JOHN MUTSAMBI writes:

Despite having the biggest HIV epidemic in the world, South Africa continues to make remarkable progress in the fight against HIV and AIDS. The country has become a hub of HIV prevention research and it has the largest anti-retroviral therapy (ART) programme in the world. On 1 June, 2016, a national programme to provide oral pre-exposure prophylaxis – or PrEP – to sex workers was launched and TB/HIV Care’s eThekwini and Pietermaritzburg sites became two of the first 10 sites in the country to roll out this novel HIV prevention tool. But PrEP advocates are urging for a wider roll-out on the grounds of ethics, cost-effectiveness and to avoid unintentionally encouraging stigma.

At the recently-concluded 21st International AIDS Conference (AIDS 2016) a senior official from the South African National Department of Health (NDoH), complimented TB/HIV Care’s eThekwini site for its sterling work in rolling out PrEP, the pill which, if taken regularly by someone who is HIV negative, helps to prevent that person becoming infected with HIV. To date, this site has initiated a total of 47 clients on PrEP while its sister site in uMgungundlovu, Pietermaritzburg, which started the rollout two weeks later, has also initiated 18 on PrEP.

This pioneering work, makes South Africa a torch bearer in rolling out a programme that could become a model for other countries, particularly those in the sub-Saharan region that have been hard hit by the HIV epidemic.

As PrEP advocates working in collaboration with civil society we welcome this programme and convey special thanks to Dr Aaron Motsoaledi, South Africa’s Minister of Health, for helping to spearhead the push for PrEP implementation.

However, the staged implementation of this HIV prevention method has sparked questions about ethics. One community member said: “Why is the government prioritising sex workers as a key population in the implementation of PrEP when there are other key population groups such as men who have sex with men, people who inject drugs, people in sero-discordant relationships, truckers and prison inmates who are also at high risk of getting HIV?”

And a sex worker remarked: “Some community members call us ‘the drivers of the epidemic’. I think that providing PrEP to sex workers only will further strengthen this stigma.”

These are all voices with concerns that should be listened to. As PrEP advocates, we urge decision-makers in the NDoH to urgently consider expanding access to PrEP to other key population groups, including adolescent girls and young women. We know that this process will not be easy and we are prepared to work very closely with civil society to support the NDoH’s efforts.

As we wait for information from PrEP demonstration projects to inform our decisions about how best to roll out PrEP, we also feel that at this point, we should also learn as we go. Further delays in expanding access to PrEP will result in continued high rates of new infections that could be averted and the associated costs of illness and providing lifetime ARVs. South Africa cannot afford to wait any longer to provide PrEP to those who are vulnerable, no matter who they are.

A consortium of partners is undertaking a viral hepatitis service provision and research project for key populations (people who inject drugs, sex workers and men who have sex with men) in South Africa. The study will assess information gaps on populations disproportionately affected by viral hepatitis and provide an evidence base to guide future interventions.

Hepatitis B and hepatitis C are infectious diseases that affect the liver. They are usually without symptoms for many years. This means that those infected are infectious without even knowing it and can silently develop progressive liver damage. This year the World Health Organisation (WHO) released the first ever Global Strategy for Viral Hepatitis. The strategy aims to eliminate viral hepatitis as a public health threat by 2030.

People who inject drugs, sex workers and men who have sex with men are at higher risk of contracting viral hepatitis B and C. Viral hepatitis is a particular concern in a context of high HIV prevalence because co-infection can result in more rapid progression of both diseases.

At present viral hepatitis services for “key populations” are limited in South Africa and there is very little information on prevalence levels, though studies that have been done indicate that rates are high in key population groups. The forthcoming study is funded by the Bristol-Myers Squibb Foundation Secure the Future, and implemented by TB/HIV Care Association, in partnership with the University of Cape Town, Anova Health Institute, the National Institute for Communicable Diseases and OUT Wellbeing.

Spanning seven cities – Cape Town, Johannesburg, Pretoria, Mthatha, Pietermaritzburg, Port Elizabeth and Durban – the study builds on already occurring service delivery processes.

