Key Populations, Key Solutions: A Gap Analysis and Recommendations for Key Populations and HIV in South Africa

This 8-page policy brief focuses on what has been identified as key populations (KPs) in HIV/AIDS prevention and response. These populations include men who have sex with men (MSM), transgender people, sex workers, injecting drug users (IDU), prisoners, and migrant populations. According to the report, because they are often marginalised by society and disproportionately affected by discrimination and stigma, these groups have become some of the most at-risk populations for HIV infection. As stated in the brief, there is a need for tailored HIV testing, prevention, and treatment and care programmes for key populations to remove barriers to access, as well as unique messaging and outreach initiatives.

The report explains that globally, HIV prevalence among KPs tends to be higher in communities where legislation does not ensure their human rights, specifically where national health responses fail to ensure their right to health. In South Africa, local evidence shows that KPs are greatly affected by HIV and that they account for a disproportionate number of new HIV infections, thereby indicating that HIV preventions to date have not reached and benefited these individuals. This policy brief is a summary of the findings and recommendations of the Key Populations, Key Responses report. Commissioned by the South African National AIDS Council (SANAC) and the South African UN Joint Team on HIV & AIDS, this report provides a situational analysis; it was developed through a literature review and complemented by consultations.

Men Who Have Sex with Men (MSM), South Africa's progressive constitution and legal framework, should facilitate equality and freedom from discrimination. Yet, research has shown the need for improved HIV prevention interventions for MSM and the barriers they face when accessing sexual and reproductive health services in South Africa. Apart from specialised MSM health services in three metropolitan areas, no national MSM programming exists and none of the NSP targets relating to MSM have been reached. Inequality, violence, insensitive health services, poor socioeconomic status, limited access to condoms and compatible lubrication, stigma, homophobia, drug use, and discrimination are social and structural factors that continue to increase the vulnerability of MSM to HIV infection. Recommendations made in terms of MSMS are:

• A Minimum Service Package (MSP) for MSM should be accessible in all provinces and should include: appropriate sexual and reproductive health messaging; access to condoms and condom-compatible lubrication; peer-based outreach activities; voluntary and confidential HIV counselling and testing (HCT); sexually transmitted infection (STI) and tuberculosis (TB) screening; access to non-discriminatory and sensitive health care services; access to anti-retroviral therapy (ART), as appropriate; mobile HIV prevention services at clubs and other spaces frequented by MSM; and established referral pathways for sensitive provision of: HIV, STI, and TB treatment; care and support viz-a-viz substance abuse and mental health services; and post-exposure prophylaxis (PEP) and other related health services.
• An Extended Service Package (ESP) should be provided by specialised MSM centres of excellence where the concentration of MSM is greatest and, in addition to the MSP, should include the provision of: STI treatment and ART, substance abuse and mental health service, hepatitis A and B screening and vaccination, post-exposure prophylaxis (PEP) as well as pre-exposure prophylaxis (PrEP) according to South African guidelines, once published.
• Development of a nationwide HIV-prevention messaging campaign that specifically addresses the risks of unprotected anal intercourse.
• Establishment of a national MSM coordination office to oversee and implement national health worker sensitivity training, advocacy, and monitoring and evaluation efforts.

Injecting Drug Users (IDU)  - The spread of HIV among IDU and their partners is predicted to be a key factor in the African HIV epidemic in the near future. Research shows that there are a significant number of heroin users, a significant proportion of whom inject drugs, in South Africa and that the number of heroin users admitted to drug treatment centres is increasing. Initial studies have shown HIV prevalence among adult IDU to range between 3 and 35%. The risk of HIV infection through injections is six times higher than that of unprotected penile-vaginal penetrative sex. The recommendation made in terms of IDUs in South Africa are as follows:

• Conduct a national assessment of HIV prevalence and drug-taking practices among drug users, including: sample size estimations; improvement of integration of HIV and drug prevention, treatment, and support services; and capacity-building and sensitisation of health care workers and law enforcement agents to manage drug use and IDU according to human rights and public health principles.
• Harm reduction philosophy - should form part of a holistic approach to HIV prevention, treatment, care, and support for people who use drugs, including IDU. The World Health Organization (WHO) guidelines for IDU need to be incorporated into drug policy and implemented in order to save lives and costs and to control the HIV epidemic. South African guidelines for the treatment of heroin and opioid dependence are also needed.
• The accreditation of heroin abuse treatment practitioners and treatment facilities need to be enforced and monitored to make sure standardised care is provided, and funding for drug prevention and treatment programmes, which explicitly include IDU, is needed. HIV information, education and communication (IEC) materials must increase awareness around HIV risks and drug use, including the specific risks of injecting drug use.

Sex Workers - The rights to freedom, access to health care, non-discrimination, and choice of occupation are violated where sex work is illegal. Sex work is widespread, and sex workers experience human rights abuses, including sexual and other types of violence. Widespread stigma and discrimination by health care providers and the community towards sex workers frequently lead to the social isolation of sex workers and discourage the use of health services. Unequal power structures and gender inequality greatly affect sex workers, have direct effects on sex workers' ability to negotiate condom use, and make them vulnerable to violence, including sexual violence. The policy brief makes the following recommendations for sex workers:

• Conduct more research on sex work and sex worker needs. There should be a decriminalisation of sex work and removal of all criminal laws and municipal by-laws pertaining to sex work, as well as the protection of sex workers under existing labour and occupational health and safety laws.
• In areas where sex worker numbers are low, sex work-friendly services should be integrated into existing services. Implement targeted sensitisation training programmes for key stakeholders, including health care workers, police, customs officials, journalists, judiciary, and teachers. Access to sexual and reproductive health services which should include: HIV counselling and testing (HCT) and ART; STI and TB screening and treatment; family planning and termination of pregnancy services; medical male circumcision; pap smears; and referral for mental health and substance abuse services.
• Capacity building of sex workers is required in order for them to exercise their rights and access to justice, and an increased sex worker representation and participation in the HIV response is needed.
• Where sex work is prevalent, specialised sex worker clinics and mobile services should be implemented, inclusive of: Peer educators to provide condoms (particularly female condoms) and lubrication; IEC materials; and linkages to services for sex workers and their clients as well as general public education and anti-stigma campaigns.

