INTERNATIONAL DEVELOPMENT SELECT COMMITTEE INQUIRY: IMPACT OF CORONAVIRUS ON DEVELOPING COUNTRIES:

Longer term issues, implications, and lessons to be learned

ABOUT FRONTLINE AIDS:

Frontline AIDS is a global partnership, working to end AIDS for everyone everywhere. Across 37 countries, Frontline AIDS and our 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.

SUMMARY:

The COVID-19 pandemic poses a serious threat for the millions of people living with HIV and tuberculosis, and for those most at risk of acquiring these infections. Frontline AIDS' partners have already documented the immediate impacts of the COVID-19 pandemic in the countries where we work, including; limited access to, and supply of life-saving anti-retroviral (ARV) and TB medications;  limited access to HIV prevention services and commodities; increasing rates of gender-based  and intimate partner violence; growing numbers of human rights abuses targeted at marginalised and criminalised communities, and the devasting social and economic impact resulting from lockdown. This submission outlines some of the longer-term issues.

While we have made great strides in expanding access to HIV treatment, more than 13 million people still are not accessing the medicines they need, and may be at heightened risk from COVID 19.  Even for those who are accessing treatment, there are acute risks of treatment interruptions as resources are diverted, health services close and supply chains are disrupted. Modelling released by the World Health Organisation today warns that if efforts are not made to overcome these interruptions, we could face more than 500,000 extra deaths from AIDS-related illnesses in 2020–2021[i].

For HIV prevention programmes, this disruption is already being felt.  Many services have shut down overnight, with disastrous consequences for those most at risk.  We know already for example that women and girls face higher risks of HIV infection under lockdown, due to increased levels of violence, yet many now have no access to life-saving HIV, SRHR or gender-based violence services. Even before COVID-19, HIV prevention was in crisis, with the number of new infections barely declining in recent years, and with rates of infection actually increasing for adolescent girls and young women[ii] .  There are very real fears that the current closures will see the target of ending AIDS by 2030 becoming a distant dream.  At the same time, new modelling now suggests that up to 6.3 million more people are predicted to develop TB between now and 2025, and 1.4 million more people are expected to die as cases go undiagnosed and untreated during lockdown.[iii]

As COVID-19 continues to take hold, the key challenge will be to sustain funding and momentum for the HIV and TB responses, both during this emergency period and later, in the aftermath of COVID-19 (Section I).

Alongside this, Frontline AIDS and our partners are advocating that governments recognise the vital role that communities responding to HIV and TB can play in the the COVID 19 response, and provide community organisations with resources so that they can adapt HIV and TB programmes to also address COVID-19, instead of setting up whole new programmes. At present, community-led organisations, the lifeblood of the HIV and TB response, are operating in increasingly difficult circumstances, dealing with lockdowns and reduced budgets while still working hard to provide quality HIV and TB services, protect their communities from COVID 19 and mitigate the social and economic impacts of lockdown (Section II).

Finally, at Frontline AIDS we are working with partners to protect human rights during the COVID-19 pandemic, particularly for those who are criminalised and marginalised, and urge the UK to support this vital work and make human rights a stronger component in the UK’s response to COVID-19 (Section III).

1. Sustaining HIV and TB services during the COVID-19 pandemic:

In many countries, stockpiles of anti-retroviral (ARV) medications are running low, and the supply chains for these medications - many of which come from China – could be disrupted for many months to come.

In addition, because of local health system closures and travel restrictions, many of Frontline AIDS’ partners are reporting difficulties for people in accessing essential HIV medication, which they are usually required to pick up from health centres on a regular basis.  They also flag challenges for people who use drugs in accessing opioid substitution therapies such as methadone. The closing of borders, transportation constraints, and blockages in manufacturers’ delivery flows are negatively affecting the import, availability and distribution of essential medicines, commodities, and services.

With the experience of Cholera and Ebola, Uganda’s health system is used to operating in crisis mode, but the current pandemic has thrown up new challenges. The price of some key commodities, including drugs for opportunistic infections associated with HIV, and masks have risen dramatically. Physical distancing means that clinic waiting areas have had to be rearranged and additional hand sanitiser stations set up. Dr Pasquine Ogunsanya, who heads up Alive Medical Services (AMS) a non-profit medical centre in Kampala, is feeling the brunt of this new threat. Here, the shutdown of public transport has prevented more than 10,000 clients from accessing their life-saving ARV treatment. However, the organisation’s well-established connections with the local community have come into their own during the pandemic. Peer educators have been delivering medications by bicycle. Where this is not possible, one community member makes the journey to the clinic to pick up ARVs on behalf of many others. “We’re a high-volume clinic,” says Dr Ogunsanya, “so it’s a lesson that we can use community distribution of medication rather than having the clinic full of clients”.

