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South Africa Scaling up Programs to Reduce Human Rights- Related Barriers to HIV and TB Services

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South Africa Scaling up Programs to Reduce Human Rights- Related Barriers to HIV and TB Services Baseline assessment –South Africa Scaling up Programs to Reduce Human Rights- Related Barriers to HIV and TB services November 2018 Geneva, Switzerland DISCLAIMER Towards the operationalisation of Strategic Objective 3(a) of the Global Fund Strategy, Invest- ing to End Epidemics, 2017-2022, this paper was commissioned by the Global Fund to Fight AIDS, TB and Malaria and presents, as a working document for reflection and discussion with country stakeholders and technical partners, findings of research relevant to reducing human rights-related barriers to HIV and TB services and implementing a comprehensive program- matic response to such barriers in South Africa. The views expressed in the paper do not nec- essarily reflect the views of the Global Fund. ACKNOWLEDGEMENTS With regard to the research and writing of this report, the Global Fund would like to acknowledge the work of the Health Economics and HIV/AIDS Research Division (HEARD) at the University of KwaZulu Natal in Durban, South Africa, as well as country and technical partners and the many others who provided contributions. ii LIST OF ACRONYMS AIDS Acquired Immune Deficiency Syndrome ARASA AIDS Rights Alliance of Southern Africa ART Antiretroviral Treatment ARV Antiretroviral medications CAPRISA Centre for the AIDS Programme of Research in South Africa CD4 Cluster of differentiation 4 CDA Central Drug Authority CDC Centers for Disease Control and Prevention COP Country Operational Plan DBE Department of Basic Education DCS Department of Correctional Services DENOSA Democratic Nursing Association of South Africa DOH Department of Health DOJCD Department of Justice and Constitutional Development DSD Department of Social Development DR-TB Drug resistant TB FSW Female sex workers GFATM The Global Fund to Fight AIDS, Tuberculosis and Malaria GIZ Deutsche Gesellschaft für Internationale Zusammenarbeit HCW Health care workers HIV Human immunodeficiency virus HEARD Health Economics and AIDS Research Division HEAIDS The Higher Education and Training HIV/AIDS Programme HSRC Human Sciences Research Council HTA High Transmission Area HTS HIV testing services IBBS Integrated bio-behavioural surveillance IPV Intimate partner violence I-TECH International Training and Education Center for Health KIs Key informants KIIs Key informant interviews KPI Key performance indicator Key Populations - Representation, Evidence and Advocacy for Change in KP REACH Health LGBTI Lesbian, gay, bi-sexual, transgender, intersex MDR-TB Multi drug resistant TB iii MSM Men who have sex with men MTB Mycobacterium tuberculosis NACOSA Networking AIDS Communities of South Africa NADCAO National Alliance for the Development of Community Advice Offices NDMP National Drug Master Plan NGO Non-governmental organisation NSP National Strategic Plan PEP Post-exposure prophylaxis PEPFAR United States President’s Emergency Plan for AIDS Relief PLHIV People living with HIV PMTCT Prevention of mother to child transmission PR Principal recipient PrEP Pre-exposure prophylaxis PWID People who inject drugs REAct Rights – Evidence – Action RSA Republic of South Africa S&D Stigma and discrimination SA South Africa SAHR South African Health Review SAHRC South African Human Rights Commission SALRC South African Law Reform Commission SANAC South African National AIDS Council SAPS South African Police Service SGBV Sexual and gender-based violence SOHACA Soweto HIV/AIDS Counsellors Association SOGI Sexual orientation and gender identity SR Sub-recipient SRH Sexual and reproductive health SRHR Sexual and reproductive health rights STI Sexually transmitted infections SWEAT Sex Worker Education and Advocacy Taskforce TAC Treatment Action Campaign TB Tuberculosis TCC Thuthuzela Care Centre UCSF University of California San Francisco UKZN University of KwaZulu Natal iv UNAIDS The Joint United Nationals Programme on HIV and AIDS UNDP United Nations Development Programme UNESCO United Nations Educational, Scientific and Cultural Organisation UNFPA United Nations Population Fund US$ United States Dollar USAID United States Agency for International Development USG United States Government UTT Universal test and treat WHO World Health Organisation WSW Women who have sex with women XDR-TB Extensively drug resistant TB Y+SA Youth Plus South Africa v TABLE OF CONTENTS List of Acronyms .............................................................................................. iii 1. Introduction ................................................................................................ 1 2. Objectives and Expected Results ................................................................. 1 3. Methodology ............................................................................................... 2 3.1. Conceptual framework ........................................................................................................... 2 3.2. Key and vulnerable populations included in the assessment ........................................... 3 3.3. Data collection and analysis .................................................................................................. 4 4. Findings for HIV ......................................................................................... 5 4.1. Burden of HIV amongst key and vulnerable populations ................................................. 6 4.2. Current trends in access and uptake of HIV services ....................................................... 10 4.3. Overview of the law and policy context for address human rights barriers ................... 12 4.3.1. Legal framework for HIV-related human rights ................................................... 12 4.3.2. National strategies and plans ................................................................................. 14 4.4. Human rights barriers to HIV services ............................................................................... 17 4.4.1. Overview ..................................................................................................................... 17 4.4.2. Stigma, discrimination and violence ...................................................................... 17 4.4.3. Stigma and discrimination in health services ...................................................... 20 4.4.4. Punitive laws, policies and practices ..................................................................... 24 4.4.5. Challenges for adolescent girls and young women to access HIV services ...... 29 4.5. Efforts to address and remove barriers .............................................................................. 34 4.5.1. Overview .................................................................................................................... 34 4.5.2. Stigma and discrimination reduction .................................................................... 34 4.5.3. Training of health care workers on human rights and medical ethics .............40 4.5.4. Sensitisation of law-makers and law enforcement agents ................................. 43 4.5.5. Legal literacy ............................................................................................................. 47 4.5.6. HIV-related legal services .......................................................................................49 4.5.7. Monitoring and reforming laws, regulations and policies ................................. 52 4.5.8. Reducing discrimination against women in the context of HIV........................ 55 4.6. Opportunities for scaling-up interventions ...................................................................... 60 5. Findings for TB ......................................................................................... 62 5.1. Burden of TB amongst key and vulnerable populations .................................................. 62 5.2. Trends in service uptake for TB and TB/HIV services .................................................... 63 5.3. Overview of law and policy context for TB-related human rights ..................................64 5.3.1. TB-related laws, policies and commitments ........................................................64 5.3.2. National strategic plans ........................................................................................... 65 5.4. Human rights barriers to TB services ............................................................................... 66 5.4.1. Stigma and discrimination ..................................................................................... 66 5.4.2. Punitive laws, policies and practices ..................................................................... 67 5.4.3. Barriers related to gender ...................................................................................... 68 5.4.4. Barriers related to poverty ..................................................................................... 69 vi 5.4.5. Harmful working conditions and exploitation ..................................................... 70 5.5. Efforts to address and remove barriers .............................................................................. 70 5.5.1. Overview ..................................................................................................................... 71 5.5.2. Integrated approaches .............................................................................................. 71 5.5.3. Reducing stigma and discrimination ..................................................................... 71 5.5.4. Reduce gender-based inequity
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