South Africa: HIV lessons for Covid-19

South Africa's third Covid-19 wave arrived in sync with winter. President Cyril Ramaphosa announced at the end of autumn that the country would be moving up to an adjusted level two of lockdown. He urged all South Africans to take responsibility for delaying the peak of the coming wave.

The announcement came two weeks after the second phase of vaccinations began in South Africa. The first phase was the Sisonke clinical study, which aimed to vaccinate 500 000 health workers. Slightly more than 480 000 people were vaccinated. The second phase targets the balance of health workers and people over the age of 60. Three weeks into the second phase, more than 400 000 people had received their first dose of the Pfizer vaccine.

While South Africa has procured enough vaccines for the adult population, they will arrive in smaller tranches. Manufacturing issues at a plant in the United States meant 1.1 million single-dose Johnson & Johnson (J&J) vaccines scheduled to be administered in phase two had not been released from Aspen's factory in Gqeberha three weeks into the second phase of the rollout, as they were still pending approval from the US Food and Drug Administration.

Additionally, the electronic registration system has been blamed for delays in getting those over the age of 60 registered. In this case, the government seems to have ignored an important lesson learnt when rolling out antiretrovirals (ARVs) for the treatment of HIV and Aids.

Francois Venter, a professor and deputy executive director of the Wits Reproductive Health and HIV Institute, pointed out that while it may be more difficult to roll out vaccines than ARVs because of the urgency of the coronavirus, "you have to try and get to people, and you have to try and deal with the vaccine hesitancy, and to get to people who are not fit.

"We have so much experience from our ARV programme, which took us 17 years to get right. You have to de-bureaucratise and make this as easy as humanly possible."

The longer it takes to complete phase two, the longer it will take for people in their 50s with dangerous comorbidities to be eligible for vaccination.

Perhaps the most striking difference between the HIV and Aids epidemic and the current pandemic is that up until now, no ordinary people have taken to the streets to demand vaccines.

No space for dialogue

In the Eastern Cape, Treatment Action Campaign (TAC) provincial manager Noloyiso Ntamenthlo is worried about the vaccine rollout in Lusikisiki. The organisational capacity built to facilitate the Siyaphila La ARV treatment project no longer exists and the TAC's presence in the area has lessened since then.

"We don't have a space where we can have dialogues, as we did with HIV, about the vaccine ... have someone who's going to answer questions and make the people understand exactly what is going to happen. I know it's not easy, but it's important to have a strategy. That is the problem, we don't have a strategy."

In Khayelitsha, Mpumi Mantangana, who was instrumental in implementing many innovations in HIV treatment in Doctors Without Borders' Ubuntu clinic, is also concerned about the lack of urgency in terms of education and vaccine literacy.

"With HIV, civil society took a lead role. It was very strong, and they pressured the government in order to do something. You know, now, we don't need to pressurise the government because the government is trying to do something. But what we need to do now is to go out in the streets and convince our communities to come forward when they attend, to come forward to vaccinate," said Mantangana. "Civil society really needs to come to the party," she said.

Building systems at community level

Various civil and non-governmental organisations have responded to the fallout of the pandemic since March 2020, attempting to alleviate hunger, halt evictions and police brutality, and pressure the government to instate a Covid-19 relief grant and then increase it.

The Health Justice Initiative (HJI) founded by Fatima Hassan, an attorney with the Aids Law Project during the HIV and Aids epidemic, is using the law to push for equitable access to vaccines. The HJI has been involved in litigation involving companies profiting from the pandemic, as well as Afrikaner interest organisation AfriForum's bid to procure vaccines privately with trade union Solidarity.

Informally, groups such as Community Action Networks have been supporting people in their neighbourhoods by providing relief through food and other means.

Civilians may have been responding to urgent needs, but TAC co-founder Mark Heywood said this is going to be "a long epidemic". He said civilian institutions, organisations and movements have to understand the urgency of Covid-19 vaccine literacy, "in building the systems at community level that support people".

Global network the People's Health Movement (PHM) has facilitated workshops aimed at educating the public about Covid-19 and combating vaccine hesitancy. "Treatment literacy worked. Ordinary people can understand complex medical concepts if the information is provided in an accessible way," said PHM member Lydia Cairncross.

"The day that the president announced that the churches were opening, I thought, 'That's it, I'm gonna run workshops,'" said Cairncross. "If people understand why they need to do something, they will figure out how to move around more safely with the virus. If you just tell people what to do, and [it's impossible], they're just not going to do anything."

The workshops were powerful, but the PHM was not able to run them at scale. In collaboration with Section27, a public interest law centre that advocates for access to health, the workshops have been converted into training manuals as part of a "train the trainers" campaign that kicked off at the end of May.

However, with the national vaccine rollout coinciding with the start of the third wave, it is moot if the campaign is able to get off the ground quickly enough to influence this phase of the rollout.

Mobilisation the ultimate aim

When the TAC started its treatment literacy programme, the aim was to educate people up to the point that they could demand ARVs. We wanted to "build a movement that reflected the demographics of the epidemic, which meant Black people, poor people, women... and to let that movement speak for itself," said Heywood.

The knowledge gained gave people a sense of confidence. They learned about HIV and opportunistic infections, as well as the different treatments available elsewhere in the world. Education was the tool and mobilisation to demand access to ARVs was the goal.

"We didn't want people to just say, 'Give me the blue pill and the red pill.' We wanted them to be able to demand it. 'We want AZT [ARV medication azidothymidine], we know what AZT is.' Or in the case of the fluconazole campaign, which was an antifungal, people understood opportunistic infections and why an antifungal medicine was necessary to treat candidiasis, etc."

TAC's successful mobilisation was a direct result of linking its treatment literacy campaigns with its broader political project of demanding access to HIV treatment.

"You need a movement that can really galvanise public opinion. And I just don't think that's happening at the moment. I think it's talking over the heads of ordinary people," said Heywood.

In a few weeks, the third wave would have passed and left hundreds, perhaps thousands, more deaths in its wake. It remains to be seen if such a movement will be formed in the troughs and crests that are sure to follow.

This project was funded by the National Geographic Society.

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