The International AIDS Society

Educational Fund meeting Outcome report 26-27 March 2019 Esulwini, Kingdom of

Science, Community and Youth in the HIV Response in Southern Africa

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Table of Contents

1. LIST OF ABBREVIATIONS AND ACRONYMS ...... 3

2. INTRODUCTION ...... 6

3. BACKGROUND AND CONTEXT ...... 7

4. MEETING REPORT ...... 9

4.1 EXECUTIVE SUMMARY ...... 9 4.2 OFFICIAL OPENING AND WELCOME ADDRESSES ...... 10

5. KEY MESSAGES FROM AIDS 2018 ...... 13

5.1 HIV PREVENTION AND TREATMENT UPDATES - PROF KENNETH NGURE, IAS GOVERNING COUNCIL REPRESENTATIVE FOR AFRICA 13 5.2 UPDATES ON CURE - PROF CAROLINE TIEMESSEN, NATIONAL INSTITUTE FOR COMMUNICABLE DISEASES ...... 13

6. REGIONAL OVERVIEW OF THE HIV EPIDEMIC – UNAIDS, LAWRENCE MASHIMBYE ...... 14

6.1 RECOMMENDATIONS ...... 14

7. PANEL DISCUSSION: HIV PREVENTION FOR ADOLESCENT GIRLS AND YOUNG WOMEN - INNOVATIVE WAYS FORWARD ...... 15

8. PANEL DISCUSSION: HIV, NON-COMMUNICABLE DISEASES AND TUBERCULOSIS - THE PATH FORWARD FOR TREATMENT AND PREVENTION ...... 17

9. PANEL DISCUSSION: REGIONAL ACTION TO REDUCE HIV STIGMA AND DISCRIMINATION ...... 19

10. CONCLUSION ...... 22

11. ACKNOWLEDGEMENTS ...... 23

12. APPENDICES ...... 24

12.1 PROGRAMME ...... 24

This report was developed in collaboration with the National Emergency Response Council on HIV and AIDS (NERCHA). The views expressed in the report do not necessarily reflect the views of the International AIDS Society.

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1. List of abbreviations and acronyms

AIDS Acquired Immune Deficiency Syndrome

AGYM Adolescent Girls and Young Women

AMICAAL Alliance of Mayors Initiative to Combat AIDS at Local Level

ART Antiretroviral Therapy

AP COUNTRIES Countries in the Asia-Pacific Region

CANGO Coordinating Assembly for Non-Governmental Organizations

CBO’s Community Based Organization

CDC Centre for Disease Control

DTG Dolutegravir

DSD Decentralized Service Deliveries

EBIS Eswatini Broadcasting and Information Services

FAO Food and Agriculture Organization

FLAS Family Life Association

FSW Female Sex Workers

GNP+ Global Network of People Living with HIV

GAM Global AIDS Monitoring

HIV Human Immuno-deficiency Virus

IAS International AIDS Society

ICAP International Centre for AIDS Care and Treatment Programs

IDU’s Injecting Drug User

INCMNSZ National Institute of Medical Sciences and Nutrition

KP’s Key Populations

LMIC Low and Middle-Income Countries

MoH Ministry of Health

MSM Men who have Sex with Men

MSF Médecins Sans Frontières 3

NCD Non-Communicable Disease

NGO Non-Governmental Organizations

NHSP National Health Support Project

NERCHA National Emergency Response Council on HIV and AIDS

NICD National Institute for Communicable Diseases

NSF National Strategic Framework

NPTG National Prevention and Treatment Guidelines

OVC Orphaned and Vulnerable Children

PEPFAR President’s Emergency Fund for AIDS Relief

PEP Post-Exposure Prophylaxis

PLHIV People Living with HIV

PrEP Pre-Exposure Prophylaxis

PSI Population Services International

PWID People who Inject Drugs

PSHAC Public Sector HIV and AIDS Committee

RFM Raleigh Fitkin Memorial Hospital

SODV Sexual Offences and Domestic Violence

SNAP Swaziland National AIDS Program

SNNC Swaziland National Nutrition Council

SRHR Sexual Reproductive Health Related

SWAGAA Swaziland Action Group Against Abuse

SWABCHA Swaziland Business Coalition on HIV and AIDS

SWANNEPHA Swaziland Network of People Living with HIV/AIDS

TDF Tenofovir Disoproxil Fumarate

TB Tuberculosis

TGM Transgender Men

TGW Transgender Women

UHC Universal Health Coverage

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UEDF Umbutfo Eswatini Defence Force

