meth, from one bag, I get twenty pulls,” she explains.

Like most people who inject drugs (PWID) Gloria is unemployed and depends on doing odd jobs around the community so she can make some money to feed her habit. “I do people’s laundry or even clean people’s houses to make some money.”

Gloria’s son is perfectly healthy. When Gloria discovered that she was pregnant she decided to quit smoking as she knew it wouldn’t be healthy for the child. When her son was born, Gloria went back to smoking Crystal Meth.

She refuses to smoke in front of her son, when she needs to take a hit, she ensures that her son is outside or otherwise preoccupied. “It’s just not right for my son to see this, and I don’t ever want him to see,” she says. Before she takes a hit in front of us, she asks someone to take her son out of the room.

While Crystal Meth is her drug of choice, she has changed the manner in which she takes it, before she would inject it, but now she has resigned herself to just smoking it.

“When I was spiking, I realized that I was becoming much slower, like my brain was slow, I was slow to respond to things and I didn’t like that.” So far, that is the only bad experience she has had with drugs.

When asked what message she would like to share with the youth, Gloria does not skip a beat. She immediately says “I want to tell the youth not to do drugs, its bad, you cause yourself and your family problems and you’ll end up on the streets.”

When her son was born, Gloria broke away from her group of friends. She felt as though the group was pressuring her into doing more drugs. “I left them, I feel lonely sometimes, but its better like this, there’s no one influencing me anymore.”

Gloria has not thought about quitting at all, for now she is content to smoke her Crystal Meth and go about her life as she does.

This article is part of a Spotlight special series on people who form part of so-called key populations.

 

 

AIDS2018: Humans in the Age of HIV-Where I work now, I actually feel like a woman

By Nomatter Ndebele

Thirty-seven-year-old Zelda Leonie, has been a sex worker since she was 17 years old. She decided to go into sex work when she realized that she could not depend on her mother to provide them with everything, so she turned to sex work. “I was desperate, I wanted things that my mother couldn’t give me, so I decided to make my own money,” said Zelda.

As she reflects, Zelda admits that in the beginning it worked out well for her, she was able to make her money and pay for everything and anything she wanted. After a few years however, the sex work got more intense, and she started to encounter a lot of abuse.

Some clients, would tie her up, beat her and throw her against the walls.  Zelda starts tearing up, as she shares this information. At one point, she looks into the camera and announces “ I can’t do this.” She bursts into tears and quickly moves out of the frame. After a few moments, she decides she is ready to continue.

Now, Zelda speaks about her new life. She has now become a masseuse, after her friend took her off the streets and tried to get her a new job. “Now I just do massages, and if a client wants a happy ending, he has to pay more.” Zelda is reluctant to say she is still a sex worker, she chooses to focus on being a masseuse more than anything else.

Zelda sees this opportunity of having a job, as a step in the right way in relation to changing her life. “Where I work now, I actually feel like a woman, the clients are respectful and they treat me like a woman,” she says smiling.

Her message for other girls who are involved in sex work is a simple one “I just want everyone who is involved in sex work, to know that if you want to get out, you can. Just like I did.”

This article is part of a Spotlight special series on people who form part of so-called key populations.

 

AIDS2018: Humans in the Age of HIV-Carmen is impossible to miss

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.

Pic by Joyrene Kramer

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.

Pic by Joyrene Kramer

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.