INTERNATIONAL DEVELOPMENT SELECT COMMITTEE INQUIRY: IMPACT OF CORONAVIRUS ON DEVLEOPING COUNTRIES
ABOUT FRONTLINE AIDS:
Frontline AIDS is a global partnership, working to end AIDS for everyone everywhere. Across 37 countries, Frontline AIDS partners provide HIV prevention and treatment to some of the world’s most marginalised people, including adolescent girls and young women, LGBT people, sex workers, people who use drugs and those living with HIV. Drawing on decades of experience, we are working hard to ensure their needs are met throughout the COVID-19 pandemic.
RATIONALE FOR SUBTMITTING:
Since the onset of the COVID-19 pandemic, we are in dialogue and providing support to our partners in 37 countries. Our partners are already raising areas of concern, with HIV prevention and harm reduction services shutting down overnight and threats to the supply of HIV medicines and key commodities, such as condoms and methadone.
Frontline AIDS has been engaged in the global HIV and AIDS response for over 25 years, working with marginalised people who are denied HIV prevention and treatment simply because of who they are and where they live. During this time we and our partners have taken action in the overlapping areas of HIV, health, & human rights, and can see that there are valuable lessons to be learned from the response to HIV and AIDS, and which can be applied to the UK government’s response to the COVID-19 pandemic. Since the onset of the COVID-19 pandemic, comparisons have been made between the current crisis and the global efforts to tackle HIV and AIDS. For decades, the AIDS pandemic and the hard-won establishment of the global response have been held up as a yardstick of what can be achieved.
The HIV response may not be perfect – on both HIV prevention and access to treatment there is still significant progress to be made – but it has provided a clear blueprint for how the UK government, international institutions, communities and citizens can work across borders, cultures and generations to tackle an epidemic that, in its earliest days, seemed insurmountable. The parallels with the current challenges we face are clear.
Of the 37.9 million people living with HIV worldwide, around two-fifths are unable to access HIV treatment to keep them healthy. While no research is yet available on the impact of COVID-19 on HIV-positive people, the experience so far suggests that those with weakened immune systems are more severely affected and likely to require more intensive treatment.
Like HIV and AIDS, COVID-19 also has a disproportionate impact on those who are already marginalised. So far, elderly people and people with existing health conditions have been especially hard hit. As the pandemic spreads to poorer countries and those with higher HIV rates, Frontline AIDS is concerned that those most affected by HIV – adolescent girls and young women, LGBT people, sex workers and people who use drugs – will also feel the effects of COVID-19 more acutely. These groups are often unable to access vital healthcare because of poverty, stigma, and criminalisation, and because they live in countries without robust healthcare and social systems. The reality of their lives means that many will be unable to practice social distancing or self-isolation, while those in insecure work will have no choice but to continue working – even when they are ill.
COVID-19 is already rapidly spreading in countries our partners are working in and which have already stretched or low-performing health systems. Of the DFID priority countries where Frontline AIDS is also operating (Ethiopia, Indonesia, Indonesia, Kenya, Myanmar, Mozambique, Nigeria, Uganda and Zimbabwe) all have reported confirmed cases of COVID-19, with Indonesia already reporting 5,516 confirmed cases as of the most recent updates. It is likely that in many of these countries the actual number of cases may be much higher than what is being identified, and that many communities are already being impacted.
IMMEDIATE RISKS AND THREATS
Frontline AIDS partners are already experiencing the impact this is having on HIV prevention, treatment, and care services, including:
Limited access to, and supply of life-saving anti-retroviral medications: The COVID-19 response has disrupted supplies, limited personal movement, and closed community clinics, leading to a reduction in the supply and availability of antiretroviral medication (ARVs). In Zimbabwe, young people living with HIV risk defaulting on medication. Frontline AIDS partners have cited struggling to access healthcare institutions or get clearance past police checkpoints owing to the strict measures that the government has adopted during the lockdown period. In Indonesia, our partners are also reporting limited supplies of ARVs, citing delays in transportation and delivery of supplies which are coming from India. Currently people are still required to go in person to hospitals to obtain their ARV medication, forcing them to break with social distancing regulations. There have been attempts to discuss disruptions such as this with Indonesia Ministry of Health staff working in the area of HIV, but many of these have been redeployed to the country’s COVID-19 response, leading to delays in response.
