News24.com | OPINION | Inequalities prevent the end of AIDS

It is possible to end AIDS by 2030, but only if governments act now to equalise access to HIV services for everyone, write Anne Githuku-Shongwe and Eva Kiwango.

The AIDS response is in danger. Inequalities are the reason why. 

The effects linger and are dire for eastern and southern Africa, a region with 54% of all people living with HIV globally. The new UNAIDS report Dangerous Inequalities shows that unequal access to rights, services, science and resources is holding back the end of AIDS. Bold and innovative approaches are needed to safeguard the region's vulnerable people and future generations.

For eastern and southern Africa, adolescent girls and young women, children and key populations are unfortunately the most affected.  

The effects of gender inequalities result in women and girls continuing to be disproportionately affected by HIV, accounting for 63% of the region's new HIV infections in 2021 and 66% of new HIV infections in South Africa. Key populations are also adversely affected, comprising 46% of new infections in 2021. 

The impact on children is of grave concern. Fifty-two percent of children living with HIV who are not on treatment compared to 76% of adults. 

Close treatment gap for children

Yet still there is hope. In 2021, Botswana was the first high-burden country to achieve Silver Tier status on the path to the elimination of vertical HIV transmission. The rate of transmission of HIV from mothers to children was only 2.2%, down from 9.0% a decade earlier. However – for the rest of eastern and southern Africa – the rate of HIV transmission from mother to child, particularly through breastfeeding, is alarming at 8.6%. 

Closing the treatment gap for children will save lives. Regionally in 2021, 5.1% of people living with HIV were children but accounted for 16% of AIDS-related deaths. In South Africa, children accounted for only 3% of all people living with HIV but 4.5% of all AIDS-related deaths in 2021.

Millions of lives are at stake. The eastern and southern African region is the home to 20.6 million people living with HIV. Six hundred fifty thousand people died of AIDS-related deaths in 2021. Of this, 280 000 were in eastern and southern Africa and 53 000 in South Africa. There were also 1.5 million new HIV infections — 1 million above the 2020 target of 500 000. Of the new HIV infections, 210 000 were in South Africa, 110 000 more than the 2020 target of 100 000. 

READ | SA population grows to 60.6 million people, 8.5 million living with HIV - Stats SA report

Health system shortcomings and biases, and harmful masculinities are discouraging men from seeking care. In South Africa, while 75% of women were accessing treatment in 2021, only 61% of men were on treatment. For eastern and southern Africa, 82% of women, as opposed to 74% of men, are accessing treatment. This contributes to higher HIV incidence among girls and women and higher AIDS death among men. 

While governments have a crucial role in accelerating the AIDS response, we as a society have a crucial part in dismantling harmful stereotypes and practices, including gender-based violence. 

As Minister of Justice and Correctional Services, Ronald Lamola said at the recently held second Presidential Summit on Gender-Based Violence and Femicide, "we need to reshape our social norms. If we do not address the core drivers of GBVF, which can be traced from a plethora of social ills defined by patriarchal practices, economic inequalities, poverty, cultural discrimination, family dysfunctions and the lack of accountability, this pandemic will not end."

Remove criminalisation laws

In a region where HIV infections are three times higher among adolescent girls and young women (aged 15 to 24 years) than among males of the same age, we need to intensify the quality and coverage of HIV prevention. Access to new prevention technologies, such as long-acting PrEP to be rolled out in Botswana, Uganda and Zimbabwe, should be expanded to the entire region, and there should be no differences in access between rich and poorer countries.

However, simply scaling up HIV prevention and treatment is not enough. At UNAIDS, we have seen the value of multi-level collaboration to address the multiple needs of adolescent girls and young women. ‘Education Plus' is such a collaboration. Such an initiative is essential in our fight against AIDS as it scales up action, funding, and policymaking for young women and girls. 

We also need to scale up access to combination HIV prevention for key populations. We also need to scale up efforts to advance the human rights of key populations, including removing criminalisation laws that ultimately cost lives.

READ | Botswana hits 'historic' UN goal against HIV - report

The criminalisation of same-sex relations in eastern and southern Africa is not only a human rights violation but affects LGBTQI+ persons from accessing and using HIV prevention, testing and treatment services. Countries in the region should mirror Angola, Botswana, Lesotho, Madagascar, Mozambique, Rwanda, Seychelles and South Africa, which have decriminalised same-sex relations.

In South Africa, where same-sex relations are decriminalised HIV incidence among gay men and other men who have sex with men has declined by 58% between 2010 and 2021. Unfortunately, in eastern and southern Africa region as a whole, where HIV incidence among adult men (aged 15 to 49 years) has fallen by 62% overall since 2010, there has been no significant decline among gay men and other men who have sex with men during that time. 

Equalise access

While in South Africa, the rights of gay men and other men who have sex with men are enshrined in the Constitution, criminalisation of sex work and possession and use of drugs still is a barrier to services for sex workers and people who use or inject drugs. 

As a sex worker who uses drugs, Mpumi* from KwaMashu, Durban, South Africa said she has sometimes been made to feel less than human while seeking healthcare at her local clinic.

"The things I am doing are not good, but it doesn't mean that the nurses should treat me like a dog—I am a person, like anyone else," she said as featured in the latest KwaZulu-Natal State of Health report.

Prevention of violence, community-led outreach, use of new communication technologies such as smartphone applications, and legal and psychosocial support are empowering interventions in uplifting key populations in the AIDS response. 

The evidence is clear—protecting the safety and human rights of people living with HIV, women and girls and marginalised people not only is a human rights imperative but also expands access to HIV services. 

Together, it is possible to end AIDS by 2030, but only if governments act now to equalise access to HIV services for everyone. Tackling inequalities will not only help the marginalised. It will help everyone.

*Not her real name

- Anne Githuku-Shongwe is the UNAIDS Regional Support Team for Eastern and Southern Africa Director and Eva Kiwango is the Country Director of UNAIDS South Africa.

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