UNAIDS Joint United Nations Programme on HIV and AIDS

UNFPA United Nations Population Fund

UNICEF The United Nations Chidren’s Fund

UNESWA

USSD Unstructured Supplementary Service Data

WFP World Food Program

WHO World Health Organization

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2. Introduction

The Kingdom of Eswatini successfully hosted the IAS Educational Fund Regional Meeting on Science, Community and Youth in the HIV Response in Southern Africa on 26 to 27 March 2019 in Ezulwini. The meeting was a post-conference workshop to the 22nd International AIDS Conference held in 2018 in Amsterdam, the Netherlands (AIDS 2018).

This meeting was part of regional meetings organized around the world through the IAS Educational Fund programme to provide key scientific and policy content from the International AIDS Conference and the IAS Conference on HIV Science. During these meetings, targeted topics relevant for the local settings are discussed and recommendations are drawn up to drive a local call to action on the translation of the latest science on the discussed topics.

The insightful two-day meeting was held in Ezulwini at the Royal Swazi Sun Convention Centre. During the workshop, key scientific and policy content from AIDS 2018 was shared, as well as implementation science priorities on prevention, treatment and stigma in Southern Africa. Specific topics included HIV prevention for adolescent girls and young women, non- communicable diseases and co-infections (TB) and strategies to reduce stigma. Scientific research results on these specific topics were also discussed for policy and programme improvements in the region.

The meeting was attended by more than 150 participants including researchers, clinicians, healthcare workers, policymakers, international organizations’ staff, civil society representatives and representatives of key and vulnerable populations. Participants from , , South Africa, and were present. Officials from the Kingdom of Eswatini also attended the meeting. Eswatini Prime Minister, Ambrose Dlamini and the Minister of Health, Lizzy Nkosi, and other cabinet ministers were present for the official opening.

Participants were encouraged to self-reflect on their national, regional, local, and organizational situation and share knowledge and experiences with co-participants. Panel discussions led by sector experts also focused on targeted populations at risk including youth, men who have sex with men, transgender groups and sex workers.

On the first day, the meeting was co-chaired by Dr Vusi Magagula, Director of Health in Eswatini’s Ministry of Health and Keratile Thabana from the National AIDS Commission- Lesotho. On the second, the meeting was co-chaired by Nokwazi Mathabela, NERCHA, from the Kingdom of Eswatini and Professor Kenneth Ngure, IAS Governing Council representative from the School of Public Health, Jomo of Agriculture and Technology of Kenya.

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3. Background and Context

The rapid pace of scientific discovery in care for people living with HIV and AIDS requires clinicians and HIV service providers to remain continually up to date on research developments and best practices.

While UNAIDS Estimates 2018 show that since 2010 there has been significant progress in controlling new HIV infections among adults in several countries in East and Southern Africa (ESA), other countries still lag behind. The percentage change of new HIV infections among adults in Eastern and Southern Africa between 2010 and 2017 showed increases in (+7%), Burundi (+25%), (+48%), (+49%), Madagascar (+162%) (UNAIDS, Global AIDS Update, 2018).

Sex workers, people who inject drugs and men who have sex with men and their partners contribute to 17% of new infections in ESA (UNAIDS special analysis, 2018). There is high HIV prevalence among sex workers and men who have sex with men (MSM) in most countries, yet condom use and knowledge of HIV status are below the recommended value in the majority of ESA countries according to data based on the 2018 Global AIDS Monitoring report. Broadly, insufficient attention is given to key populations despite extremely high prevalence (UNAIDS, Global AIDS Update, 2018).

