Protect everyone’s rights to protect everyone’s health against Aids

Zero discrimination is essential to if we are to change the fact that 7.8 million South Africans live with HIV, but 5.8 million people are on ARVs, highlighting a treatment gap

Today (March 1) is Zero Discrimination Day, established 10 years ago by the United Nations Joint Programme on HIV (UNAids) to protect the rights of everyone and build healthier societies. The evidence is clear: only by protecting everyone’s rights, can we protect everyone’s health. 

At the beginning of the Aids epidemic, most countries in the world criminalised lesbian, gay, bisexual, transgender, queer and intersexpeople, now two-thirds of countries do not criminalise LGBTQI+ people, South Africa being one of them.

Progress has been made, especially in South Africa. 

In 1996, South Africa’s new Constitution made discrimination based on sexual orientation illegal. The Constitution states that: “No person shall be unfairly discriminated … on one or more of the following grounds … colour, sexual orientation …”. 

The Employment Equity Act 55 of 1998 ensured that employers could not discriminate against employees based on their sexual orientation. The 1996 South African Schools Act was implemented to ensure that schools were more inclusive.

On 1 December 2006, the South African government passed the Union Bill, which legalised same-sex marriage, making South Africa the first African country to do so. 

In 2000, South Africa published a Code of Good Practice on Key Aspects of HIV and AIDS and Employment (the Code) in line with Chapter 2 of the Employment Equity Act, No 55 of 1998 (as amended). Twelve years later (2012), the department of employment and labour revised the Code to align it with the International Labour Organisation Recommendation concerning HIV and Aids and the world of work (No 200) to ensure non-discrimination. The Code is intended to protect and promote mutual respect, dignity and the workers’ rights through the elimination of unfair discrimination against people living with or affected by HIV and Aids. 

And, to date, South Africa has the largest HIV antiretroviral (ARV) programme in the world. 

Hard-fought gains

About 7.8 million South Africans are living with HIV, of which, 5.8 million people are on ARVs, highlighting a treatment gap, according to the Thembisa model (version 4.5). Thembisa is a mathematical and demographic projection model of the South African HIV epidemic, designed to answer policy questions relating to HIV prevention and treatment and a source of demographic statistics.

The estimates paint a stark picture. Women continue to bear a disproportionate burden of the HIV epidemic. Almost a quarter (24.1%) of women aged 15 to 49 years are HIV positive compared to 13.1% of men, according to the National Strategic Plan on HIV, TB and STIs 2023-2028.

The HIV incidence among adolescent girls and young women aged 15 to 24 years is 3.7 times higher than males of the same age and the ratio has increased in the last 10 years.

Although South Africa has a generalised HIV epidemic, it is characterised by distinct sub-epidemics among key populations which include sex workers, transgender people, men-who have sex with men (MSM), People who inject drugs and inmates. Key population groups have the highest prevalence and incidence of HIV, with inadequate efforts to reach these populations, stigma, discrimination and punitive laws contributing to high infections. 

HIV prevalence among female sex workers is 57.9%, 51.9% among transgender women, 29.9% among MSM and 21.8% and 17.5% among people who inject drugs and people in prisons respectively, according to the Thembisa model.

Both HIV- and TB-related experiences and internalised stigma varied from low to moderate levels across six districts in KwaZulu-Natal, Mpumalanga and the Free State, according to the 2020-2021 Human Science Research Council HIV Stigma Index 2.0 survey. In addition, experienced stigma ranged from 10% to 27% and internalised stigma ranged from 14% to 31.5% in the three provinces. 

The survey further found that the 15 to 24-year age group experienced the highest levels of internalised stigma and a greater risk to experience cyberbullying. Higher levels of internalised stigma were also found among key and vulnerable populations, specifically people with disabilities, sexual and gender minorities, and sex workers.

The 2023 Ritshidze State of Healthcare for Key Populations report, launched this week with data collected from interviews with 13 832 people shows that people who are queer or trans, use drugs or are sex workers often face uncaring, disrespectful, cruel and even abusive treatment at public health facilities. 

Report findings show confidentiality violations remain common; 57% of gay, bisexual and MSM, 61% of trans people, 65% of sex workers and 74% of people who use drugs did not think privacy was respected. The report details an alarmingly number of people who had been refused health services in the last year because of being queer or trans, using drugs, or doing in sex work — 8% of gay, bisexual and MSM, 10% of trans people, 11% of sex workers and 31% of people who use drugs.

When marginalised people are criminalised or stigmatised, their vulnerability to HIV and TB infection increases, and their access to HIV and TB prevention, treatment, care, and support services is obstructed. This holds back progress towards the end of Aids.

It is therefore imperative that we continue to advocate for the decriminalisation of sex work. 

With sex work being stigmatised and criminalised as it stands, sex workers are deterred from seeking healthcare and recourse from the justice system. 

Sharing their experiences, sex workers at the South African Aids conference last year reported travelling to clinics outside of their areas because of the stigma and discrimination they receive at the hands of some healthcare workers. They also spoke of fear of reporting incidences of abuse from clients because of criminalisation. We must continue to challenge these stereotypical prejudices to ensure that their human right to health and justice is attained. 

Criminalisation drives people from support services

Recognising pervasive stigma, South Africa’s 5th generation National Strategic Plan (NSP) for HIV, TB and sexually transmitted infections (2023-2028) promotes a new and urgent focus to reduce inequalities and has been designed to place people at the centre. It includes services and social support for sexual and gender-based violence, human rights violations and mental health.

To continue the progress South Africa has made, UNAids urges support for women’s movements and movements for the rights of LGBTQI+ people, for racial justice, for economic justice, for climate justice and for peace. 

It is those most affected by discrimination that are leading the pushback against the erosion of their right to health, against the right to life. They are uniting their efforts to protect and advance human rights. They need, and deserve, our support.

UNAids executive director Winne Byanyima emphasises that “For HIV responses to be fully effective and for impact to be sustained, all people must have their right to health fulfilled. Countries need to have rights-based and  person-centred approaches, and communities most affected by HIV must be meaningfully involved.”

Protecting everyone’s rights is not a favour to any group; it is the way that we can protect everyone’s health, end Aids and create happier societies for all.

Eva Kiwango is the country director for UNAids South Africa.