Opin­ion

Dr Sandile Buthelezi says the South African Na­tional AIDS Coun­cil must lead the Pre­ven­tion Revo­lu­tion

Public Sector Manager - - Contents: - *Dr Sandile Buthelezi is the CEO of SANAC.

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.

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