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Antiretroviral treatment coverage of children (0-14) has more than doubled (25% to 59%) and new infections and deaths have been reduced by around half between 2010 and 2017 according to UNAIDS Estimates 2018.

According to UNAIDS, the East and Southern Africa region has 5% of the world's population but is at the epicentre of the disease and home to 20 million of the estimated 34 million people who are living with HIV globally. The region also accounts for 45% of the world's total number of new HIV infections annually.

The Kingdom of Eswatini, which hosted the regional meeting, subscribes to the global agenda to End AIDS by 2030. In fact, the Kingdom holds the vision to End AIDS eight years earlier in year 2022. The fight against HIV remains key in the successful socio-economic development of the Eastern and Southern African region. Notably, HIV features prominently in five of the United Nations Sustainable Development Goals (SDGs).

The IAS organized in collaboration with National Emergency Response Council on HIV and AIDS (NERCHA) the two-day AIDS 2018 post-conference workshop focusing on Southern Africa. The workshop organizers selected three key themes of major interest for the region: HIV prevention for adolescent girls and young women, HIV, non-communicable diseases and co- infections (TB) and strategies to reduce HIV stigma and discrimination.

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4. Meeting Report

4.1 Executive Summary The IAS Educational Fund Regional meeting hosted in Ezulwini, Eswatini was held on 26 and 27 March 2019 in the context of an AIDS 2018 Post-Conference Workshop. The key theme was Science, Community and Youth in the HIV Response in Southern Africa.

Leading experts and IAS Members presented regional data and intervened regarding the latest status of the epidemic. This was followed by panel discussions and group work to discuss how to effectively translate the latest scientific data into local policy and practice in the Southern Africa region.

On the first day, IAS Governing Council Representative Professor Kenneth Ngure from the School of Public Health Jomo Kenyatta University of Agriculture and Technology of Kenya, highlighted the background of the IAS Educational Fund and reason for its existence and acknowledged the Swiss Agency for Development and Cooperation, ViiV Healthcare and Merck Sharp & Dohme as the sponsors of the workshop.

Prof Ngure indicated that the IAS is the world’s largest independent association of HIV professionals with over 11,000 members from over 170 countries including Eswatini and other South African countries. The IAS is the steward of the world’s most prestigious HIV conferences: the International AIDS Conference, the IAS Conference on HIV Science, and the HIV Research for Prevention Conference.

During the official opening, the Minister of Health, Lizzy Nkosi, (Kingdom of Eswatini) expressed her gratitude for Eswatini to be hosting the regional meeting which would benefit the Kingdom in many ways. The Prime Minister, His Excellency Ambrose Dlamini, delivered a keynote address to the participants. The Prime Minister described the meeting as very important and highlighted that positive developments have been witnessed in recent years locally and in the region, including a possible HIV cure. He encouraged the gathering to be open and to find practical solutions to challenges in the sector during the two days.

The first day’s presentations and discussions began with Key Messages from the AIDS 2018 conference presented by Prof Kenneth Ngure, IAS Governing Council member, from Kenya. Prof Ngure also presented on treatment challenges including the roll-out of Dolutegravir, risk reductions, HIV and non-communicable diseases (NCDs) and co-infections.

Prof Caroline Tiemessen, Cure researcher, from the National Institute for Communicable Diseases, South Africa, gave a presentation on cure’s updates including antibodies treatment.

Lawrence Mashimbye, from UNAIDS, Kingdom of Eswatini provided an overview on the HIV situation in the Southern African region. He shared progress and gaps in the Eastern and Southern Africa epidemic and response, status of epidemic control, new infection trends and progress on testing and treatment. He also highlighted challenges faced by key and vulnerable populations, including female sex workers (FSW), men who have sex with men (MSM), transgender (TG), people who inject drugs (PWID) and adolescent girls and young women (AGYW), who are often left behind.

