The new strategy is the first in a decade that does not advocate for the decriminalisation of sex work.
South Africa’s recently released HIV plan will help to guide the country’s response to everything from sex work, drug use and treatment for the next five years. But the document has been met with fierce civil society opposition amid allegations of high-level political meddling.
The South African National Aids Council (Sanac) was meant to launch its latest five-year national strategic plan on HIV and tuberculosis (TB) publicly in March but because the document was not finished, Sanac launched a summary instead.
The body quietly debuted the document earlier this month. The release prompted many civil society groups to begin sifting through the more than 100-page plan to see what had made it in after months of consultations and several drafts for public comment.
But now some organisations are saying the plan has some glaring omissions. Notably absent is any call for the decriminalisation of sex work — already an official Sanac policy position — to increase access to health services for sex workers and their clients. This plan is the first in a decade to exclude a proposal to decriminalise sex work.
What’s in, what’s out
Sex worker network Sisonke took part in the consultations, and national co-ordinator Kholi Buthelezi says their voices have been ignored.
She explains: “We know that decriminalisation creates an enabling environment that empowers sex workers to access health services, carry condoms and negotiate safer sex practices with clients.
“The fact that this is not in the plan … is not only disappointing but also makes it difficult for sex workers to support it.”
“If sex workers are not able to access their basic human rights because they are seen as criminals, it is unlikely that they will be able to access the health services offered by this plan,” argues Ishtar Lakhani, advocacy and human rights defence manager with the Sex Workers Education and Advocacy Taskforce.
A 2014 study conducted by the University of California San Francisco among about 2 200 female sex workers in South Africa found HIV infection rates of between 40% and 72% among participants. Proponents of decriminalisation argue that the move will allow sex workers greater access to health services and safe working conditions to combat new infections and gender-based violence.
An initial “draft zero” of the national HIV strategic plan had also included calls to decriminalise drug use. Although this too has been cut, government has committed to increasing access to services such as HIV and hepatitis C screening and opioid substitution therapy (OST) for drug users. Tshwane recently started Gauteng’s first OST programme that allows people to stop using illegal drugs — and avoid withdrawal symptoms — by carefully monitored use of prescription medicines such as methadone.
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It’s a step in the right direction, says Shaun Shelly, head of policy, advocacy and human rights for people who use drugs for the TB/HIV Care Association. But Shelly warns that the almost R20-million budgeted in the next five years to provide OST and other harm reduction services such as needle exchange programmes is likely not enough.
He explains: “Currently, it costs R4.5-million per year to reach around 3 500 people who inject drugs and supply them with sterile injecting equipment — and those are suboptimal levels. That excludes methadone, which costs between R500 and R1 000 per month, and is the most evidence-based intervention for heroin use.
“These are interventions that are proven to save lives and reach people but what are we spending on criminal justice sanctions, which makes the situation worse?”
OST programmes have been shown to reduce illegal drug use, criminal activity linked to drugs as well as overdose deaths and new HIV infections among people who use drugs, according to a 2011 study published in the Bulletin of the World Health Organization.
Did politics decide what made the cut?
Former Sanac chief executive Fareed Abdullah, who helped to oversee the plan’s formulation in its early stages, raised concerns about the document as early as April. In an article written for the Daily Maverick, he described the plan’s drafting and alleged that politics might have been the deciding factor in terms of what was ultimately put in the plan and what was not.
“A technical team was contracted to review progress and the latest evidence and make recommendations, and a steering committee was established to provide a higher-level strategic view to guide the technical work. Instead, we had a political commissariat cherry-picking technical work with the aim of making government look good while at the same time giving just enough airtime to the latest evidence to avoid criticism from technical constituencies inside and outside the country,” Abdullah wrote.
In the piece, he also criticised the plan for failing to set ambitious treatment targets and said it was telling that HIV lobby group the Treatment Action Campaign (TAC), had publicly refused to endorse earlier drafts. TAC has yet to announce its support for the current version.
Sanac maintains the process of drafting the plan was a combination of consultation and technical work that was led by a steering committee. This committee was headed by former Sanac chief executive and current special adviser to the deputy president, Nono Simelela, and co-chairperson of Sanac’s civil society forum Mabalane Mfundisi, according to spokesperson Kanya Ndaki.
She explains: “The decisions about what should be in the NSP [national strategic plan] was made by this steering committee, after reviewing input from all sectors. Civil society was well represented on the steering committee. The final shape of the NSP is decided by Cabinet.”
But Marcus Low, former TAC head of policy and editor of HIV and TB magazine Spotlight, says there is “widespread unhappiness about the drafting process”.
“With the previous two [national HIV plans] there was more of a sense that of civil society owned the plans even though they weren’t perfect. [This strategy] feels like … a government document rather than the product of meaningful consultation.”
He warns: “Civil society has to figure what the way is forward because there is both a lot of unhappiness about the plan and very serious concerns about the state of the Sanac — it certainly appears that over the last few months there has been a worrying lack of leadership.”
Abdullah left Sanac in January. His position has not yet been filled.
Laura Lopez Gonzalez is a freelance health journalist and editor. She was Bhekisisa's news editor then deputy editor between 2016 and 2020.
