The political, social and economic contexts in the eight countries of the KP REACH Project are firmly located within the global contexts of tensions between advancing social justice for all and the competition of actors for power to take control of decision making and resources. These tensions sometimes play out in positive ways but often they have negative consequences and impacts because of the high stakes involved in the competition for power.
The following six areas provide a wide perspective in which realities and experiences can be recorded and understood from both a personal and political perspective:
- Militarism and conflict
- The global neoliberal and capitalist economic crises
- The crises in democracy
- Patriarchy and heteronormativity
- Extremisms and fundamentalisms
- Environmental exploitation
The context matters as it creates conditions and consequences within the society that shape the realities of each person within that society. These conditions can be enabling or hindering of the ability of each person to live in dignity and freedom. When we seek to surface, name, confront and address the root causes of ill health, the context becomes key as it points us towards addressing systemic/structural factors that shape freedoms and oppressions in society.
The troubled political, social and economic contexts globally and in this sub-region are key in shaping the possibilities of access to health, including health services in the context of HIV and AIDS and in the main, are currently constraining access. Such contexts are responsible for conditions that make people more vulnerable.
Key populations and barriers to health in Southern Africa
According to the UNAIDS 2014 Gap Report, there are an estimated 24.7 million people living with HIV in sub-Saharan Africa, nearly 71% of the global total. Ten countries in sub-Saharan Africa, of which five are located in Southern Africa – Malawi, Mozambique, South Africa, Zambia and Zimbabwe – account for 81% of all people living with HIV in the region. Despite enormous achievements in the last decade in the provision of treatment and the reduction of AIDS-related deaths, which fell by 39% between 2005 and 2013 in sub-Saharan Africa, new infections among individuals from key populations are on the rise, specifically among young individuals from KPs, sex workers, men who have sex with men and trans diverse people remain disproportionately affected. Little information is available on people who inject drugs. For women who have sex with women, there is a growing body of evidence to suggest that this group in Southern Africa are at greater risk for HIV infection than was previously believed. Women who have sex with women face increasing vulnerability to gender-based and sexual violence and hence greater exposure to HIV. Further, recent research[AT1] has found that forced sex[AT2] is the most important risk factor associated with HIV infection among women who have sex with women in Botswana, Namibia, South Africa and Zimbabwe. So while not explicitly a KP, women who have sex with women need to be taken into account in the context of HIV in Southern Africa.
Prevention, treatment, and care programs funded to reverse the epidemic often neglect these populations. Stigma and discrimination, deterring key populations and marginalised groups from accessing health services, flourish with impunity in countries that receive significant donor funding for HIV. National planning documents and donor funding agreements at times mention men who have sex with men and sex workers, but little programming actually exists. Epidemiological surveillance that would help inform programs serving these populations lags far behind strategic information collected on other populations. Little to no attention is paid to the needs of trans diverse people or women who have sex with women.
The evolving disease epidemiology in the region shows that :
- While HIV incidence is declining in many parts of the Southern African region, incidence among some key populations and marginalised groups appears to be isolated from this progress.
- Studies conducted in Southern Africa have found HIV prevalence rates 10–20 times higher among SWs than among adults in the general population, with rates of HIV infection reaching 50% of all sex workers tested, and HIV prevalence reaching 86% in one study from Zimbabwe.
- Among men who have sex with men, evidence shows prevalence is 9 times higher than among general population in contexts such as Southern Africa.
- Several recent studies make it clear that HIV does affect Southern African WSW including lesbians and bisexuals and even more significantly than was previously believed. Despite this, this group of women is completely ignored by policy and programming for HIV.
- Though data for trans diverse people in Southern Africa is next to non-existent, evidence from more than 11,000 transgender people worldwide found HIV prevalence of 19.1%. In those settings analysed, transgender women were 49 times more likely to be infected with HIV compared to adults in the general population.
- Reliable data on HIV prevalence, knowledge, prevention and treatment among KPs in the region is lacking, especially for trans* communities, people who inject drugs and women who have sex with women.
- Data on HIV infection among people who inject drugs is also lacking in the region. Understanding the needs of people who inject drugs and the interrelations between men who have sex with men, women who have sex with women, trans* people, sex workers and people who inject drugs is particularly necessary for targeted programming for key populations.
Men who have sex with men, trans* people, sex workers and people who inject drugs in Southern Africa still struggle to obtain the most basic of health services. For myriad reasons, not limited to legal and policy environments, societal attitudes, traditional and religious norms, cultural values and indifferent leadership, HIV prevalence among key populations and marginalised groups remains high and access to services remains a challenge. Individuals from these groups face significant barriers in accessing prevention and treatment services.
Sex workers: High prevalence rates among sex workers are compounded by criminalisation, violence and lack of consistent access to HIV prevention programs and integrated sexual reproductive health (SRH) and HIV services across the region. As a result of these structural barriers to health, female sex workers are roughly 13.5 times more likely to be living with HIV than other women, with most evidence suggesting HIV prevalence rates of close to 70% in the Southern African region. A recent study noted that although data about HIV risk among female sex workers is scarce, the burden of disease is disproportionately high. While not strictly illegal in all Southern African countries (other than South Africa, which criminalises both the buying and selling of sex), sex work is criminalised through laws targeting related activities such as procurement, living off the earnings of prostitution and “soliciting for immoral purposes”.