Lack of access to critical HIV prevention services and commodities: Existing modes of HIV transmission - sexual intercourse and drug use - may undergo adaptations due to social distancing policies, but they will not stop. Indeed new HIV prevention needs may emerge rapidly as different relationship patterns develop - including more hidden ones in the virtual space replacing meeting venues like bars. Protection in the form of condoms, contraceptives, PrEP, opioid substitution therapy and access to sterile needles and syringes remain essential to avoid acceleration of HIV, STI, Hepatitis and other epidemics while addressing COVID-19.
Increasing levels police brutality and human rights violations: As coronavirus lockdowns have been expanded globally, people have found themselves facing unprecedented restrictions. In a number of countries, essential HIV services have been curtailed due to lockdown restrictions, or providers of these services have been denied permits to travel, leading to an absence of HIV prevention and treatment services. With these limitations most affecting community and peer-led providers, they are having a particular effect on already marginalised and criminalised populations. Increasingly, human rights violations targeted at already stigmatised communities are also being reported. Frontline AIDS partners in Uganda for example have reported increased persecution of the LGBT community, with one shelter providing accommodation to LGBT young people being raided and 19 residents arbitrarily imprisoned, on the spurious grounds that the shelter was violating the restrictions on group gatherings during the COVID-19 outbreak.
Devastating socio-economic impact: Many people may risk losing their salary or employment. This is a particular risk for people in precarious employment situations, or in employment without paid sick leave. Fear of losing employment, or lack of employment can prevent people from taking necessary steps to keep healthy, such as seeking testing and treatment or - in the case of COVID-19 - from self-isolating.
While some countries have announced packages of support, often this assistance is not universal. In Vietnam, Frontline AIDS partners have reported gaps in the government response, with the income support being offered excluding those who work in the informal economy, including sex workers. Similar issues have been seen in South Africa, where civil society organisations representing sex workers are campaigning to ensure that they can access income support.
Increasing levels of intimate partner violence: Frontline AIDS partners in India and South Africa have been reporting an increased amount of intimate partner violence linked to social distancing/isolation and “stay home” responses. Additionally, public lockdowns and the closure of HIV and SRHR services that often accompany them, create a likelihood of a spike in unintended pregnancies, unsafe abortion, HIV and maternal morbidity due to lack of access to contraceptives and condoms.
Other forms of gender-based violence have also been reported as increasing, with partners in India observing that sex workers have been placed at greater risk of violence from clients, having less negotiating power and less access to safety networks. The emptying of public spaces may also make people more vulnerable to non-partner violence, when making necessary excursions (shopping, health services, market etc),
More generally, as we have been in contact with our partners across various countries and regions, additional concerns have been raised in the light of COVID-19, including:
In the different countries Frontline AIDS works in, our partners are already proactively engaging with the impact of COVID-19 on their programmes.
In Vietnam our partners are communicating with the Vietnamese government to raise awareness of the economic impact on people without a formal income, such as sex workers, who are going hungry and are not able to apply for the government support being offered to those in the formal economy. Partners are also educating their communities on COVID-19 prevention measures using social media platforms and have procured an order of 30,000 masks and hand sanitiser to distribute among these communities as well.
Similar initiatives have been taken by other partners. Zvandiri, a Zimbabwean organisation that works with children, adolescents and young people, has already developed an online video targeted at adolescents which outlines key information about COVID-19. Our partner NACOSA in South Africa have developed their own guidelines on COVID-19 for those living with both HIV and TB, and the African Sex Worker Alliance have produced education materials on COVID-19 for sex workers.
In Kenya, partners have been utilising their social media platforms and bulk SMS to disseminate COVID-19 messages in most parts of the country and are supporting a hotline to provide psychosocial support. Considering the restrictions on movement and social gatherings, they have also successfully arranged the provision of ARVs to more than 8,000 clients for the next 3months and provided PrEP for two months.
In Uganda, our partners have successfully requested a waiver from the government to allow for their vehicles to still be used freely during the lockdown, so as to continue to carry out their activities. Partners have also been working with lawyers to secure the release of the 19 people imprisoned from the LGBT youth shelter.
THE UK GOVERNMENT RESPONSE
Frontline AIDS and our partners strongly believe that going forward the UK government needs to bring three important lessons from the HIV epidemic to the COVID-19 response:
The Essential Role of Communities
For decades, Frontline AIDS has urged governments to view communities as an integral part of their health systems. Now, we believe the communities on the frontline of the HIV response can also play a critical role in tackling COVID-19 – and some already are.
This new pandemic has prompted a public health response far more urgent and all-consuming than anything seen with HIV and AIDS. Yet the urgency required by this initial response has sometimes made it feel like interventions are happening ‘to people’, not ‘with people’. A key learning from the HIV epidemic is that this approach will not be sustainable.
