SAMJ 7201

Neglected high-risk groups a top priority in AIDS prevention/treatment

Sex workers, truckers and young women top a compre­hensive new government list of HIV-vulnerable groups identified in specific geographical areas. Now the first two are being considered as targets for pre-exposure prophylactic drug pilot programmes, complementing a successful array of HIV and other healthcare interventions being rolled out, albeit inadequately, to these ‘core transmission’ groups.

This emerged during several expert presentations, and individual interviews conducted by Izindaba, at the sixth South African AIDS Conference held in Durban from 18 to 21 June this year. So far, at least 29 shipping-container healthcare clinics have been put in place along South Africa’s major trucking routes, primarily thanks to a six-year roll-out by North Star Alliance, the World Food Programme’s public/private partnership transport alliance based in Holland.

Meanwhile, the highly successful Esselen Street Clinic in Hillbrow, Johannesburg, which mainly treats sex workers, will soon be replicated in Pretoria and Ekurhuleni. The Hillbrow project is run by the University of the Witwatersrand Reproductive Health and HIV Research Institute (WRHHRI). At the conference, a large scientific audience was enthralled by a report of its successes and challenges in a session entitled ‘Highway to Health: Rolling out HIV Services to a Mobile Population’.

The CEO of the South African National AIDS Council (SANAC), Dr Fareed Abdullah, said the time has come to ‘properly address key populations’. He added that rising HIV prevalence among women aged 15 - 24 between 1990 and 2005, driven by intergenerational and transactional sex with older men, has put them at the ‘top of the pyramid’ of subgroups requiring interventions. ‘This is not just one homogenous group of 4 million women,’ he stressed. ‘We have to customise HIV programmes to where they are (geographically) and link this to contraception and family planning. We can no longer afford to pay lip service.’

Sex workers and truckers easy to reach

Professor Francois Venter, Deputy Executive Director of the WRHHRI and former Head of the South African HIV Clinician’s Society, told Izindaba that ‘massive numbers’ of sex workers are spread across the country – sex-work NGOs estimate the number at 153 000 nationwide, with 4 427 in Hillbrow alone. Venter pointed out that many sex workers tend to congregate around truck stops, and that this facilitates treatment and prevention efforts for both groups. Venter stressed that pre-exposure prophylactic (PrEP) drug treatment for both groups would require rigorous initial examination plus regular oral testing at least once a month. In previous studies, over 90% protection has been achieved in the minority of participants who show high adherence to PrEP, but generally adherence has been ‘appalling’. Clinicians are basing their optimism about the new programmes on ‘real-world settings’, where groups such as sex workers are highly HIV-drug compliant because they know their work is risky.

Venter admitted that PrEP is complex and labour-intensive, ruling it out for widespread public sector use under current conditions. It requires the patient to be negative for both HIV and hepatitis; not be diabetic or hypertensive; and to have good kidney function; they must also receive individually tailored adherence counselling. In spite of this he remains upbeat, pointing out at least two mitigation tools for motivated, high-risk patients: home oral HIV tests and urine dipstick tests for detecting any mild renal abnormalities. Warned Venter, ‘You don’t want [patients] to get HIV while on the drug, which is not entirely protective, because you’ll get drug resistance.’ He described PrEP as an excellent addition to the preventative armament in high-risk settings, where an adherent recipient understands the risk/benefit equation. Indeed, knowledgeable general practioners in the private sector report good results for well-monitored eligible patients.

It’s a harsh reality that any future roll-out will miss smaller groups of sex workers, ‘but to go where the densities are makes complete sense, not least from a cost-effectiveness point of view,’ Venter points out. The WRHHRI, in partnership with government and the US President’s Emergency Plan For AIDS Relief (PEPFAR), put up their first truck stop clinic this July, on the N4 in the Maputo Corridor between Mpumalanga and Maputo. Seven others will follow, in locations including northern KwaZulu-Natal and Harrismith. ‘We’re trying not to duplicate services,’ Venter said, alluding to the highly successful North Star Alliance project’s 29 sites.