The criminalisation of sex work creates immense barriers to HIV prevention, and it is difficult to evidence these gaps without sufficient data. Subjected to sexual and physical abuse by the police, other state actors and members of the public, the negotiation of safer sex is often difficult. Further, while most countries have implemented risk-reduction programs for sex workers, the coverage and impact of these programs is difficult to determine due to the lack of reported data and the absence of strategic and statistical information on sex worker population size, behaviour and geographic distribution. Stigma and discrimination compound vulnerability with health care facilities, resulting into irregular access to condoms and SRH services. These factors provide the rationale for increased and targeted regional work advocating for strengthening SW organizations, working with health care workers and law enforcement offers, changing social attitudes and promoting decriminalisation.
Men who have sex with men: While evidence is fragmented, it is generally accepted that MSM in the region have significantly higher prevalence levels than men in the general population. The perception of these epidemics as generalised and driven by heterosexual sex has obscured the needs and vulnerabilities of sub-groups, especially MSM. While the role of sex among men is increasingly described in concentrated epidemic settings, studies from Southern Africa within generalised epidemics, where KPs are conventionally not thought to play a significant role, have also shown MSM to have high prevalence of HIV, syphilis and the hepatitis B virus, with disease burdens equal to or greater than those of men in the general population. Further, HIV prevalence among MSM in Southern Africa appears to be seemingly isolated from recent overall declines in prevalence, which is another important factor in assessing overall vulnerability of this group. This is likely in part due to a disabling environment; one study found that 61.7% of the 323 MSM they surveyed in Swaziland reported fear of seeking healthcare. Another factor is lack of targeting messaging, leading to lack of knowledge among MSM. One study from Lesotho found that more than 20% of MSM believe HIV can be cured. Further, only 37% could name three ways of preventing HIV, which is well below Lesotho’s national target of 85% by 2015.
Structural factors, such as stigma, discrimination and violence based on sexual orientation and gender identity [AT5] and the criminalisation of same-sex sexual practices, contribute to hindering the availability, access and uptake of HIV prevention, testing and treatment services among gay men and other MSM.
Trans* people: Of all populations affected by HIV worldwide, evidence suggests that trans diverse people – especially transgender women – may be the most heavily burdened; globally, available evidence suggests that transgender women are 49 times more likely to be living with HIV than the general population. While more data on men who have sex with men is available, and some scant data on women who have sex with women exists, there is a very significant lack of research on transgender populations in Southern Africa, and almost no data on how HIV impacts these individuals. As such, trans* people in Southern Africa are currently invisible in epidemiological research and they are almost certainly being ignored in HIV service provision. Due to stigma, neglect, and institutionalised discrimination, the HIV response has not yet succeeded in addressing the health needs of trans* people.
Where trans* people have been included in research, there is the tendency to subsume transgender individuals into men who have sex with men or women who have sex with women categories within HIV data and research. Without considering the differences between transgender men and transgender women, prevalence data is inaccurate with serious and negative implications for comprehensive service delivery.
Program priorities include network strengthening, advocacy for improved access to appropriate and quality HIV health services and increased evidence generation.
People who inject drugs: The importance of including people who inject drugs is critical as the criminalisation of this group impacts severely on service provision and their health-seeking behaviour. There is furthermore a need to address injecting drug use as an overlapping risk factor within the KP groups and to make sure that all marginalised and highly affected groups are targeted in the HIV response so no group is left behind. Evidence from South Africa highlights how drug use augments HIV vulnerabilities among men who have sex with men. Recent research from Southern Africa points towards the high level of injecting drug use among sex workers, too, finding that almost 40% had injected drugs at some point during their lives and 31% had done so in the past three months. Lastly, among transgender people, injecting drug use and sex work all combine to increase HIV vulnerability and reinforce barriers to accessing care.
Women who have sex with women: While women who have sex with women are not a key population group, there is a strong case to be made for including them as a result of the prevalence of sexual violence they experience and their exclusion from policy, plans and services. Epidemiological data from available studies shows that women who have sex with women are in fact at risk for HIV infection, though at lower prevalence levels than the general population. Findings from recent research indicate that women who have sex with women cannot be regarded as a ‘no-risk’ group within the context of HIV in Southern Africa. One study, focusing on African lesbians living with HIV in South Africa, Zimbabwe and Namibia, uncovers widespread misperceptions that WSW are not an at-risk group and that African lesbians often hold wide-ranging misconceptions about their HIV risk. Further, some research shows that the most important risk factor for self-reported HIV infection among WSW in Southern Africa is forced sex.
