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A Supplement to the South African Civil Society Priorities Charter

Written by Key Populations

On the
23-24 of April 2015,
South African key populations
met in Johannesburg to discuss
the countrys upcoming HIV/TB Concept
Note to the Global Fund to Fight AIDS, Tuberculosis
and Malaria. The meeting brought together gay men &
other men who have sex with men, transmen and transwomen,
adolescent girls & young women, male, female & transgender sex workers,
people who inject drugs & TB survivors. Called by Brian Kanyemba, South Africas
Country Coordinating Mechanism (CCM) representative for key populations, the meeting
was an opportunity for constituency consultation. Recommendations by key populations, for key
populations have been made using the Global Funds modular approach. The intention is to add depth to
the South African Civil Society Priorities Charter, focusing on key populations issues.

These are our stories. These are our solutions.

Module: TB Care and Prevention

I am a final year medical student and a
TB survivor. I contracted TB in my fourth
year of training, while working in hospital. I
did not expect it at all. It was quite a scary
experience as I was bedridden for three
weeks. I had to take four massive tablets
every day for six months. I now understand
why compliance is an issue for a lot of
patients. I had no medical aid and had
to pay for all my expenses in cash. I want
my story to create awareness for medical
students and health care professionals that
we are not immune to TB. We are at risk.


Activity: Create safe hospitals through implementing TB infection

control. We must implement TB infection control in health care facilities,
focusing on administrative controls (surgical masks to coughing patients,
fast-tracking patients with TB symptoms and providing occupations
screening to health care workers), environmental controls (opening
windows), and the provision of fit-tested respirators to health care workers
(HCWs). We must also promote HIV testing of HCWs and redeployment
into low risk settings (limiting occupational exposure). Partners for this
activity may include the Office of Health Standards Compliance, DoH,
HCWs, TB Proof and the UnmaskStigma campaign.

Activity: MCC to accelerate approval of novel drug-resistant TB

drugs (Linezolid, Delaminid & Bedaquiline). Using compassionate
use programs, we must improve access to tolerable drug-resistant TB

~ Workshop Participant
(TB survivor)

In 2012, only 11.4% of the

14,161 cases of diagnosed
MDR-TB were enrolled on

Activity: Strengthen the role of community health workers in

combating TB. Prioritise the education of community HCWs on TB,
including DR-TB and how to implement TB infection control at home.
Foundation for Professional Development could be a key partner.

330,000 of South Africas

520,000 new TB infections in
2011 occurred among PLHIV
a 60% co-infection rate.

In 2012, 101,937 (only 31%)

of HIV-positive incident TB
cases were receiving ART.
Source: SANAC (2014) Global AIDS Response Progress Report.

Module: Prevention Programmes for Adolescents and Youth

(In and Out of School)

I am dating a guy for the last five years.

The problem is he has another girlfriend. He
promised to break up with her last year in
December, but until now he hasnt. When
I ask him, he says he will try, but the girl
tried to kill herself so he felt guilty. He
says he just does it to make her calm. I
dont want to lose him. I love him, and he
says he loves me, and I can see that he
means that. The problem is that I know I
am sharing him with someone else and its
killing me. He said I must be patient with
him and he will fix this and marry me.


Activity: Advocacy for Sexual Orientation and Gender Identity to be

taught in high schools.
Teaching SOGI in high schools is the top priority activity for this module.
Part of this includes programmes on healthy masculinity and destabilising
patriarchy, which is closely linked to preventing gender-based violence.

Activity: Community-based HTC

HIV testing and counseling should be youth-friendly and available at the
community level. We do not want school-based HTC, as it fuels stigma in
our learning environments. Behaviour change can only follow after HTC.

Condom promotion is not a high priority for young women because we

cannot negotiate their use. Instead, initial discussions about PrEP and TasP
for young women must be had, combined with HIV and SRHR integration.

~ Workshop Participant
(Adolescent girl)

HIV prevalence among adolescent girls (15-19) is 5.6%,

eight times higher than among adolescent boys (0.7%).

In 2012, 33.6% of adolescent girls aged 15-19 had

sexual partners five or more years older than they were.