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There was also an insightful panel discussion on HIV prevention for adolescent girls and young women and innovative ways forward. Discussions highlighted that a focus should be placed on policies needed by countries from Southern Africa to ensure that girls and young women are protected from HIV infection.

Participants then discussed, within a group work session, key questions regarding HIV prevention for adolescent girls and young women. Each group presented their interpretations and recommendations of what their local, national and regional situations are, in order to guide and make decisions on how to address next steps, to improve current circumstances and translate the latest science on these topics in the Southern Africa region.

On the second day Dr Nomthantazo Lukhele, from WHO, Kingdom of Eswatini, provided a presentation on HIV, non-communicable diseases and tuberculosis. She highlighted the need for universal health coverage and patient centred primary healthcare response. She called for equitable access to quality services by all at no financial hardship for the clients. Her presentation was followed by a panel discussion on HIV, NCDs and TB and it included deliberations on policies required to limit the impact of the NCD/HIV in low and middle-income countries (LMICs).

Emmanuel Ndlangamandla, Director for the Coordinating Assembly for Non-Governmental Organisations, Eswatini, provided an introductory presentation prior to a panel discussion on regional actions to reduce HIV stigma and discrimination. Mr Ndlangamandla shared insights on the roles of individuals, institutions, media, civil society, workplace and employers in reducing stigma and discrimination. He called for systematic actions, multi-sectoral collaboration at all levels, distribution of facts, positive support and the inclusion of everyone. He emphasized that there is no possibility of ending AIDS without the elimination of stigma and discrimination and called upon the region to act. The panel discussion that followed on this topic included questions relating to initiatives to counteract stigma for people living with HIV and key populations. During the discussions, it was suggested that expressions such as People Living with HIV should be changed to Persons Requiring Care in order to reduce stigma.

Participants worked in groups to present series of recommendations on the topics presented during the second day.

The two-day workshop ended on a high note with positive next steps presented.

NERCHA’s director, Dr Mabuza in his closing remarks emphasized that the workshop was not just about presentations but most importantly about learning what is needed to service better all sections of the population. He called on everyone to integrate the recommendations discussed into the HIV fight.

IAS Governing Council representative Prof Ngure summed up the meeting as one of the best organized so far and thanked all partners who supported it.

4.2 Official Opening and Welcome Addresses This session was chaired by the Director of Health Services in Eswatini’s Ministry of Health Dr Vusi Magagula, who highlighted that the fight against HIV still continues despite the great strides that have been made over the last few decades. He noted that HIV is still a leading

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cause of deaths amongst the population together with tuberculosis and diabetes and hence it is still relevant to the Kingdom’s national health agenda.

NERCHA’s Executive Director, Khanya Mabuza, valued the presence of international partners, IAS representatives, UN representatives, international representatives in the HIV and AIDS response, researchers and all delegates. He highlighted that the Kingdom’s mandate to end new HIV infections by 2022 was still a priority and stated that the Kingdom was honoured to have been chosen to host this meeting in the Southern African region.

IAS Governing Council Representative for Africa, Prof Kenneth Ngure, gave an overview of the IAS Educational Fund and its mandate. He highlighted the need for healthcare professionals to remain up to date on issues within the health sphere and on the latest scientific advances in order to be better equipped to deal with a very changing environment. He acknowledged the Swiss Agency for Development and Cooperation, ViiV Healthcare and Merck Sharpe & Dohme as sponsors of the workshop. He indicated that since 2016 18 meetings had been held throughout the world and in 2019 over 10 meetings would be organized including one in Western Africa and one in . Eswatini’s Minister for Health, Lizzie Nkosi, thanked the IAS and NERCHA for hosting this regional workshop to respond to the epidemic. She expressed hope that this workshop would add value to healthcare professionals and further provide them with a networking platform to learn and share ideas with colleagues. The minister expressed her gratitude to the IAS for choosing Eswatini as the host country, saying this would benefit the Kingdom in many ways. She then introduced the Prime Minister to present his keynote address.

