Dr Sandile Buthelezi says the South African National AIDS Council must lead the Prevention Revolution
The world's attention was on the issue of HIV and AIDS recently with 1 December designated as World AIDS Day. In South Africa, the South African National Aids Council (SANAC) took up a challenge highlighted by Deputy President Cyril Ramaphosa.
He is the Chairperson of SANAC and at the end of the South African National AIDS Conference in June 2017 he called for a Prevention Revolution to prioritise taking action early in the same way we do with treatment.
In South Africa approximately 270 000 people are newly infected with HIV every year, at same time almost 48 million South Africans are HIV-negative. Our major task is therefore to keep them free of HIV and AIDS.
Combination prevention approach
We know what to do and how to do it. Over the past few years we have gained knowledge and appreciated the efficacy of new tools to prevent HIV, from pre-exposure prophylaxis to the knowledge that an undetectable viral load dramatically reduces the risk of transmission. SANAC's urgent and immediate task will be to rally everyone behind a new prevention revolution that harnesses a combination prevention approach, especially in communities hardest hit by HIV.
In a UNAIDS Discussion Paper on prevention, combination programming is defined as “rights-based, evidence-informed, and community-owned programmes that use a mix of biomedical, behavioural, and structural interventions, prioritised to meet the current HIV prevention needs of particular individuals and communities, so as to have the greatest sustained impact on reducing new infections.”
While we appreciate that the pace of decline in new infections is not fast enough, the reality is that we have not put prevention back at the top of our priority list. SANAC will have to take major strides to address this, which is why the new National Strategic Plan for HIV,TB and STIs (2017-2022) has placed prevention as the first goal with the bold target of reducing new HIV infections by more than 60 percent and cutting TB incidence by at least 30 percent.
South Africa has made significant progress. More than 10 million people are tested for HIV each year and new HIV infections declined from 367 946 in 2011 to 266 618 in 2016.
We have also recorded major successes in the reduction of mother-to-child transmission of HIV from 3.6 percent to 1.5 percent which is the lowest rate in southern Africa. In addition, the number of infants born HIV-positive has dropped from 70 000 in 2003 to less than 6 000 in 2015, putting us on the road to eliminating mother-to-child
transmission of HIV. But these gains could be reversed if we do not take urgent and immediate action to step up our prevention efforts.
What does a Prevention Revolution look like?
Everyone speaks of combination prevention, but we have not committed to specific programmatic priorities and actions.The referral pathway for HIV-negative individuals for instance, is poorly defined and implemented therefore it is an area that must be strengthened. Although targets for a multi-sectoral prevention response exist, they are not as memorable as the treatment targets. Every AIDS council must have a robust prevention plan and be capacitated and financed to monitor, track and review implementation progress.
Service providers also need guidance regarding the range of new combination prevention options that are now available.They are grappling with the rapidly changing landscape and face the challenge of conveying increasingly complex sexual health information in a way that resonates with key populations such as men who have sex with men, young girls and women. Furthermore, we need to create coherent and consistent prevention messages so that we don't overemphasise one at the expense of others. We can't afford to leave anyone behind.
To maximise impact and use resources optimally, proven high-impact HIV prevention interventions must be delivered to key locations and priority populations. Protecting human rights, safeguarding gender equality and ensuring access to services for key and vulnerable populations have a pivotal role in the HIV response. Social and structural drivers which place people at risk of infection must also be addressed earnestly by investing now for sustainable long-term solutions.
We know that people at risk of HIV infection have a cascade of HIV prevention needs.They need to be aware of risk, learn how to protect themselves (including knowing their HIV status) and have the means to protect themselves.They also need the power to make informed decisions about HIV prevention options and to receive support for their choices.
Just as innovation has changed the landscape of HIV prevention in the past, it will remain critical going forward. We can't continue doing the same things hoping for different outcomes.
“Social and structural drivers which place people at risk of infection must also be addressed earnestly by investing now for sustainable long-term solutions. ”
Communities have a role to play
Combination prevention will only work if it is based on a genuine understanding of the nature of the epidemic in each community. Communities and local organisations are well placed to contribute their knowledge and expertise to highlight who and where to focus and what works.They should be at the forefront of the local prevention response.
Communities will need to use their power to push this new HIV-prevention revolution and hold governments, donors and themselves accountable. Without community ownership, the target of reducing new HIV infections by 50 percent by 2022 and virtually eliminating them by 2030 will not be achieved.
I am also committed to making sure SANAC provides the leadership needed to achieve these goals. For SANAC to reach its full purpose and potential, it too must change. It is time for us to recognise our shortcomings and reform the way we work.
Let our actions count!
Dr Sandile Buthelezi.