Hepatitis B and C diagnosis usually require expensive and time-consuming laboratory activities. In this study, participants will be tested for HIV, hepatitis B and C at service delivery sites. The point-of-care (‘rapid’) hepatitis C testing will be done in a variety of ways, and the results will be compared to standard laboratory tests. This will indicate whether inexpensive rapid test mechanisms can be reliably used in the South African context. If this proves to be the case, it opens up new possibilities for making hepatitis testing a common part of health screening processes.

The study’s results will provide an evidence base to support national efforts to reach the WHO 2030 target of reducing the public health threat of viral hepatitis to zero.

Durban was the centre of the HIV and TB world’s attention this week as the International AIDS Society hosted both the TB Conference 2016 (incorporating the biennial South African TB Conference), and the 21st International AIDS Conference 2016 in the city.

TB/HIV Care was engaged in a variety of activities to raise the importance of addressing TB as well as HIV, to highlight the importance of health services directed at key populations and to advocate for increased investment in community-based health services.

On Sunday the 17th July, TB/HIV Care provided health services to visitors and the congregation at an event at eThekwini Community Church where the South African Minister of Health, Dr Motsoaledi, addressed the congregation on the challenges associated with TB. The Premier of KwaZulu-Natal and the KwaZulu-Natal MEC for Health as well as other high-profile guests were also be present.

A high-level delegation from UNAIDS visited TB/HIV Care’s HIV prevention in sex worker site in Durban where pre-exposure prophylaxis (PrEP) is being delivered as one of South Africa’s pilot sites.

For the duration of the AIDS Conference 2016, from the 18th-21st July, TB/HIV Care hosted a TB HIV Networking Zone in collaboration with AERAS and ACTION to ensure that TB was highlighted at the AIDS 2016 Conference. Sessions at the networking zone explored the way in which TB and HIV affect different populations differently, how to adopt a human rights-based approach when dealing with TB and HIV, and the importance of community-based and patient-centred health services.

Much of TB/HIV Care’s work with key populations was represented at AIDS 2016 through posters and presentations. These included a poster on working with communities, law enforcement agencies and political leaders to enhance HIV prevention programmes for people who inject drugs, and a roundtable discussion on fostering enabling environments for key populations for key populations with law enforcement agencies. In addition, Shaun Shelley, Advocacy and Psychosocial Co-ordinator for the Step Up Project, presented at a satellite event on harm reduction with an emphasis on programmes, policy and policing.

Finding and reaching key populations was another sub-theme for TB/HIV Care as Andrew Lambert presented a model of how to reach female sex workers with mobile health and HIV prevention services, while Andrew Scheibe, a Technical Advisor for TB/HIV Care, presented a poster on ‘using programmatic mapping to identify locations where people who inject drugs congregate and to estimate their population sizes in three South African cities’.

In the Global Village, Prof Harry Hausler, TB/HIV Care CEO, presented on improving HIV and TB services in South African correctional centres and Shaun presented a talk on harm reduction funding in South Africa, and spoke about a report on human rights violations experienced by people who inject drugs. As part of a satellite session on Hepatitis C (HCV) and HIV, Andrew Scheibe presented ideas on ‘assessing HCV and HIV co-infection among key populations in South Africa’.

Finally, TB/HIV Care submitted 22 quilts to the international HIV Quilt Project, which is co-ordinated by the South African National AIDS Council (SANAC). These quilts were made by people involved in TB/HIV Care’s programmes, including people who inject drugs, sex workers and prison inmates, as well as those dedicated to supporting them.

The quilts are part of a larger display of quilts made by people affected by HIV, which tell the story of what has been achieved since the last time the International AIDS Conference was held in South Africa in 2000. Among the successes since then is the establishment of the world’s largest antiretroviral treatment programme.

It was a busy week for Durban, and for TB/HIV Care, as researchers, policy-makers, donors and programme-implementers meet to better define problems and identify solutions.