The Prime Minister, His Excellency Ambrose Dlamini, noted that the fight against HIV remains key in the successful socio-economic development of the Eastern and Southern African region. The Prime Minister said HIV features prominently in five of the SDGs, adding that the 2016 Political Declaration to End AIDS in the age of Sustainable Development comes at a time when Eswatini commits to realize an era that is free of AIDS. He added that Eswatini subscribes to the global agenda to End AIDS by 2030 and holds the vision to End AIDS eight years earlier in year 2022. He further said that it is a necessity to accelerate efforts to attain the targets of zero new HIV infections, zero AIDS related deaths and the elimination of all forms of HIV stigma and discrimination.

His Excellency indicated that since its inception, the HIV response in Eswatini has leveraged on the Kingdom’s strong cultural and traditional backbone of annual cultural event such as Umhlanga and Lusekwane which gather young maidens and male regiments which are continuously supported with on-the-spot HIV prevention programmes. He said the women’s regiment, Lutsango, is working tirelessly in the socialization of young girls and caring for orphans and vulnerable children (OVC) and the sick in communities. This collective mobilization of all stakeholders and implementation of new technologies have been the main strengths for Eswatini’s success story against the scourge of HIV and AIDS.

His Excellency highlighted that the Kingdom has reduced new infections by almost 50% in five years since 2013 and is estimated to have averted over 80,000 AIDS related deaths. He noted that there are ongoing researches that may lead to the possibility of an HIV cure and preventative vaccine, adding that together with the rest of the world, the Kingdom looks forward to the day when people living with HIV will receive curative treatment.

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The Prime Minister said that the goal of ending AIDS will be completed through increased efficiency in research and technology, the procurement of ARV drugs at reduced costs and by fostering integrated regional progress. He expressed hope that all the research presented and that the discussions during the two-day workshop would create a renewed spirit of focus towards the future and encourage all countries represented to continue to translate research findings into policy and planning.

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5. Key Messages from AIDS 2018

5.1 HIV Prevention and Treatment Updates - Prof Kenneth Ngure, IAS Governing Council Representative for Africa

Prof Kenneth Ngure highlighted that during the AIDS 2018 conference held in Amsterdam in July 2018, temporal trends of key HIV parameters including incidence, population viral load and viral load suppression were presented and these indicated a decline in HIV incidence in men but this was not consistent in women. He also mentioned that research from Zimbabwe, Zambia and Malawi showed that every 1% increase in viral suppression resulted in a decreased predicted probability of a recent infection by 8%. Like any other field, innovations are needed in the field of HIV prevention and treatment. He mentioned a study presented during AIDS 2018 reporting that technology-based interventions prove to be acceptable in hard to reach populations including young men who have sex with men and transgender women. He gave an overview of studies on HIV prevention innovations from Thailand, Vietnam, China and the USA. He also highlighted other study outcomes on key population led services, ANRS Previnir, PrEP and treatment challenges in the roll out of Dolutegravir (DTG).

5.2 Updates on Cure - Prof Caroline Tiemessen, National Institute for Communicable Diseases

Prof Tiemessen highlighted that the AIDS 2018 conference discussed the need for an HIV cure and the complexities around finding a cure. Her presentation also covered models for the study of HIV cure/remission, post-treatment controllers, elite controllers, stem cell transplantation and therapeutic strategies which aim to cure HIV infection. Prof Tiemessen took the delegates through a few recent studies including the VISCONTI cohort (Viro-Immunologic Sustained Control after Treatment Interruption) where therapy was started 10 weeks after primary infection and HIV was controlled. Other studies highlighted included the ‘French Teenager’, the ‘South African Child’, the ‘Berlin Patient’ and the ‘London Patient’. She also briefly discussed Gene therapy against HIV, Activating latent HIV, “Shock and Kill” approaches and Silencing HIV expression “Block and Lock”. She emphasized that cure research requires a lot of time, patients and financial resources. She pointed out that a lot of headway has been made towards finding a cure but medical research still needs to continue.

