From the early days of the HIV epidemic, political leadership was identified as an essential ingredient of successful HIV prevention strategies. In the words of the first executive director of the Joint United Nations Programme on HIV and Aids (UNAids), Peter Piot: "Until something is not a political priority, lives don't get saved."
As a result, from the 1980s onwards, much of the efforts of HIV activists went into waking up governments and bringing HIV out of the shadows, where governments would have preferred that it remain.
Once political leaders had recognised HIV was there, activists made them face up to the existence of people they would rather pretend didn't exist, and protect and advance their human rights. As a result, gay men, sex workers and drug users all started to fight their way into the HIV prevention and treatment response as rights holders and as equals. By the early 2000s, political commitment was required to roll out antiretroviral (ARV) treatment on a mass scale through public health systems.
Sixteen years ago, when South Africa hosted the 13th International Aids Conference in Durban, commitment was said to exist in the governments of Thailand, Brazil, Uganda and Botswana. In those countries you could find political will directed towards prevention, treatment and challenging patent laws.
But this did not exist in South Africa under then president Thabo Mbeki. Instead, for the next seven critical years, we had political obfuscation. Let us not forget that the Treatment Action Campaign and our allies had to take to the streets and the courts to achieve political commitment. People died unnecessarily to achieve it.
South Africa has now turned the tables; HIV denialism is dead. Our country has become the paragon of political commitment, the shining star. Granted, we have made huge strides, the most sterling being the reduction of the rate of mother-to-child transmission of HIV from 25% to less than 2%, according to health department statistics. Granted, we have driven HIV denialism into sad and shameful corners. Granted, we have raised life expectancy by 10 years.
But is this good enough? Do we really have the political commitment to tackle HIV and tuberculosis (TB), and how do we measure it?
It's a tired truism that Aids is "not just a health issue" and that it requires a multi-sectoral response that mobilises crucial government departments such as education, business, trade unions and faiths. But if that is the case, we must assess political commitment to HIV, not only by the leadership of Minister of Health Aaron Motsoaledi, but in the political leadership displayed of the whole government.
How do we fare when we look at it this way? Badly.
We missed the chanceIn recent years, South Africa's response to HIV and TB has largely been a health response. The multi-sectoral response to HIV has been in decline at the very time when it should have been stepped up. The huge rollout of ARV treatment, medical male circumcision, HIV counselling and testing, and other interventions gave us the edge. With a total onslaught on HIV we could have nailed it.
We missed the chance.
As a result, HIV is still a national crisis that requires the highest levels of leadership to be overcome. UNAids statistics show up to 1 000 people in South Africa are still infected with HIV a day. Over 300 people still die daily of HIV-related diseases and TB. Orphans still struggle to survive. Yet when was the last time you heard President Jacob Zuma say anything on HIV or TB?
Political leadership on HIV is largely invisible. Although Deputy President Cyril Ramaphosa chairs the South African National Aids Council (Sanac), the failure of Sanac's civil society sectors to connect with their constituencies means tens of millions of ordinary people are none the wiser about what is said and done by that body. Large-scale business and trade union responses to HIV — vital to awareness and expanded HIV testing — have all but collapsed.
There are really only two government departments that deserve great credit: the departments of health and the treasury. In a difficult financial climate the treasury has consistently done what is needed to provide funds for vital health interventions. In 2016, budget spending on HIV and TB is one of the few areas of health in which spending has continued to rise.
The rest all fail badly. Departments that are crucial to a multi-sectoral response are failing to assist the health department.
The most obvious is the department of basic education. Epidemiological surveys repeatedly show us that most new HIV infections are occurring in girls and young women of school-going age. Knowing this means we have a clear target for intense, focused HIV prevention campaigns. Yet we dilly and we dally and give in to conservative sectors rather than starting up a serious dialogue with them.
The rates of HIV infection in schools and teenage pregnancy tell us that young people are having sex. It is not against the law for young people to have sex with each other, but we are still without a policy on condom access in schools. We are also without a quality programme of sexuality education.
Shockingly, a survey released two years ago by the Human Sciences Research Council showed that basic knowledge of HIV is declining.
Vulnerable still left behindThe department of justice fares little better. The National Strategic Plan on HIV, TB and sexually transmitted infections, 2007-2011, recommended the decriminalisation of sex work by government. Nothing has occurred other than talk! Sex workers, mostly young women from impoverished backgrounds, remain criminalised and therefore extraordinarily vulnerable to rape, abuse and HIV.
When it comes to provincial governments, very few provincial HIV councils are functional — if functional means doing something other than sitting in meetings at hotels. In some provinces, notably the Free State and Mpumalanga, political leadership works to destroy health systems needed to support the HIV response, causing stock-outs, the loss of doctors and nurses and the dis- missal of essential community health workers.
Political leadership at a national level is too consumed in factionalism and corruption to deal with these problems, despite organisations like the Treatment Action Campaign and Section27 repeatedly drawing attention to them.
In our prisons, while there have been marked improvements in HIV testing, TB diagnosis and treatment, rates of TB and multidrug-resistant TB remain frighteningly high. TB is still the highest cause of death.
So, the answer, I'm afraid, is that the standard of political leadership we have for HIV and TB is partial, inconsistent and insufficient.
I am sure that some readers will say I am an eternal naysayer; that I refuse to recognise progress. They are wrong. I welcome the real progress and give credit where it is due, but in the context of UNAids' ambitious targets of 90-90-90 (by 2020, 90% of people living with HIV will know their HIV status, receive sustained ARV therapy and have viral suppression) and talk of "ending HIV as a public health threat" (both of which South Africa has agreed to), political commitment means demanding what government still seems unwilling to give: total commitment to a co-ordinated and holistic approach to HIV and TB that does not relent until there is indisputable evidence that both epidemics are firmly and sustainably under control.
We still have a long way to go.
Mark Heywood is director of social justice organisation Section27 and a board member of the Treatment Action Campaign.
Read more from our special AIDS 2016 report.
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