As lockdowns and social distancing restrictions continue – alongside uncertainty about when these precautions will be lifted or reapplied - partners are increasingly relying on virtual platforms to ensure vital HIV prevention, treatment and care services are maintained. In India, our partner Vasavya Mahila Mandali (VMM) has witnessed a stark increase in the number of domestic violence cases being reported to their Family Centre because of new social distancing and “stay at home” orders. To address this growing need, VMM have started a new telephone guidance and counselling service for people experiencing gender-based violence. Counsellors are now able to speak to clients over the phone and report cases directly to the police department – a development that has helped build stronger relationships between the organisation and law enforcement agencies.

While service providers must be agile and adapt to changing circumstances, bilateral donors like the UK Government, and multilateral institutions like the Global Fund, must continue to show the same level of flexibility.

Recommendations:

• To reduce the risk of significant stockouts, the UK government must continue to support the actions of the WHO, the Global Fund, UNFPA and other key partners, and work with them to ensure the uninterrupted supply and delivery of essential medicines including ARVs, pre-exposure prophylaxis (PrEP), post-exposure prophylaxis (PEP) and OST, as well as other sexual and reproductive health supplies, like condoms and other contraceptives.
• To ensure the continuity of HIV and TB services, the UK government must commit to sustaining current levels of overseas development assistance for the HIV and TB responses, and ensure that key bodies like the Global Fund for AIDS, TB and Malaria do not divert funds from these diseases to tackling COVID-19.  The Department for International Development (DFID) should also use its influence with other donors and with national governments to commit to sustaining HIV and TB services through the COVID-19 crisis, and should urge governments to lift travel restrictions for NGOs and community-based organisations that are providing HIV and TB services during COVID-19 lockdowns.
• To ensure that programming remains responsive to most marginalised, DFID must offer flexibility to its current implementing partners and work with them to identify adjustments within its current portfolio of programmes and contracts, especially those focused on HIV, sexual and reproductive health and rights, and TB, as well as those focused on marginalised communities and civil society strengthening, under the UK AID connect grant. DFID's grant management approach should allow for greater flexibility on key performance indicators and programme expenditures, and should also allow for reprogramming, so that implementers are able to respond to the COVID-19 threat and to the consequences of lockdown, such as increased levels of gender-based violence. In the long term, donors like DFID may need to adapt further, to ensure that NGOs can cover core costs and retain staff during the crisis, even if service delivery or activities are reduced.
• Finally, the UK has shown great leadership and called for greater investment in COVID-19 research. As part of this work, they must advocate for new research on the impact of COVID-19 on people living with HIV and TB - and if specific vulnerabilities exist – push for guidelines to ensure all programmes are delivered safely.

2. Adapting HIV and TB programmes to address COVID-19.

There are already inspiring examples of communities adapting their programming to respond to the COVID-19 threat. For Alliance India, a major concern is keeping people who use drugs alive and healthy, by ensuring vital harm reduction services can continue. As in Uganda, it is existing community networks that are extending a lifeline to a population that might otherwise be overlooked during this pandemic. Recent investment by Alliance India and Frontline AIDS in drug-user forums at both state and national level is already paying dividends in the coronavirus pandemic. The community of people who use drugs sprang into action when the lockdown was announced, putting in place systems to deliver the OST drug buprenorphine, sterile needles and syringes, and even sanitary products for female drug users. Charanjit Sharma, Alliance India’s harm reduction programme manager, says: “This is an example of the effectiveness of using the community network in an emergency. The community felt there was a need and so the community came together and started dividing responsibility for who should be doing what.”

Changes in market dynamics – namely the increase in the price of drugs like heroin – means the demand for buprenorphine has gone up because it is needed to counter acute withdrawal symptoms. Kunal Kishore, Alliance India’s associate director for harm reduction, says: “These drug-user forums are now filling in the strategic gaps.” With Alliance India’s support, the forums have been busy lobbying for new clients to be accepted in harm reduction programmes, and for take-home supplies of OST to be initiated in some states, something which was difficult to push forward, pre-lockdown.

With help from Frontline AIDS, Alliance India is also in the process of setting up six additional drug-user forums to be able to quickly provide naloxone, an antidote for opioid overdoses. “We are anticipating that there will be a large number of overdoses as drugs start to come on to the market again.” Charanjit says: “We should continue investing in community system strengthening because the community is at the forefront, whether it’s HIV, whether it’s hepatitis C, or whether it’s COVID-19.” The speed and agility with which the drug-user forums have mobilised have without doubt saved lives and are a valuable illustration of why governments must engage communities in the COVID-19 response.

