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A large chunk of our reporting focuses on HIV. Since the launch of Bhekisisa in 2013, we’ve covered HIV in-depth — from the impact of the virus on former president Nelson Mandela’s family to the advances in antiretroviral treatment and anti-HIV pills and injections. We’ve also looked at the impact of inequality and discrimination on the spread of HIV, the link between gender-based violence and HIV — and ways to fix it.

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Could South Africa’s next HIV plan call for the decriminalisation of drug use?

Almost 300 000 South Africans will contract HIV this year. The country may be targeting a crucial five-year window to stem the tide of new infections.

The country’s next national plan to tackle the twin epidemics of HIV and tuberculosis may aim to slash new HIV infections and TB deaths by about a third in the next six years. This is according to a document released late Wednesday for public comment. Although the document is marked as a “zero draft” of the national strategic plan on HIV, TB and sexually transmitted infections, the South African National Aids Council says it is not a draft but “an in between document that is moving towards a draft zero.”

What some are calling a “discussion document” is the first such paper in South Africa’s history to propose decriminalising drug use. But civil society bodies have expressed reservations about whether the document goes far enough.

Whatever its name, the paper lays the groundwork for a strategic plan that will ultimately determine the country’s policies on not only HIV and TB but also sexually transmitted infections until 2022.

The country’s fifth such strategy, the next national HIV and TB plan is likely to mark a shift away from previous plans that focused on increasing access to HIV treatment in favour of one that concentrates heavily on preventing new infections.

The strategy is also likely to align South African targets with those of the United Nations, which seek to ensure that the bulk of people living with HIV are diagnosed and on treatment by 2030, according to the discussion document.

“South Africa had an estimated 288000 new HIV infections in 2015, a quarter of all new infections globally. TB remains a national crisis, replacing HIV as the leading cause of death … This is no time for complacency,” writes the South African National Aids Council in its introduction to the report.

“The next five years present a critical window of opportunity to ramp up the HIV, TB and sexually transmitted infection responses and to get on track to end the diseases by 2030. If the opportunity goes unseized, the epidemics could spring back even stronger.”

Decriminalise sex work and drug use

If this week’s document is any indication, South Africa’s next plan will continue to prioritise groups at high risk of contracting HIV such as young women, men who have sex with men, and sex workers. Like its predecessor, the plan may also likely issue renewed calls for the decriminalisation of sex work.

A 2014 study published in The Lancet medical journal found that decriminalising sex work could prevent up to almost half of all new HIV infections among workers and clients globally in the next decade. The research argues that decriminalising the trade would allow workers to operate more safely and protect them from sexual and gender-based violence.

Another study published in the journal at the same time estimated that sex work is linked to about 6% of all new HIV infections.

This year, the South African government began providing HIV-negative sex workers with the one-a-day antiretroviral pill Truvada to prevent HIV infection. About 300 sex workers are now taking the pill.

The current draft document proposes that 90% of HIV-negative sex workers should have access to the drug by 2022. It is also the first such document to propose decriminalising drug use.

2010 review published in The Lancet — by, among others, former International Aids Society president Chris Beyer and Michel Kazatchkine, the former head of international financing mechanism the Global Fund to Fight Aids, TB and Malaria — called on governments to decriminalise drug use to reduce barriers to HIV care among users. The call followed Portugal’s decriminalisation of drug use.

Just the beginning

The former head of policy at the Treatment Action Campaign, Marcus Low, has welcomed the document’s release but cautions there may be more work — and some battles — ahead.

“While the zero draft contains a number of good things, it is far too long, unfocused and filled with jargon. There is clearly an attempt to keep everyone happy and not to step on any toes,” he says.

“The price of all its political correctness might be a plan without any teeth. If the new plan is to resonate with and inspire people outside of the HIV and TB world, it needs to be much shorter and more focused.”

He adds that the national Aids council will need strong leadership to save a future plan “from irrelevance”.

Soul City Institute for Social Justice executive Sue Goldstein is pleased the document tries to look at the societal factors and behaviours that can fuel HIV and TB. But she says the plan will have to address the drivers of HIV more meaningfully such as alcohol abuse and gender, particularly patriarchy and intimate partner violence.

The council will collect inputs and corrections before presenting a draft plan to council members, including Deputy President Cyril Ramaphosa. A final draft will be presented to the Cabinet.

Laura Lopez Gonzalez is a freelance health journalist and editor. She was Bhekisisa's news editor then deputy editor between 2016 and 2020.