Prisoners - Together with crowded conditions, sexual activity, and drug use, prisons are environments conducive for the transmission of infectious disease. The HIV prevalence among South African prison inmates is estimated to be between 20 and 41%. Unprotected consensual penile-anal penetrative sex, drug use, tattooing, and sharing of blades are known to occur, yet the prevalence of such behaviours and their impact on HIV within the correctional services is not well understood. Efforts have been made by the Department of Correctional Services to provide comprehensive HIV prevention, testing, and support services; however, staffing shortages, limited technical support, and gaps in policy and training contribute to the high demand for appropriate services to promote the sexual health and rights of inmates and to prevent and respond to sexual abuse. The following recommendations are made in terms of the inmates in the country and those who are responsible for them:

• There should be HIV education for inmates and staff, workshops for staff on addressing sexual abuse of inmates, and education for inmates and staff on the nature and implications of sexual offences that also promote progressive understanding of sexuality and gender. Additional research into HIV prevalence, sexual and drug use practices in detention settings is needed.
• Increased access to appropriate HIV prevention, treatment, care, and support services in prison settings - specifically, voluntary testing and counselling, condoms appropriate for anal sex, lubricant, STI symptom recognition and treatment, and TB screening - is needed. Activities like education, work, and sport to serve as harm reduction interventions that decrease high risk behaviour should also be considered.
• Develop and implement a gang management strategy in conjunction with a policy framework on addressing sexual violence and overcrowding, privacy and confidentiality, and infection control.
• Ensure appropriate care for inmates who are raped: victims must be taken to the local hospital to receive medical care, a forensic examination, testing for HIV and other STIs, PEP, related counselling, and timely follow-up. These services must be carried out at no cost to the victim and only with the victim's informed consent.
• Apply the Sexual Offences Act in detention settings: the gender-neutral statutory offence of rape; the establishment of other crimes pertinent in detention settings; and the right to receive counselling and PEP in cases of possible exposure to HIV as a result of a sexual offence.

Migrants - Migration is a global phenomenon and has played, and continues to play, an integral part of South Africa's development. Circular migration, the pattern of leaving one's place of birth to spend time in a different area before returning, is typical and occurs within South Africa. Discriminatory attitudes, isolation, language, and cultural barriers, as well as integration challenges are just a few of the many factors that increase the risk of some migrant groups to acquiring HIV and increase the vulnerability of some migrant groups to the effects of HIV. Undocumented cross-border migrants face greater challenges in accessing services. Currently, few services are sensitive to the needs of migrant populations, and there is a lack of evidence-informed focused programming. Appropriate policy exists in South Africa to ensure that all migrant groups have the right to access HIV prevention and treatment services, but dissemination, implementation, and monitoring of these policies are inadequate. For migrants, the following recommendations are made:

• Increase migrant population access to prevention services, tools, and technologies; implement peer-led social and behaviour communication interventions, including the development of culturally sensitive IEC material; address barriers to access of health care, including language barriers and discrimination; and disseminate, enforce, and monitor existing migration policy.
• The International Organization for Migration (IOM) and other stakeholders have recommended that migration be mainstreamed into existing health policies, and that building capacity to better engage with migration within the public health sector in South Africa and the Southern African Development Community (SADC) become a priority. In addition, one should conduct research to understand the social factors that increase migrant vulnerability, map migrant communities for better understanding of the HIV epidemic, and strengthen health information systems to capture data on migrants (for example, health passports).
• Develop key advocacy messages that reflect and communicate the following objectives: The rights of migrants to access health services, the need for public health policy that incorporates migration health issues, the need to include migration health onto the public health agenda, and the need for dialogue at policy and strategy level, while raising the profile of migration health through dissemination of key information to inform policy.

Transgender People - Transgender people consist of a wide spectrum of individuals with diverse sexual practices, preferences, and identities. Increased vulnerability to HIV is associated with barriers to accessing health care and prevention services. Other factors leading to increased vulnerability include poverty, discrimination, high rates of sex work as a result of economic need, abuse, rape, and substance use. Pervasive stigmatisation, denial, and the hidden nature of some transgender people have led to the exclusion of transgender people from much research. This policy brief makes the following recommendations:

• Although transwomen are most often found in MSM communities, it is important to recognise their vulnerability separate from people who identify as male. Their vulnerability is located in their roles as the receptive sexual partners when expressing feminine identity. It stands to reason that their position should be examined from that perspective in the same manner as one would examine the different roles of men and women when dealing with men having sex with women (MSW), and all future programming should take gender identity into account.
• Programmes should cater to the needs of transgender people, including usage of gender-neutral and transgender sensitive language/training material and examples. Instead of using binary language such as male and female condoms, name them internal and external condoms. Active representation and participation by transgender people on lesbian, gay, bisexual, transgender, and intersex (LGBTI) platforms and other bodies should be ensured that both gender identity is appropriately acknowledged and that transgender people are empowered with the right to self-determination.
• Transgender people should have self-determination and not be limited through inclusion under MSM and women who have sex with women (WSW) groupings. Gender identity of individuals should allow them to participate and engage in services which they choose to use. It is suggested that practitioners implement sentinel HIV surveillance and behavioural surveys to build an evidence base around HIV epidemiology among transgender people.

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