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6. Regional Overview of the HIV Epidemic – UNAIDS, Lawrence Mashimbye

Mr Mashimbye gave a regional overview of the Eastern and Southern Africa (ESA) HIV epidemic based on the UNAIDS 2018 Global Report. He highlighted progress in the ESA epidemic and response including a decline of 42% in total AIDS-related deaths from 660,000 to 380,000 from 2010 to 2017 and that ART scale-up tripled from 4.3 million people in 2010 to 12.9 million people on treatment in 2017. He indicated that since 2010 there has been significant progress in controlling new HIV infections among adults in several countries – but other countries still lag behind and therefore there is a need to focus more on those.

Mr Mashimbye said that there was an urgent need for renewed commitment to combination prevention and treatment access for populations left behind such as sex workers, people who inject drugs and men who have sex with men and their partners, adding that these populations contribute to 17% of new infections in the ESA region.

Mr Mashimbye emphasized with concern that in many countries HIV prevalence among female sex workers and men who have sex with men is very high and the same is experienced among people who inject drugs and those in prisons (in countries with available data). He added that there is also high HIV prevalence among female sex workers in most countries, yet condom use is below the recommended value. Mr Mashimbye added that there is insufficient attention given to key populations despite extremely high prevalence and that an estimated one million sex workers need services but programme coverage for them is low.

6.1 Recommendations

 Substantial progress has been made in ESA towards epidemic transition by reducing new infections, however scaling-up treatment hides disparities in individual countries that should be addressed.  Renewed commitment to combination prevention to address sources of new infections needs to be matched by removing underlying barriers.  Invigorating combination prevention approaches is critical to success in reducing new infections among specific populations based on age, gender or those at higher risk who are stigmatized or discriminated against.  There is a need to focus on locations and populations in most need.  Adolescent girls and young women are particularly vulnerable to HIV infection. Programmes to reduce inequalities, harmful gender norms, and other underlying social, economic and structural drivers are required. Community and key populations’ involvement in the HIV response is imperative to sustain progresses in prevention, care and treatment.

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7. Panel Discussion: HIV prevention for adolescent girls and young women - Innovative ways forward

Before the discussions took place with the panellists, Dr Ellen Mubanga, National AIDS Commission in Zambia, gave a keynote address. Dr Mubanga indicated that it was critical to focus on adolescent girls and young women (AGYW) in the region because 70% of HIV infections are in Sub-Saharan Africa and 56% of these concern females (amongst these 56%, 66% are young women aged 15-24). She noted that HIV among AGYW is fuelled by a combination of factors that contribute to the increasing risk of contracting the virus. Harmful social and cultural norms, lack of AGYW-friendly services, inadequate legal and policy protections for women and girls, inaccurate knowledge about HIV and sexual and reproductive health (SRH), shaming AGYW for being sexually active and social and cultural inequities and stigma all contribute to AGYW being at risk. She provided the following suggestions as innovative ways forward:

 Increase adapted models of layering of services targeting AGYWs  Grooming of champions from within  Keeping girls in school  Use social media for HIV prevention messages  Organize adolescents wellness days that offer focused service provision for adolescents.

NERCHA’s Director, Dr Khanya Mabuza, moderated the panel discussion.

Mohasoa Lehlohonolo (Phelisanang Bophelong, Lesotho) indicated the need for youth friendly SRH services to be easily accessible and for the service offering to be done more creatively in order to appeal to young people. He added that household structures are critical as a support system so that every member of the household understands what role they can all play towards the provision of support to the youth.

Zandile Masangane (WHO, Kingdom of Eswatini) noted that adolescent girls and young women do access services provided although there was still room for improvement. She said the Kingdom of Eswatini recently adopted youth friendly standards for all healthcare facilities. She highlighted that at least 84% of the country’s facilities are accessible to young people. Ms Masangane said it was imperative to involve young people in the design and implementation of programmes.

