14 September 2020

We, representatives of 41 civil society organisations working regionally and in 12 countries in the Southern Africa Development Community (SADC) (1) to promote the health and rights of our communities – including people living with HIV, sex workers, people who use and/or inject drugs, women (including adolescent girls and young women), men who have sex with men, transgender people; religious leaders living with and affected by HIV, and human rights organisations – met virtually on 1 September 2020 to deliberate on the status of HIV prevention in Southern Africa. 

The meeting aimed to strengthen meaningful civil society engagement in the Southern Africa Development Community (SADC) Stocktaking and National AIDS Council (NAC) Directors meetings from 14-16 September 2020, to be held virtually due to the ongoing COVID-19 pandemic.

This meeting was the 3rd annual meeting of civil society on the status of HIV prevention, with a focus on advocacy for the removal of structural barriers to HIV prevention. Each year since 2018 we have convened ahead of the annual SADC HIV Prevention Stock-taking Meetings, and NAC Directors Meetings to reach consensus on the status of HIV prevention in the region and to agree on recommendations to SADC NAC Directors to be shared with the SADC Ministers of Health.

During the consultation, we reflected on the indicators in the SADC HIV prevention Scorecard and the specific programme targets for HIV prevention, supported by five pillars (2), considering where progress has been made over the past 5 years, and where it has stalled or moved backwards. Looking forward to the next decade, we developed recommendations for Member States on how to strengthen efforts to reduce new HIV infections, in order to end HIV as a public health threat by 2030.

As representatives of civil society, we recognise the vital role of the SADC Secretariat in convening Member States and facilitating peer-learning and sharing of lessons learned on HIV prevention policy and programming. We also appreciate the opportunity presented to us to address multi-sectoral stakeholders, as well as NAC Directors, and share some perspectives on the status of HIV prevention in the region.

Remembering the commitments

Our meeting was overshadowed by the realisation that the deadline for the 2020 Fast-track targets and a commitment by the SADC Ministers of Health in December 2017 to reduce new HIV infections in the SADC region by 75% between 2010 and 2020 had arrived. 

We also remembered that, in 2016, our Heads of State committed, at the African Union Assembly, to implement the African Union Catalytic Framework to End AIDS, TB and Eliminate Malaria by 2030, which included a specific commitment to reduce new HIV infections on the African Continent to under 375 000 in 2020, as well as commitments relating to ending discrimination and gender-based violence, and repealing HIV-related discriminatory laws, policies and regulations.

We further recalled that, at the 2016 High Level Meeting on Ending AIDS, our countries solemnly committed to achieving several Fast-track targets by 2020, in order to end HIV as a public health threat by 2030. These targets included: 

• Reducing new HIV infections in young people and adults (aged 15 and older) by 75%; 
• Reaching 90% of those at risk of HIV infection (including key populations, and adolescent girls and young women and their male partners, with comprehensive HIV prevention services; 
• Eliminating gender inequalities and end all forms of violence and discrimination against women and girls, people living with HIV and key populations by 2020. 
• Ensuring that 90% of young people have the skills, knowledge and capacity to protect themselves from HIV and have access to sexual and reproductive health services by 2020, in order to reduce the number of new HIV infections among adolescent girls and young women to below 100 000 per year.
• Ensuring that at least 30% of all service delivery is community-led by 2020.
• Ensuring that by 2020, a quarter of HIV investments are allocated to HIV prevention and 6% for social enabling activities; and
• Empower people living with, at risk of and affected by HIV to know their rights and to access justice and legal services to prevent and challenge violations of human rights. 

2020 – taking stock 

We recognised that progress had been made towards meeting these commitments and that this was a result of the political will, leadership, and commitment to accountability the SADC Member States. Amongst others, this is evident through the adoption of several regional normative guidelines including the SADC Framework for Target Setting for HIV Prevention in the SADC Region, the accompanying HIV Prevention 2020 Roadmap and score card; the Regional Strategy for HIV Prevention, Treatment, Care and Reproductive Health and Rights among Key Populations and the SADC Strategy for Sexual and Reproductive Health and Rights in the SADC Region (2019 – 2030) and score card.