Professor Francois Venter
, Deputy Executive Director of the WRHHRI, and fellow delegate Dr Leila Mansoor, a senior scientist at the Centre For the Aids Programme Of Research in South Africa (CAPRISA).

AIDS-hit trucking industry gets innovative

Luke Disney, Executive Director of the North Star Alliance, said that the genesis of their project came during the Malawian food crisis in 2003/4, when ‘we simply couldn’t find enough truck drivers to deliver. We subsequently discovered that a whole generation of truck drivers had been decimated by HIV and trucking companies were folding, having lost 20% or more of their revenue – so there was a business and a humanitarian imperative.’

Disney said an average truck driver is away from home 27 days a month, and that from the outset their project also treated other communities, including sex workers. His organisation began putting down containers at highway truck stops and building networks, linking patients to clinics via tracking software in the form of ‘an electronic health passport’, that enabled patient records to be downloaded instantly at whichever clinic they happened to attend. ‘We made a heck of a lot of mistakes with the project in the beginning, but we had to do something – my message to others would be, “Don’t wait for the perfect plan; there are a lot of folk out there with expertise, willing to partner and help,”’ he advised, citing Venter’s WRHHRI, NGOs and government. The North Star Alliance has 70 partners and, over the next 18 months, plans to expand the project throughout the South African Development Community region, right up into central Africa. Disney said that so far his organisation has conducted 262 721 clinical and educational sessions, in which most patients were community members. For example, in a session for primary healthcare, 71% of patients served were ‘community’, 10% sex workers and 19% truck drivers. In a session for sexually transmitted infections, 62% were ‘community’, 20% sex workers and 18% truckers; while in a session for HIV counselling and testing, 61% were ‘community’, 14% sex workers and 25% truckers.

Because of the stigma attached to HIV, the project learned to use an ‘inside out’ approach: they started by offering drivers training in occupational skills (e.g. defensive driving, how to handle dangerous goods) and issuing relevant competence certificates. ‘It’s then that you ask them, “By the way, have you had your HIV test?” and so build relationships,’ said Disney. ‘After six-and-a-half years we’re starting to get some traction.’

Luke Disney, Executive Director of the North Star Alliance, the World Food Programme’s public/private partnership transport alliance based in Holland.

Mapping the hot spots for treatment/prevention

A session on ‘Removing Barriers and Increasing Access to Treatment and Prevention’ reported on the progress of the framework being built to protect HIV-vulnerable communities. Dr Thato Chidarikire, HIV Prevention Director at the National Department of Health, revealed that 865 ‘high-transmission sites’ have been identified, with a scale-up to 1 000 planned this financial year. Dedicated conditional grant funding for each province is already in place. The sites include taverns, night clubs, migrant labour hostels, informal settlements, tertiary education and the transport industry, and covered men who have sex with men, sex workers, transgender groups, detained people and drug users. Many covered young women, drawing 4 866 peer educators from the ranks of all high-risk groups.

A multi-stakeholder national sex-work symposium has already been held, to draw up a sector plan and devise healthcare worker sensitisation training guidelines. Abdullah said the departments of social work and education were taking ‘a deep and keen interest in this work and would form an integral part of the government and SANAC’s response’. SANAC had also organised a 3-day sex-worker workshop involving some 80 sex workers to start building capacity.

Sally Shackleton, from the Sex Worker Education and Advocacy Task Force (SWEAT) and leader of SANAC’s sex-worker initiative, said that a health system that has to date been unresponsive and even hostile aggravates sex workers’ disproportionately high risks of HIV infection. ‘Sex workers live and work in a hostile environment, with constant harassment by police and sexual and physical assault. It’s brutal,’ she said. Her technical team is finalising a programme that works on the basis that sex workers are equal citizens with families, and having rights and dignity that need to be respected. ‘They are not victims by virtue of being sex workers: it’s a livelihood option and we need to do ‘nothing about them, without them,’ have an evidence-based response and do no harm in our interventions. Empowerment is central’, she stressed. She added that ‘We have to move beyond what we think is right to what we know is right.’ Abdullah said that if targeted funding was approved, the SANAC programme will kick off in October this year, reaching 33 000 sex workers.