Sources: SANAC (2014) Global AIDS Response Progress Report. HSRC (2014) South African National HIV Prevalence, Incidence and Behaviour Survey 2012.

Module: Prevention Programmes for Sex Workers & Their Clients

I am a sex worker and I know in our country
it is illegal to be a sex worker. I want people
to know that there are male sex workers
out there and I want them to stop hiding
themselves, because I know there are a lot
of risks out there that we face from the
community. We are equal like the female sex
workers, the problem is I know we dont have
the brothels, and sometimes its dangerous
to go to the clients place. Other ladies, they
dont prefer condoms. I want us as male sex
workers to stop hiding ourselves. Now here I
am, Im helping others. I am a peer educator.

~ Workshop Participant
(Male Sex Worker)

HIV prevalence among female sex

workers is 59.6%, compared to
13.3% among women in the general



Activity: Outreach & Workshops

Outreach will be done through peer educators visiting hot spots (brothels,
truck stops, highways, bushes, busy streets, taverns and private houses)
to mobilise sex workers to attend workshops. The workshops will be
mobile, community-based safe spaces, free from stigma, where sex
workers can share views and challenges. HIV testing and counseling
will be provided, along with referrals for Pap smears and provision of
contraceptives. Street-based sex workers will be the primary target group
for this activity, followed by sex workers who use drugs, MSM and TG sex
workers, as well as very young sex workers. This activity will strengthen
the capacity of sex workers not only as peer educators, but also as
researchers, facilitators, and professionals. Sisonke is well placed to run
this activity, as a sex worker-led organisation. Others who may also be in a
position to play a leadership role could include CPC for S, PHRU, TB/HIV
Care, North Star, Lesedi Letshabile Primary Care, Womens Legal Center,

In 2012, 60% of sex workers

were reached with HIV prevention

88% of sex workers received an

HIV test in the last 12 months and
know their results.
Source: SANAC (2014) Global AIDS Response Progress Report.


Prevention Programmes for People Who Inject Drugs and their Partners

I was withdrawing off heroin and I had

just scored and I didnt have a needle. I was
desperate to use. I went into the pharmacy
to ask if they could give me one. I begged and
pleaded it was only R4.50. I was laughed at
and chased out of their store. I was so sick
and all I needed was a needle. I then thought,
who could I borrow from? I remembered a
good friend of mine who was a sex worker.
I found her two blocks up. I borrowed her
needle. I used it without cleaning it as I
was so sick I just wanted to get it in me.

~ Workshop Participant

HIV prevalence among the 67,000

people who inject drugs in South
Africa is 19.4%.


Activity: Peer-led distributions of needles/syringe, collection and correct
disposal. Currently, there are no comprehensive NSPs, supplying clean needles
and syringes to injecting drug users in South Africa. NSPs are easily initiated and
have been shown to reduce HIV incidence amongst PWID1 and provide significant
returns on investment.2,3 Peer-led NSPs are needed because the PWID community
is highly stigmatised, criminalised, hidden and hard to reach. Peers from the PWID
community (as well as inter-linking communities such as sex workers) have existing
links to PWID and are trusted by these communities, mitigating safety concerns.
Women PWIDs, PWID MSM, sex workers and street dwelling populations should
be targeted, in Cape Town, Durban and Pretoria (in the hot spots identified during a
recent formative assessment). Traditional substance-use intervention organisations
that are not familiar with the philosophy and practice of harm reduction are not best
suited for NSP (i.e. SANCA and DoH). Instead, organisations which have experience
with marginalised communities would be better suited, such as OUT LGBT
well-being and TB/HIV care.
Wodak, A., & Cooney, A. (2006). Do needle syringe programs reduce HIV infection among injecting drug users: a comprehensive
review of the international evidence. Substance Use & Misuse, 41(6-7), 777813.
Kwon, J. et al. (2012). Estimating the cost-effectiveness of needle-syringe programs in Australia. Aids, 26(17), 22012210.
Nguyen, T. et al. (2014). Syringe Exchange in the United States: A National Level Economic Evaluation of Hypothetical Increases in
Investment. AIDS and Behavior, 21442155.

49% of people who inject drugs

reported reusing a needle the last
time they injected.

