In South Africa, two outbreaks are colliding and one thing may shape the future of both.
Aupa Noge opens the combi door and steps out onto the payment. It’s early but the Durban air is already warm and humid. The van has come to rest in front of an old industrial park surrounded by panel beaters, taverns and takeaway stalls.
The crowd is already gathered.
Maybe today will finally be the day, he thinks, and closes the quantum’s door behind him.
For two days, Noge, a nurse, has arrived here at the Dalton Hostel, where rows of red brick warehouses with roofs of zinc sheeting line the road. Conditions are cramped, windows are scarce in some sections, and proper water and sanitation are non-existent.
It’s early May and the hostel has just had its first coronavirus case. South Africa has confirmed more than 6 000 cases and KwaZulu-Natal has become a hotspot for the new virus.
Noge and his team from the Johannesburg-based Centre for HIV-Aids Prevention Studies (Chaps) are here to conduct coronavirus community screening, testing and education on behalf of the KwaZulu-Natal health department.
But for two days he and his medical team have been turned away. No one, it seems, has bothered to tell the hostel’s leadership to expect the group.
So every morning Noge comes to negotiate with a crowd of men and women who would much rather talk about a lack of running water than a virus none of them has seen.
In the meantime, a secretary for the hostel committee has been on the phone with the local office of the department for cooperative governance and traditional affairs.
Noge remembers how he heard an official from the department telling the secretary: “I’ll speak to the guys from the health department. Don’t allow them to enter the hostel.”
But today on the third day, the crowd has relinquished. Noge and the Chaps team can enter the hostel, residents say, but they must use the back entrance.
The clinicians jump back into their vans, drive down the road and pull into a small, rear parking lot. Noge is in the lead combi. From the car window, he can see people emerging from the hostel’s buildings curious about the strangers in the branded cars.
As he steps out of the van, Noge is met by a different crowd. This time, there are no women — just men.
“You’re bringing this corona to us,” yells one man. “We’re not going to test.”
Then the man pauses and announces: “Leave this place now or else you won’t leave alive.”
What happens to HIV programmes during COVID-19? They adapt. This is how
Just days earlier, the highway from Johannesburg to Durban is nearly empty as the landscape changes from high-rise buildings to farmlands. A convoy of seven, nine-seater vans heads south towards the port city, stopping at each provincial border so its occupants can show police they have permits allowing them to travel.
It’s 29 April and South Africa is almost a month into a coronavirus lockdown that has banned travel between provinces in a bid to contain a growing outbreak.
The motorcade might have seemed excessive under normal circumstances. The team of 20 Chaps nurses, clinical associates and administrative staff could have easily fit into just three of the vehicles if it had not been for requirements to social distance.
Under normal circumstances, clinical associate and Chaps trainer Nompulelelo Magagula would be flipping through diagrams of foreskins, not rushing off to track a virus she — and the world — knew little about.
Chaps specialises in HIV testing and voluntary medical male circumcision (VMMC), which several major international studies have shown can reduce a man’s risk of contracting HIV through vaginal sex by up to 60%.
But medical male circumcisions ground to a halt under the national lockdown as non-essential procedures were cancelled and Chaps found itself — like many HIV organisations — pivoting to respond to the world’s latest pandemic. So Magagula and three teams from Chaps headed to Durban to help the overwhelmed province conduct community COVID-19 screening and testing.
Life after lockdown: Could HIV drug resistance rise?
Although the public health clinics like those that Magagula would typically visit to train staff on VMMC, stayed open, health workers say patients stopped coming.
Almost one in 10 people surveyed by the Human Sciences Research Council said they were unable to access chronic medication during the first month of the lockdown and this proportion shot up to 25% among people in informal settlements.
HIV viral load testing measures the amount of the virus in a person’s blood. When people take their HIV treatment correctly, their HIV viral loads can fall so low that they are unable to transmit the virus, two decades of research shows.
But as patients miss doses, their viral loads rise, resulting in them becoming more likely to pass HIV onto others, Bekker warns.
“[Viral loads] are an indication of a bigger problem — that people aren’t picking up treatment or taking treatment well,” she explains. “With all of the anxieties and fear right now, people might not take treatment well or might take… an ‘enforced treatment holiday’ — all of those things clearly can lead to resistance, which is a huge problem.”
COVID-19 could “effectively set the clock on Aids deaths back to 2008”
South Africa’s HIV programme didn’t need any more stress than it already had.
The COVID-19 outbreak comes at a time when South Africa is trying to increase access to the HIV prevention pill — a daily tablet that can dramatically reduce someone’s chances of contracting the virus. At the same time, the country is in the process of introducing a three-in-one antiretroviral that includes the newer medication, dolutegravir.