Speaking from a policymaker’s perspective, Tobile Dlamini (SWABCHA, Kingdom of Eswatini) emphasized that like many other African countries, Eswatini has benefitted a lot from external aid. She indicated that it was important to rethink spending patterns and to stretch national budgets more to accommodate innovative programmes. Ms Dlamini highlighted that most health programmes are very expensive to run, which brings about a need to start getting more internal resources and relying less on foreign aid. She said countries need new policies that will ensure there is a national fund for HIV.

Mandisa Zwane Machakata (SAFAIDS, Kingdom of Eswatini) indicated that it was imperative to explore innovate ways to reach young people. She indicated that young people are no longer interested in traditional media like newspapers and radio but are keener on using technology such as social media and relevant apps that are tailor-made for them. She said SAFAIDS is preparing to launch a mobile app to be used at Lobamba Clinic to give feedback to service

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providers, adding that this would contribute towards strengthening the advocacy agenda as young people want to speak directly to the programmers and policymakers.

Discussions with the audience included points on how youth in all areas of the Kingdom can be reached with comprehensive healthcare services. It was noted that adolescents are still not getting sexual healthcare services and this is deeply rooted in cultural stereotypes. It was further highlighted that young people are still being reprimanded for trying to access what is their right and this happens even in facilities within tertiary institutions. It was discussed that negative attitudes by service providers towards adolescents need to be changed by health professionals. In the Kingdom of Eswatini, the Ministry of Health, supported by PEPFAR, now has mobile clinics dubbed ‘Dreams on Wheels’ in communities where young people can access services. Delegates from Lesotho shared that they have started targeting boys and young men by bringing services closer to them in areas where they are found in large numbers.

After the panel discussions, participants engaged in group work to reflect on and discuss key questions regarding HIV prevention for adolescent girls and young women.

Key Recommendations to improve HIV prevention for AGYW

 Engage continuously and meaningfully traditional and religious leaders  Adopt a multi-sectoral approach to the response  Implement the domestication of international protocols  Increase domestic funding and strengthen health systems infrastructure  Include young people minorities, such as young transgender and indigenous people, in discussions  Heighten male engagement in HIV prevention  Increase the engagement of school management and community involvement in addressing risky socio-cultural practices  Establish community forums where information is shared on HIV and SRHR issues and provide access to this information in local language  Adopt tools to increase access and information such as apps and social media, unstructured supplementary service data (USSD) technology and public speaking  Train legal aides to assist with legal issues in communities

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8. Panel Discussion: HIV, Non-communicable diseases and Tuberculosis - The path forward for treatment and prevention

In introduction to the panel discussion the keynote speaker for the session, Dr Nomthantazo Lukhele from WHO Eswatini made a presentation on non-communicable diseases (NCDs) and tuberculosis (TB). Dr Lukhele outlined that NCDs were responsible for 41 million deaths each year and account for 71% of all deaths globally. She indicated that each year, 15 million people between 30-69 years of age die from an NCD. She also spoke on the strong linkages between HIV and NCD saying deaths from NCDs occur in many of the countries with substantial HIV epidemics. In terms of TB and diabetes she indicated that a weak immune system provided a high risk for progression from latent TB to active TB and that diabetes increases this risk three-fold – about 15% of TB cases globally can be linked to diabetes.

As a way forward, she noted a need for integrated health services. She advised for global partnerships as in a country context there was a need to reorient the health system in terms of model of service delivery and integration to existing programmes. She said it would be good to have an integration of NCD management across the different levels of the healthcare system and integration of interventions that address multiple common risk factors together.

The panel discussion was led by Dr Monde Muyoteta (TB Programmes Director, Centre for Infectious Disease Research, Zambia).