58% of PWID had received HIV

prevention information for drug

Sources: UNODC (2015). Rapid assessment of HIV prevalence and HIV- related risks among people who inject drugs in fiveSouth African cities.SANAC (2014) Global AIDS Response Progress Report.

Module: Prevention Programmes for MSM and TGs


I was 17 years old when I realised that I

am gay, and was raped by a group of guys
in my community because of my sexual
identity. I never reported it to the police
because they always make jokes about gay
and lesbian cases reported to them. I never
even bothered to seek medical attention
because the same thing was going to
happen. Time went by and I started to
be sick so I saved my money and went to a
private doctor, who did an HIV test without
my content and told me I was HIV-positive.

Activity: Behaviour change campaign for MSM

A wide-scale behaviour change campaign should be implemented using
social media, community radio, peer education, CBO-based outreach and
safe spaces (including all MSM adherence clubs for MSMLHIV), MSM print
culture, community newspapers and TV. This must also include some advocacy
watchdog capacity to monitor government and media. The key messages of
the SBCC campaign should be anti-discrimination messaging, affirming gay
identities and behaviours messaging, HTC, combination prevention (PEP, PrEP,
TasP, condoms, lube) and anti-MSMLHIV stigma. The target group for the
campaign will be young MSM (12-35), and older MSM (recognising prevalence of
inter-generational relationships). Target areas will include rural areas, townships,
informal settlements and mining communities. Some possible implementing
partners could include OUT LGBT Well-being, Durban Gay and Lesbian Centre,
Triangle, Project, Boithato, The Other Foundation, and CBOs in partnership with
youth-focused organisations and mens organisations (Brothers4Life, Sonke).
Possible Principle Recipients could include Anova Health Institute and NACOSA.

~ Workshop Participant

In one study, 37.1% of MSM in Cape Town

reported police discrimination based on sexual

HIV prevalence among MSM in South Africa is

estimated to range from 10.4% - 34.5% as reflected
in different studies.

SANAC (2014) Global AIDS Response Progress Report. HSRC (2014) South African National HIV Prevalence, Incidence and Behaviour Survey 2012.

South Africa has a long surgical waiting

list for gender affirming surgery for trans
people. The list is 26 years long. I am now
in my 14th year on the list. I am always
thinking of what this means for the trans
community with such high HIV prevalence. I
also think about what that list means for
people who are taking feminising hormones
and ARVs. There is a link between HIV and
access to gender-affirming care. Placing
my health needs on a 26-year waiting
list is a form of gender-based violence.

~ Workshop Participant


Activity: Research and Advocacy Campaign

Establishing the link between gender-affirming care and HIV prevention and
retention in care for transgender people is critical. Anecdotal evidence points
to better efforts of taking care of oneself (including HIV prevention, retention in
care, access to treatment, care and support) in trans people who have access
to gender-affirming care. Trans people should lead the work, in partnership
with a variety of key strategic partners: research institutions, CBOs and youth
programmes, the media, the WHO, SANAC, Medical Aid Board of South
Africa, Legal Partners, UNAIDS, UNDP, CDC, HSRC, MRC, Medical Fraternity,
Chapter 9 Organisations and the DoH. Particular research institutions identified
for this activity include Steve Biko Academic and George Mukari, Baragwanath,
Universitas+, UKZN (King Edward), Nelson Mandela Academic Hospital, Dr.
Rob Ferriera and Groote Schurr. This activity should be implemented from
2016/2017-2019, by transgender people, academia, policy makers (SANAC),
funding partners, media, legal and medical fraternity, and other collaborative

50% of transwomen take some form of chronic medication.

Only 25% of trans and intersex people receive gender

affirming primary or secondary health care.

Module: Removing Legal Barriers to Access


Transgender and Intersex Africa (2014) Transilience Report

Activity: Lobbying and Mobilising

This is a cross-cutting intervention which will include engaging with Parliamentarians and other people who are influential in policy-making, such as
religious groups, ward councilors, civil society, and government departments. This activity will also have a component of mobilising sex workers,
PWID and other key populations who face legal and policy barriers, to be able to speak out and stand up for our rights, since no one can tell our
stories and design our solutions better than us.