Dr Thobile Mbengashe, Director of HIV/AIDS and TB in the National Health Department, said that reducing HIV vulnerability, breaking the transmission of new infections and helping people from all groups live longer and healthier lives will require widening access to healthcare and reforming the legal framework, while getting religious groups on board. ‘We must ensure, for example, that 60% of new infections coming from sex workers and their clients become a thing of the past’.

Dr Thato Chidarikire, HIV Prevention Director at the National Department of Health.

Hillbrow’s sex-worker clinic leads the way

Maria Sibanyoni, project manager for the WRHHRI’s Sex-Work and Trucker Project, is based at Hillbrow’s Esselen Street Clinic. She said that from servicing 14 brothels in 2010, the clinic and its mobile unit now work with 22. The clinic is open to any sex worker from 8 am to 11:30 am, Monday to Friday, while on Fridays the mobile van targets street-based sex workers. She described Mnyamandawo (‘the dark place’) – a slum of dilapidated buildings where sex work is ‘not for the faint-hearted’. ‘The women are physically tough and very strong, because they need to survive. We’ve watched them soliciting clients: they do it Al Capone style, talking softly – but if he moves, they grab him so hard he can’t move, before disappearing into a dark place.’

Sibanyoni’s teams, each consisting of four professional nurses, two community health workers and two peer educators, schedule visits to one brothel per month. Each team ‘owns’ an area and has built relationships with brothel keepers and pimps, distributing 52 000 male condoms a month. She revealed that 59% of Hillbrow’s sex workers are foreign nationals (86% of them are Zimbabweans, followed by Swazis and Mozambicans, all displaced during the upsurge of xenophobic violence in surrounding townships in 2008) and that 99% reported using condoms with clients, though only half used them with their boyfriends or partners.

A full 71,7% of 2000 patient files the researchers analysed showed the sex worker patients to be HIV positive and already on antiretroviral therapy, (ART).Sibanyoni described conditions both in Mnyamandawo and in brothels as highly challenging. ‘Imagine two sisters and two sex workers in a tiny room, one [sister] interviewing and the other examining. It’s less than optimal, and sometimes our security is threatened, especially when “swimming” takes place’. She explained that this involves theft from a sex worker or client ‘while in the act,’ resulting in angry chases, often into a mobile van where ‘they hit anybody they come across’. Her team’s work also involves police sensitisation (with widely varying degrees of success), artistic workshops for sex workers which form valuable bonds and relationships, and ‘brother-counselling’ (in taverns and brothel pubs).

Mario Sibanyoni, Project Manager for the WRHHRI’s Sex-Work and Trucker Project.

‘Let’s treat the sick first’ – Deputy Health Chief

After one AIDS conference session, Izindaba button-holed Dr Yogan Pillay, National Deputy Director-General for HIV/AIDS, TB, Maternal, Child and Women’s Health. Pressed about PrEP, Pillay said that soon after the new World Health Organization treatment guidelines on ‘who to treat, and how’ came out at the end of June, a national multi-stakeholder convention would take place. Its recommendations would be put to the National Health Council (consisting of National Health Minister Dr Aaron Motsoaledi and his nine provincial counterparts) for a decision.

‘If anything changes we’ll announce it on 1 December this year, and implementation would then happen from 1 April 2014,’ he said.

When the challenges of adherence to PrEP were put to him, Pillay said that the key national priority ‘has to be covering everyone that’s sick’. He explained that this means a major scaling up of antiretrovirals and fixed-dose combination antiretroviral therapy. He ranked PrEP well below male medical circumcision and prospective vaginal microbicide gels as an effective prevention strategy, but conceded that it could be a highly effective tool with ‘most-at-risk’ populations – provided adherence challenges were overcome and ongoing testing performed.

Chris Bateman

S Afr Med J 2013;103(8):503-505. DOI:10.7196/SAMJ.7201

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