Depending on whether the country sees successive waves of COVID-19 outbreaks, Bekker predicts it could take at least a year to 18 months to get a sense of how the pandemic has impacted HIV care and treatment and other health programmes such as childhood immunisations.
If the pandemic disrupts HIV treatment broadly in sub-Saharan Africa, it could lead to an extra 500 000 Aids-related deaths — including those from TB — between 2020 and 2021, according to mathematical modelling released in April by Imperial College London researchers. Because of weakened immune systems, HIV-positive people are up to 20 times more likely to fall ill from TB, according to UNAids. But several studies have shown that taking antiretrovirals can drastically decrease that risk.
This would, the World Health Organisation (WHO) said in a statement, “effectively set the clock on Aids deaths back to 2008, when more than 950 000 Aids-related deaths were observed in the region”.
And people could continue to die in large numbers, the international body warned, for at least another five years. The modelling was published in The Lancet this month.
A WHO survey showed that two dozen countries had a critically low stock of antiretrovirals or had already experienced stockouts as of early July, and another 73 warned they are at risk of HIV drug shortages.
- Read more: How COVID-19 affects HIV and TB care
COVID-19 is already shaping HIV’s present. What it means for HIV’s future will depend on many things, including countries’ ability to ensure it can get people onto antiretroviral treatment and stay on it. But in some parts of South Africa, initial responses to the globe’s newest outbreak may have repeated one of the HIV response’s early mistakes: Leaving community consultations for last.
Back in the combis on the road to Durban, the atmosphere is cheerful but tense.
“We were asking ourselves how this would pan out,” Magagula remembers. “KwaZulu-Natal was becoming a hotspot… we wanted to make sure we didn’t bring it back to our families.”
A warm welcome cools — and fast
In the days preceding Magagula and Noge’s arrival, KwaZulu-Natal had kicked off a community COVID-19 screening programme. The provincial health department distributed pictures of the Health MEC, Nomagugu Simelane-Zulu, donning a bright orange and yellow safety vest, hitting the streets with community screeners. In the images, featured in the local paper, the MEC was almost unrecognizable under a dark broad-brimmed hat, sunglasses and face mask.
When the Chaps team arrived, they met with Simelane-Zulu.
“We were so excited and they [the health department] were happy we were there,” Magagula remembers. “They pointed us to where our services were needed.”
Simelane-Zulu handed the teams the keys to mobile testing units. Soon, Noge was headed south towards the Dalton Road Hostel while Magagula drove west to the Kennedy Road informal settlement.
Her team arrived around 10 am in the community, the morning mist having already cleared. They found an open veld, parked the mobile testing van and began to erect a small tent off to the side along with folding chairs and tables.
A woman, walking by, asked: “Who are you guys?”
- Read more: Old lessons, new pandemic: ‘We showed up to do COVID-19 testing & communities told us to pack our bags’
She was part of the Kennedy Road Development Committee. If something was happening in the settlement, she said, she needed to know about it.
“The woman was apprehensive and trying to figure out why we were there,” Magagula remembers. “I don’t know if the district had not informed them, but [the community] didn’t know we were coming.”
Back at Kennedy Road, the woman took out her cellphone, placed a call to the community forum leader, and warned: “There would be no screening or testing without the forum’s sign off.”
‘There is no community that doesn’t have a structure’
Sb’u Zikode shakes his head.
“It’s as if people think communities have no brains and you can just do as you please,” he says.
Zikode is the former chairperson of the Kennedy Road Development Committee and founding president of the national shack dwellers movement, Abahlali baseMjondolo.
On the first day of South Africa’s lockdown, Zikode and Abahlali baseMjondolo members say they wrote to the office of the KwaZulu-Natal Health MEC to request an urgent meeting.
“We knew that if there was an infection in the informal settlements, it would spread like wildfire,” Zikode explains. “We wanted to show the minister and the MEC our commitment to work with them and facilitate the required discussions with communities.”
Abahlali baseMjondolo made follow-up phone calls to the office but received no response.
On a scale of least to extremely vulnerable to a COVID-19 outbreak, the Council for Scientific and Industrial Research ranked Kennedy Road as extremely vulnerable as part of its recent nationwide vulnerability mapping.
The settlement is in many ways the birthplace of Abahlali baseMjondolo. In 2011, Zikode penned a forward to a University of KwaZulu-Natal book that described the movement’s ideology and how the thinking of liberation theorists such as Franz Fanon influences the way it consults with its members and outsiders.
