Communities essential to pandemic responses

Dr Alti Zwandor

When Covid-19 first hit Africa’s shores, there were real concerns that an additional 500 000 people could die from AIDS-related causes, including tuberculosis, in sub-Saharan Africa in 2020–2021.

Innovative measures from the continent, community responses and adherence to World Health Organisation guidelines to maintain essential services amid the pandemic, among other factors, have mitigated this impact.

But HIV services have been disrupted. And there are indications that Covid-related restrictions are having a disproportionate impact on our most vulnerable communities.

The UNAIDS report ‘World Aids Day Report, Prevailing Against Pandemics by Putting People at the Centre’ notes almost no decline in the number of people living with HIV receiving antiretroviral therapy in 25 countries reviewed since April 2020 when lockdowns were implemented around the world.

Some African countries like Botswana have even expanded treatment coverage. Still, treatment coverage dropped in other countries like Sierra Leone and South Africa while there has been a general drop in HIV testing across the region.

The pandemic is thus undermining efforts to diagnose new HIV infections and start newly diagnosed people on treatment.

This is true also of testing and treatment for pregnant women. Lesotho and Uganda are among the countries that quickly rebounded, but Ethiopia, Kenya and South Africa – where sustained lockdowns were in place – registered ongoing disruptions.

The impact is not just on health services. Manufacturing of HIV-related commodities was also disrupted, leading to concerns of possible shortages and even price increases down the line.

Globally, progress towards the 90–90–90 testing and treatment targets – that by 2020, 90% of people who are HIV infected will be diagnosed, 90% of people who are diagnosed will be on antiretroviral treatment and 90% of those who receive antiretrovirals will be virally suppressed — has been a relative bright spot.

At the end of last year, 81% of people living with HIV knew their HIV status, and among those people, 82% were on treatment—more than 25 million people—and 88% of those on treatment had achieved viral suppression.

New HIV infections among children fell by more than half from 2010 to 2019 but there has been insufficient progress on combination HIV prevention among adults.

In sub-Saharan Africa, both Botswana and Eswatini have achieved the 90–90–90 targets (with Eswatini exceeding the 95–95–95 benchmarks). In Zimbabwe, community mobilisation saw the country achieve the global target for viral suppression (73% of all people living with HIV), and new HIV infections and AIDS-related deaths fell by 44% and 61%, respectively, from 2010 to 2019. And the country has done so by mobilizing domestic resources.

Namibia has surpassed the UNAIDS 90-90-90 target since 2017 and remains on track to sustain the 95–95–95 benchmarks as committed in its HIV National Strategic Framework 2017-2022. As at end 2019, of all people living with HIV 94% knew their HIV status, 85% were on ARV treatment and 74% had viral load suppressed.

HIV infections and AIDS-related deaths fell by 36% and 22%, respectively, from 2010 to 2019. There is a faster decline in new infections among adolescent girls and young women (AGYW) 15 – 24 years at 39% and this is an encouraging indication that investment in the youth is making an impact.

However, Namibia is facing HIV prevention crisis due to low uptake of services such as condoms, PrEP, VMMC and programming key populations and AGYW. Available data shows a low condom use at last sex with non-regular partners whereby young women are at 64% compared to 78% of young men. There is better utilisation among sex workers (86%) compared to their clients (67%). A major challenge has been ensuring regular supply of commodities such as condoms and lubricants. The uptake of HIV services varies by age, gender, population and location. The uptake of HIV testing is lower among young people, with only 48.4% young men knowing their HIV status compared to 79.6% in adult men. Similarly, only 69.6% of young women compared to 90% adult women are aware of their HIV status. In Katima Mulilo only 25% of sex workers know their HIV status compared to 53% of sex workers in Walvis Bay and Swakopmund. Stigma and discrimination remain a barrier in accessing care as 12.4% people living with HIV reported that they had faced some form of rejection because of their HIV status.

The challenge of Covid-19 need not derail our efforts. We can get back on track by using the lessons learned from the AIDS response.

This includes the effectiveness of people-centred responses that start by tailoring services to reach those who need them the most. It means a holistic approach to address the wider challenges faced by people living with HIV, as well as those at high risk of HIV infection.

We know that communities best understand their own needs, possess the passion and insights that underlie effective advocacy, policy development and service design, and have the motivation to ensure accountability.

When communities lead in design and delivery of such services, we minimise the hurdles to success. Such responses also help address gender inequalities and other societal and structural factors that affect HIV vulnerability. We are better able to hold providers accountable and strengthen feedback mechanisms for evidence-based review.

UNAIDS Namibia supported civil society organisations to design and implement integrated HIV, health and Covid-19 services. These projects increased access to HIV, Covid-19 and sexual reproductive health (SRH) services among over 3 000 vulnerable and key populations. The project included the rollout of the Covid-19 Community Engagement Toolkit in two border regions (Zambezi and Ohangwena). Through the support provided, there was an increased uptake of COVID-19 and HIV/ SRH services. For instance, in Walvis Bay the number of men going for HIV testing increased despite Covid-19 challenges.

COVID-19 has imposed profound challenges on all our countries and communities. HIV responses and people most affected by HIV are no exception, including vulnerable populations such as adolescent girls and women in all their diversity, sex workers, men who have sex with men, transgender people and people who inject drugs.

But even as Covid-19 has disrupted HIV services, the pandemic has underscored the transformative nature of HIV investments and the essential role that communities play in responding to pandemics and building sustainable socio-economic development.

There are many lessons we have learned from our HIV response that can be used in our fight against Covid-19.

And it starts with ensuring we put community responses first when we build back better.

* Dr Alti Zwandor is the UNAIDS country director in Namibia for World AIDS Day.