During this unprecedented period, communities have a critical role to play in sustaining services and keeping people safe. Since the earliest days, communities and community-led organisations have been on the frontline of the HIV response. A top-down, government-led approach will not end this epidemic. Community and civil society must be viewed as critical partners within this response and resourced adequately.

Recommendations:

• The UK Government must recognise communities and community-led organisations as an integral part of health systems – and resource them accordingly, with both core and project funding
• It is also critically important that the UK invests in adapting existing programmes, including programmes that are working to tackle HIV and TB at community level, rather than starting from scratch. Whilst we welcome DFID’s £200 million package of support to countries impacted by COVID-19, only 10% of this funding is being made available to non-governmental organisations (NGOs), and only a handful of UK registered organisations will be eligible to apply. Additional funding must be made available to smaller, grassroots organisations working on the frontline, especially those working with communities most affected by HIV and TB.
• Going forward, community systems strengthening should also be included as a key pillar DFID’s new health systems approach and their new preventable deaths strategy, which are both yet to be finalised.
• The UK government must also use its position within global policy spaces, such as the upcoming World Health Assembly, to advocate for greater prioritisation and investment in community-led responses.

3. Protecting human rights in the COVID-19 response, particularly for the most marginalised:

As COVID-19 responses by governments continue, many of Frontline AIDS' partners are seeing a rise in militarisation, an increased level of human rights abuses, and a rise in stigma related to COVID-19 and marginalised communities more generally. The Frontline AIDS’ Rapid Response Fund, which provides grants to LGBT people in emergency situations, has received almost triple the number of applications since January - with the highest volume coming from Uganda and Kenya. This spike in demand underlines the acute challenges facing marginalised communities, as this pandemic continues to take hold.

Individuals applying to the fund have reported restrictions on movement with significant impacts on access to ART medication, food and other essentials; hate speech blaming LGBT people for the genesis and spread of COVID-19; the exclusion of LGBT asylum seekers from health systems and COVID-19 responses, as well as an increased risk of COVID infection due  to cramped conditions and limited resources in camps and temporary forced gatherings. Organisations working with LGBT people applying to the fund have reported hostility towards outreach workers. There have also been severe restrictions placed on operating hours, movements and gatherings, with our partner in Uganda being denied permission to travel.

In South Africa, the Rapid Response Fund has received concerning reports on how COVID-19 regulations have led to the creation of displacement camps, which are supposed to accommodate people who are not able to self-isolate. In Cape Town, people who are homeless, including many people who use drugs and transgender women, have been identified and targeted by city management, who have set up a large ‘camp’ outside the city. People have been rounded up in buses, with promises of warm food and shelter. People living in temporary structures (squatters) are also being rounded up. In many cases, these new lockdown regulations are being used as an opportunity to implement pre-COVID plans, to carry out these forced removals from the city.

Conditions in the camp, however, are far from what was promised, and are putting the health of newly arrived residents at risk. There is reportedly no possibility for adequate social distancing within the camp; no protective equipment; a shortage of WASH facilities; poor availability of health services for people with underlying conditions such as HIV and TB; and the administrators have so far refused to allow provision of opioid substituion therapy or needles and syringes, with reports that many people are going through severe withdrawal.  People’s ability to leave is severely restricted, with approximately 130 law enforcement and private security personnel operating within the camp. So far two deaths have been reported, both reportedly among people who use drugs.  There have also been reports of rape. Local organisations wishing to provide support to clients living in the camp have very limited and inconsistent access.

An inclusive global response, which prioritises the human rights of the most marginalised and vulnerable people - is critical. Stigma, discrimination, undue restrictions, harmful criminal sanctions and a hostile policy environment undermine our collective approach.

Recommendations

• The UK must make human rights a stronger component in the UK’s response to COVID-19 (Section III), and increase its advocacy efforts in this area.  In particular, as a vocal defender of LGBT rights, and the host of the Equal Rights Coalition Conference, the UK Government, must step up efforts to defend and protect the rights of LGBT facing persecution and violence as a result of new police powers.
• More widely, as it increases support for their wider COVID-19 responses, the UK should be working closely with national governments to ensure that their responses are respecting and protecting human rights, particularly the rights of marginalised groups. This includes removing barriers to HIV, SRHR and harm reduction services; addressing human rights violations and hate crimes and ensuring that new regulations and powers are not abused.
• The UK Government must also support efforts to document human rights violations and hate crimes being committed under new COVID-19 regulations, especially in countries where DFID or the FCO have a significant presence. This includes submitting evidence as part of the Universal Periodic Review process.
• The Foreign and Commonwealth Officer should consider providing emergency funding, perhaps through its national embassies, to support civil society organisations who are responding to this increase in human rights violations. It must also consider providing additional funding to support community-led advocacy and monitoring of national COVID-19 responses.