“Fanon believed that everyone could think,” Zikode wrote. “He believed that the role of the university-trained intellectual was to be inside the struggles of the people.”
He continued: “We have learnt to draw a clear distinction between those forms of leftism that accept that everyone can think and which are willing to journey with the poor, and those forms of leftism that think only middle-class activists, usually academics or NGO people, can think and which demand that the poor obey them.”
Local government never returned Abahlali base Mjondolo’s calls, Zikode says, but the national health department did. The department asked Abahlali baseMjondolo to become part of the Sikhaba iCOVID-19, or Kick COVID-19, campaign. In this capacity, Zikode and other members worked with researchers and the department to develop awareness messaging about COVID-19 for their communities in their own languages.
“I feel sorry for healthcare workers, because for me, it’s like they are just being dumped,” Zikode says. Often, there’s no prior consultation with communities before they arrive.”
He concludes: “When healthcare workers come here, they come to save the community. The community needs to respect them. We know that some of them have been discriminated against and seen as people who are actually bringing coronavirus into the community.
“Who defends [healthcare workers] when the community and local leaders are not involved?”
How to fight a pandemic
In June 2011, experts from the United Nations and large international HIV funders proposed a new approach to battling that pandemic — and financing it. The old way of allocating money to HIV, they argued in a paper published in The Lancet, was too focused on commodities: how much it would cost to get what countries wanted — let’s say condoms or pills — to the biggest number of people. This narrow view, experts reasoned, not only wasn’t very nuanced, it also wasn’t very efficient.
Instead, they proposed focusing on six types of programmes, including treatment and VMMC, to reduce people’s risk of passing HIV to others, contracting it and to keep HIV-positive people virus alive and healthy. They also suggested leveraging these investments by critical enablers — or elements that would allow HIV programmes to operate well and would facilitate people taking part in them. Chief among these critical enablers, the paper argued, was mobilising communities and making sure programmes catered for their needs.
[WATCH] COVID realities: ‘There is one toilet for eight doctors and this is also used by patients and the admin staff’
Doing so would not only mean that services were taken up and used by the right people, but that money spent would be used efficiently. And because civil society representation was already built into major local and international funding mechanisms such as the Global Fund to Fight Aids, TB and Malaria, the HIV sector might be better poised than most to capitalise on this.
This month, UNAids released its annual report. Although the document acknowledged the threat posed by COVID-19 to HIV programmes around the world, it also revealed how HIV activists were on the frontlines of the coronavirus response, working to try to ensure that they were consultative and human rights-based while holding up HIV programmes in the process.
In Nigeria’s Cross River State, for instance, community treatment teams based outside of clinics were responsible for 92% of HIV diagnoses during that state’s coronavirus lockdown, the United Nations agency reports.
“Successful pandemic responses must be rooted in human rights, be evidence-based, community-led and fully funded,” writes UNAids director Winnie Byanyima. “We must learn the lesson once and for all.”
Second time’s a charm
Back in Durban, it’s Magagula’s second day at Kennedy Road after an initial rough start.
“We were lucky she was actually passing when she saw all the cars,” she says now of the lady who stopped her and her COVID-19 screening and testing team the day before.
The chairperson whom the woman called, in turn met with Magagula.
“They thought that we were there to deliver food parcels because, during that time, that’s what people who were coming to the community were doing,” she says. “We explained that … there had been someone who tested positive for [COVID-19] prior and we wanted to make sure that the person didn’t spread it so we needed to test the whole community.”
The chairperson agreed, asking only that Magagula and her mostly all-female team did not enter people’s homes. Conditions were cramped, he said, and it might not be safe — even with the metro police escort that the provincial government had given the clinicians.
Magagula had been hopeful after her crew had managed to squeeze in a couple of hours of screening and testing following the meeting but she was unprepared for the site that awaited her at the veld the next morning.
Hundreds of people were waiting for them, queueing to be screened. Her team parked, throwing open the doors of the mobile clinic and scrambling to set up.
Eventually, the team couldn’t keep up. Magagula picked up the phone to call Noge, fresh from his defeat at the hostel, across town.
“We’re going to need help, can you come after you’re finished?” she asked him.
When Noge arrived, the veld was still packed.
“People were surprised to hear someone had tested positive,” Magagula says.
“No one had come to tell them about the virus so they just had a lot of questions: How do you get it, how is it spread? If I’m coughing, does it mean I have it?” she remembers. “Our communities are actually starved for information. Every second person will be asking you, but what is this virus?”
She adds: “You know, information — people really value that.”