Other evidence shows elevated HIV prevalence among WSW for certain age groups; among adolescents (14–19 years) in Soweto, South Africa, 10.3% of young women who identified as lesbian or bisexual reported living with HIV compared with only 2.3% who identified as heterosexual. Socio-structural and behavioural factors include drug use, transactional sex and sex work, rape and sexual violence (including homophobic rape), low risk perception, low levels of healthcare provider knowledge, among other factors. As a result, evidence suggests that ART coverage levels for WSW living with HIV in South Africa are disproportionately low, at 29% compared to 79% for the general population. Further, among WSW living with HIV, evidence shows 45% have been forced to have sex and 47% have been hit by a partner. Studies have also shown that WSW living with HIV are more likely to be involved in the buying (18%) and selling (33%) of sex than women in the general population.
SW, MSM, TG, PWID and WSW are limited in exercising their civil, political and social rights in the Southern African region and are confronted with a wide set of problems linked to prejudice, stigma, and discriminatory policy and practice. Aside from South Africa, countries in the region share a repressive legal environment for MSM, TG and WSW. Sex work and injecting drug use is criminalised in all SADC countries. Social norms and values are a significant barrier to addressing the health needs of these groups. Faced with challenges in accessing public services, these groups are extremely marginalised and are often unable to access appropriate health care, and are sometimes denied care completely. Widespread and pervasive stigmatisation is a critical barrier to negotiating access to integrated SRH/HIV prevention and treatment services.
The exclusion of key populations is often institutionalized in national laws and policy frameworks and has a direct negative impact on health outcomes. With the exception of South Africa, all countries have penal codes and/or constitutions that directly or indirectly criminalise same sex practices and relationships, especially among men. A practical impact is that in some countries, KP organizations are not officially registered, limiting their capacity to fundraise, publicise their services, organise, and conduct advocacy. Many health and HIV-related frameworks such as National Strategic Plans (NSPs), HIV-specific legislation, public health acts, and service delivery policies are yet silent on the rights and specific needs of KP communities. Even where specific vulnerabilities have been mentioned, interventions have not been defined or budgeted and certainly not actioned. Human rights barriers and gender inequalities are tightly interwoven due to the nature of predominant patriarchal and heteronormative discourse and behaviour in the region. Even where supportive policies are in place, there is a gap between policy and implementation greatly due to stigma and discrimination.
Access to Health: Limited budgets coupled with the absence of explicit strategies for KPs create enormous obstacles for systems to function at a level that is commensurate with the disease burden in the region. Evidence from all across the region shows that delayed entry into care – or a lack of access to care altogether – is one of the biggest issues for KPs in terms of their right to health. These structural barriers represent challenges which KP REACH aims to address, in part contributing to the strengthening of health systems through advocating for better policies and programs. One of the most commonly cited reasons for KPs’ struggle in accessing care is fear of stigma and discrimination from public health care workers. As such, KP-specific services and programs are often limited to civil society and community providers. Most public health services still lag behind in awareness and sensitisation about how to address the specific needs of MSM, TG, SW and PWID as well as those of WSW in the context of HIV. A health needs assessment has been recently conducted by 15 LGBTI organizations from Botswana, Namibia, South Africa, Lesotho, Swaziland, Mozambique, Zimbabwe, Zambia and Malawi, reaching over 2500 LGBT people in 27 locations. Results from this survey confirm – on a wide scale in the region – that KPs people have low uptake of HIV/STI testing, limited knowledge on safer sex practices, misconceptions about risk and risk-behaviours, difficulty accessing commodities such as dental dams, condoms and lubricants, limited ability to negotiate the use of protection, particularly in situations involving transactional sex. Some of the KPs reported being denied health services.
While treatment coverage in Southern Africa has improved dramatically for the general population in recent years, MSM, SW, TG, PWID and WSW have not benefitted from this scale up and remain under-served by the health system. For instance, while the proportion of pregnant women living with HIV who have received ART has doubled over the past five years (from 33-68%), MSM remain one of the most difficult groups to target with treatment campaigns in Africa.
Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.
Key Populations is a term used to refer to groups of people who are among the most likely to be exposed to HIV. Their engagement is critical to a successful HIV response everywhere – they are key to the epidemic and key to the response. Key populations (KPs) often suffer from punitive laws or stigmatising policies. Populations most commonly called key populations are gay men and other men who have sex with men, sex workers and their clients, transgender people, people who inject drugs and prisoners and other incarcerated people. However, UNAIDS also urges countries to define additional specific populations that are key to their epidemic and response based on the epidemiological and social context.
The term “Key Populations” is increasing used in Southern Africa, and programmes for MSM and female, male and to a lesser extent transgender sex workers are being included in National AIDS Plans and various funding proposals. Often this appears as “window dressing” and tokenism, as the global push to include KP’s means that on some level there is an obligation to provide services and programmes but these are mostly top down, non-inclusive and do not address the specific social, political and economic realities of marginalised groups.
Marginalised groups refers to different groups of people within a given place, context and history who are at an increased risk of being subjected to multiple discrimination due to the interplay of different personal characteristics or grounds, such as sex, gender, age, ethnicity, religion or belief, health status, disability, sexual orientation, gender identity, education or income, or living in various geographic localities. Belonging to such groups or even being perceived to belong to them heightens the risk of inequalities in terms of access to rights and use of services and goods in a variety of domains, such as access to education, employment, health, social and housing assistance, protection against domestic or institutional violence, and justice.