Political inaction and dwindling investment – what’s next for HIV prevention?

Even before COVID-19 hit, Indonesia was having a challenging year for its HIV response. It has the fourth lowest coverage for antiretroviral treatment in the world and one of the fastest rising rates of new HIV infections in the Asia Pacific region. The national HIV and AIDS strategic plan is two years behind schedule and although the Ministry of Health has now announced a launch date, community-based organisations involved in providing crucial HIV prevention services have not seen a recent draft.

On top of that, an unstable political situation has given rise to a febrile atmosphere across the nation where the last 12 months have seen widespread protest, including the draft criminal code proposed at the end of last year which, if passed, would have potentially made gay and lesbian sex illegal, restricted the promotion of sex education and placed new limits on condom distribution programmes.

Then came the news that the Global Fund to Fight AIDS, Tuberculosis and Malaria had rejected Indonesia’s bid for its 2021-2023 funding cycle, granting only an extension year in 2021 for unspent funds from this year but with no new investment. According to Aditia Taslim, Executive Director of Rumah Cemara, a Frontline AIDS partner with expertise in harm reduction: “COVID-19 just adds to all this chaos. AIDS is not over yet for Asia Pacific. If you look at new infection trends in the region, it remains key populations and their partners, they are still heavily criminalised. As donors are moving away, there’s no funding for HIV prevention for these groups or for community organisations.”

“Bring back the investment,” he pleads. “Next year will see a reduction in funding, a reduction in intervention areas, and a reduction in prevention activities.”

Cause for concern across Africa

In Malawi, Grace Kumwenda who is Chief of Party with the Pakachere Institute for Health and Development Communication echoes Aditia’s anxiety. “One of the longer-term impacts of COVID-19,” she says, “is a shift in resources to address the pandemic. So in some countries, and some contexts, resources that were supposed to go into HIV programmes are being reallocated for COVID work and that will lead to longer term impacts in terms of the progress that we make.”

This shift in attention is something that keeps Massogui Thiandoum, technical director with the Senegalese organisation ANCS, awake at night too. “If COVID continues like this,” he warns, “our health system will become more fragile in trying to contain it, and because we are so focused on the epidemic, other priorities like malaria, TB and HIV will be side-lined. This will only create major complications for the population and risks destroying all the good results we’ve had to date in the fight against such chronic diseases.”

In Kenya, where new HIV infections among young people are particularly worrying, LVCT Health’s Senior Technical Advisor (Policy and Partnerships), Patriciah Jeckonia, is similarly concerned. “In general, the HIV response has lost traction,” she says. “During the pandemic, some of the key population drop-in centres ran by communities had to be closed as they were not considered essential services centres. This affected access to HIV prevention commodities.”

“We have experienced shortages of Septrin ,” she adds, “which has led to people living with HIV having to spend money to buy the supply they need. There will be a surge of opportunistic infections if we continue experiencing shortages.”

Phyllis Mavushe works with Africaid’s Zvandiri programme that focuses on HIV prevention, treatment and care services for young people in Zimbabwe and thinks that HIV prevention efforts have been set back because of COVID-19. “Some of the clinics were temporarily closed and some were used as quarantine centres,” she says. “Accessing HIV services was challenging due to lockdown and travel restrictions. There was a notable reduction in the numbers of young people accessing HIV testing because they were unsure how to access those services. Now we have to adapt to the new normal – virtual support groups, virtual coordination meetings, virtual service delivery.”

Putting words into action

For some, like Aditia at Rumah Cemara, what’s needed is a public message of solidarity from the highest levels. “We don’t have a mandate coming from the very top,” he says. “Within the country, there was never a single time that our President, or previous Presidents, made an official statement on HIV, unlike other diseases like TB. We need that kind of commitment, a political statement. As soon as he made a statement on TB in July this year, domestic funding came flooding in.”

Advocates hope the new UNAIDS Strategy, together with the Global Prevention Coalition’s new HIV Prevention Road Map (2021-2025) can foster the bold political leadership, strong accountability and financial investment that is required to get us back on track. But for others, like Grace at Pakachere, it’s a question of a little less conversation and a lot more action. “I would ask for commitment and resources beyond rhetoric, beyond talk,” she says. “We’ve moved forward quite a lot with HIV treatment but let’s not forget to close the gap. Let’s make sure that we’re actually addressing new infections at the same time.”

She’s also keen to point out that there are now more options for HIV prevention and that governments need to be rolling them out as fast as possible. “The science is moving quite fast and we have other tools that will most likely be on the market quite soon like the dapivrine (vaginal) ring and injectable PReP. The wider choice we have, the better the opportunities we have to prevent HIV.”

Patriciah at LVCT Health agrees: “We have to lobby for more investment in HIV prevention and need a shorter turn-around time for moving new prevention products from research to practice.”

Building the evidence base

Grassroots community-based organisations have long operated on the frontlines of the HIV response, leading the way in developing innovative and effective programmes responding to the needs of marginalised groups. According to Massogui from ANCS, that’s a wealth of knowledge that could really be brought to the fore at this time.

“We have to be scientific in our approach,” he says, “and show what works through demonstrating evidence from the community level. The HIV experience is something that could be learned from – at ANCS we have 25 years of community experience that could be applied to COVID-19.”

Patriciah at LVCT Health has a similar outlook. “We need to provide evidence on the impact of government funding for the vulnerable to build a case for continued or increased funds whilst ensuring there is value for money.”

In Indonesia, Aditia is planning to document some of the best practices adopted during the pandemic and use the study as a key advocacy tool. “Despite the disruptions during COVID,” he says, “like lots of communities around the world we’ve been adapting and looking at different ways for people to access antiretrovirals and services. We have done a lot of home delivery and telemedicine and we are very aware that this is a good opportunity to push the government to recognise community-led services.”

In a year that has brought unprecedented disruption, we reaffirm our commitment to addressing the barriers that are preventing us from achieving success. The evidence presented in our new series of HIV prevention shadow reports calls on governments and donors to sustain and protect HIV services, during COVID-19 and beyond. This is not the time to take our foot off the pedal. Action is needed now more than ever. Communities hold the expertise to drive change, but without bold political leadership, the future for HIV prevention remains uncertain.