We are encouraged by the combined efforts of all stakeholders in the HIV response in the SADC region, which have resulted in a greater reduction in new HIV infections than in any other region in the world. However, we observe with great concern that, as the deadline for reaching the 2020 Fast-Track targets has arrived, no country in the region has met the Fast-Track target of reducing new HIV infections by 75%, and that, worryingly, some countries are even experiencing an increase in new infections.

We commend Member States for the areas where we as civil society have observed that the greatest progress has been made. These include: 

• Biomedical interventions, chiefly treatment as prevention, preventing mother-to-child transmission, and intensified scale up of voluntary medical male circumcision (VMMC); 
• The adoption of packages of services and guidelines for AGYW in several countries; 
• The adoption of package of services and guidelines for key populations in several countries; and 
• The engagement of civil society organisations in national multi-sectoral platforms such as the development of national plans, formulation of targets.
• The decriminalisation of same sex relationships in Mozambique, Angola and Botswana, which has already been observed to have had a positive impact on improving access to HIV and other health services.

However, we are concerned that there has been a persistent failure to progress in certain areas, and we note that many of these areas relate to structural barriers to HIV. These include: 

• reducing stigma and discrimination; 
• funding for community systems and community-led services; and 
• the removal of legal and policy barriers which contribute to increased risk of HIV acquisition and deter people from accessing HIV services.

We urge Member States to intensify their focus on what are, from our perspective, the greatest challenges facing HIV prevention in the SADC region, including: 

• Stigma and discrimination towards people living with and affected by HIV, and in particular towards key populations 
• inadequate coordination and accountability; 
• inadequate domestic resource mobilisation for HIV prevention, particularly for interventions to address the HIV prevention needs of key populations;
• harmful social and cultural norms; and 
• condom shortages in several countries, related to a decline in funding for condoms, as well as weaknesses in procurement and supply chain management.

How has SADC progressed on the prevention pillars? 

Reflecting on the programme targets for HIV prevention (AGYW & MP; key populations; condoms; VMMC and Pre-exposure prophylaxis), we agreed that interventions for incarcerated people and other people in closed settings as well as transgender people should also be prioritised. We also agreed that, overall, the SADC region is generally not making “good” progress in any HIV prevention area.

The region is generally making “fair” progress in the following programme areas:

•  Adolescent girls and young women and their male partners; 
• Sex workers; 
• Condom programming; 
• VMMC; and 
• PrEP

The region, however, is generally making ‘poor’ progress in the following programme areas: 

• People who use drugs; 
• Incarcerated people and other people in closed settings; and 
• Transgender people

Opinion on progress on meeting the HIV prevention needs of men who have sex with men (MSM) was equally split between ‘fair’ and ‘poor’ progress.

Stigma and Discrimination 

We are alarmed that stigma and discrimination continues to present a significant structural barrier to us ending AIDS as a public health threat. We wish to highlight to Member States that there is now a substantial body of evidence of interventions that work to reduce stigma and discrimination, including: providing information and dispelling the myths around HIV transmission; enacting and enforcing protective laws; providing access to justice; rights literacy; skills-building; counselling and support; contact (i.e. interactions between people living with HIV /KVPs and duty bearers); and biomedical interventions. There is also a sizeable body of resources (e.g. toolkits, guidance) and expertise to draw upon (including substantial expertise amongst civil society). With a concerted and coordinated effort by Member States, HIV-related stigma and discrimination can indeed be eliminated.

Moving forward to 2030 

Moving forward to 2030, civil society recommendations to Member States are to: 

• Demonstrating commitment and political will towards improving HIV prevention; 
• Focusing on scaling up prevention programmes for amongst key populations and AGYW; 
• Adopting a harm reduction approach in programmes for people who use and inject drugs; 
• Sensitising health care workers and other stakeholders to provide ethical and non-stigmatising services to key populations and AGYW; 
• Fostering meaningful participation of communities and affected groups;
• Supporting and strengthening community-based and community-led prevention interventions; 
• Implementing and reinforcing existing policies; and 
• Efforts to remove legal barriers.