For global action on COVID-19 from the UK government to have the best possible chance of success, it is vital that communities are placed at the heart of all responses. As we watch even the best-resourced health and social systems buckle under the unprecedented strain of this pandemic, governments will increasingly need to look towards communities and civil society to engage the people that they cannot reach. This should not be seen as a failure, or as a last resort, but as a vital part of the solution.
Governments and international organisations must quickly accept that working only through formal or state health systems will not bring desired outcomes. Everything we have learned from our long struggle against HIV and AIDS tells us that empowering and mobilising communities has a vital role to play in increasing people’s uptake of health information and services, accelerating progress on both prevention and treatment and ultimately, strengthening the whole health system. Partnerships and engagements with the most marginalised communities are essential to address COVID-19 and this requires resources. It is important to work collaboratively with communities in order to engage the hardest to reach people in COVID-19 prevention and response programmes.
Community-led systems are at the heart of building resilient health systems to prevent, detect and respond effectively to COVID-19. But in many countries, they remain marginal to the mainstream health care systems, and this must change. Community workers and knowledge in community organisations are key for the effective COVID-19 response. For example partners in India have written to the Union of Health and Social Welfare Ministers and offered themselves as frontline workers and partners to prevent a further increase in infections, as well as to tackle violations of human rights and to prevent deaths due to the shortage of essential harm reduction services.
Communities and civil society organizations are already pulling together in a similar way all over the world. HIV organisations are adapting and innovating, hosting information sessions on social media, setting up community hand-washing points and negotiating longer prescriptions for HIV treatments and medications like methadone, essential to HIV prevention. Negotiating longer ART prescriptions was identified as a key first step by Frontline AIDS partners in Bolivia and Ecuador, while our partners in Indonesia have temporarily negotiated take home Methadone, a highly innovative step in Indonesia where the state’s approach to drug policy is a largely repressive one.
The UK government must harness and support proactive efforts such as this. They must build them in to their strategies, mobilising communities and resourcing them as they would any other part of the health system—including ensuring communities have access to vital personal protective equipment to prevent infection.
In the longer term, DFID should strengthen its recognition of the role that communities play in the health system, particularly as it moves forward with its Ending Preventable Deaths Strategy and its long awaited Strategy on Health Systems Strengthening. Through formalising and strengthening partnerships with community-based or community-led health services, donors and governments can fill critical gaps in public health systems, whether it’s working effectively with the marginalised people who are especially vulnerable to COVID-19, playing a role in tackling stigma and fake news around the pandemic, or simply by extending the reach of healthcare services further and faster.
Dignity and Human Rights for All
As an HIV organisation, we know only too well the stigma and human rights violations that can rapidly erupt in the face of a health crisis, and we are urging governments and all other actors to uphold dignity and human rights for all people throughout the COVID-19 crisis.
We have already seen examples of marginalised people facing additional hardship and mistreatment during the COVID-19 pandemic. As mentioned above, we have seen state violence against the LGBT community in Uganda, where police took advantage of the COVID-19 situation to target the residents of an LGBT youth shelter, and arrested 23 people, holding 19 in prison, under the charge of non-compliance with social distancing.
The UK Government has been a strong voice in defending the rights of LGBT people around the world, and was due to host the international conference of the Equal Rights Coalition later this year. While this is now unlikely to go ahead, the UK should continue to challenge human rights violations against LGBT people and other marginalised communities in the COVID-19 response – both in its interactions with other governments and in supporting human rights institutions to take remedial action.
Ensuring new treatments and vaccinations for COVID-19 that become available are accessible to all of humanity from the outset
From HIV we have learned bitter lessons about the need to ensure that new treatments or new uses for existing medicines are available and affordable for all, rather than to a privileged few. As the UK rushes to invest public funding in research and development on COVID-19, we urge the UK government to include public interest conditions from the outset and ensure that treatments or vaccines developed will be accessible to all countries.
In addition to the above points, we also urge the UK to help realise the World Health Organisation’s advice, issued in the light of COVID-19, to ensure that all people with HIV who aren’t yet on treatment are enabled to start as quickly as possible, as a key strategy to protect their health and reduce their vulnerability to the coronavirus. While recognising the enormous challenges of the COVID-19 pandemic, we urge the UK and other governments and international agencies to support efforts to sustain the HIV response and ensure that the gains made on HIV are not lost.
 Technical Brief: Community Systems Strengthening. The Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria. 2019. pp. 3-4 https://www.theglobalfund.org/media/4790/core_communitysystems_technicalbrief_en.pdf