Dr Velephi Okello (Ministry of Health, Kingdom of Eswatini) responding to a question on what policies needed to be put in place now to limit the impact of the NCD/HIV synergy in LMICs, indicated that there were many lessons learned from HIV management that should be applied to NCDs. She noted that there was a need to strengthen prevention. On policies, she highlighted that many countries were still lagging behind in establishing policies that will reduce risk factors. She indicated that there is a need to have wellness clinics that can target men as they are mostly affected by NCDs. In addition, she also emphasized the need to implement policies on decentralization and integrated service delivery. She also recommended that governments should revise healthcare packages, strengthen rehabilitation programmes and introduce national health insurance systems. She also recommended that policies on healthy ageing should be introduced to ensure older people are well taken care of with, for example, health visits to their homes.

Ntombi Ginindza (MoH, Kingdom of Eswatini), on expected major challenges as NCD/HIV services are scaled up, said resistance may be experienced among clinicians as they will view this as an added responsibility. She advocated for capacity building for all health workers. She said that in terms of human resources for NCDs there is currently not enough trained workers to support integration and that systems to support data are weak (M&E). She also noted that funding for NCD service delivery was minimal and that all these are challenges that needed to be addressed collectively.

Duncan Moeketse (GNP+, Y+ Network, South Africa) provided his perspective as a key population representative and person living with HIV on whether NCD management should be integrated into existing NCD services or into existing HIV services. He indicated that creating a holistic healthcare system started a while ago and that integration of services has been quite prominent since HIV was discovered. He pointed out that it was important to leverage on systems that already exist. Moeketse suggested that the multisectoral approach that HIV took 17

should be followed for NCDs as well and that integration should be evidence based. He also noted that this could be expensive though as there will be needs for capacity building.

Dr Welile Sikhondze (TB programme, MoH, Kingdom of Eswatini) spoke on why most high burden TB countries in the African Region are not on course to meet the global End TB strategy targets. She indicated that a more decentralized approach was needed when it comes to TB screening. She added that an integration at community level was also critical as this is where the general population is. She also recommended that screening be available at all points of contact within the healthcare system and that early screening should be strengthened. She noted that investments in the fight against TB were necessary because although new diagnostic tools are available, they are not being used as much as they should. In addition, Dr Sikhondze recommended timely treatment initiation. She also highlighted that research and quality data provision should be strengthened. On a humanitarian level, she also emphasized that stigma and discrimination needed to be fought as it is a real issue in TB management.

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9. Panel Discussion: Regional action to reduce HIV stigma and discrimination

Emmanuel Ndlangamandla, Director of the Coordinating Assembly for Non- Governmental Organizations, Kingdom of Eswatini delivered an introductory presentation on HIV, stigma and discrimination prior to the panel discussion. He presented a description and history on the issue noting that HIV stigma builds on other prejudices such as gender, sexuality and race. He indicated that stigma associated with HIV is linked with marginalized and stigmatized key populations including sex workers, people who inject drugs, men who have sex with men and transgender people.

He highlighted that stigmatization and discrimination have terrible consequences including denying people access to treatment and care, resulting in suffering and undermining the HIV agenda.

Ndlangamandla shared recommendations on what should be done individually, institutionally, in the media, with civil society and at the workplace with employers as well as regional action to reduce stigma. He pointed out that there is a need to be systematic, multisectoral at all levels, distribute facts, focus on positive support and include everyone. He said the fight against stigma can be won by changing mindsets. He also noted that human rights-based approaches are critical for fighting stigma.

The panel discussion was led by Tobile Dlamini (Swabcha, Kingdom of Eswatini).

Melusi Simelane, (Rock of Hope, Kingdom of Eswatini) shared on foreseen challenges related to stigma and discrimination which hinder access to health services for key populations noting criminalization and socio-cultural issues as the main ones. He said there was a need to look deeply into the issue of human rights and also to adopt more client-centred approaches.

Sindy Matse (SNAP, Kingdom of Eswatini) explored the initiatives that should be implemented or strengthened to counteract stigma for people living with HIV. She advised that the MoH ensure universal access to quality services – including key populations, as stigma takes place at all levels – family, church, work and service providers such as police. She emphasized on the need to work with healthcare workers to ensure this happens including capacity building and conducting sensitization of all providers in health facilities as a continuous engagement. Mrs Matse said CBOs need to build their capacity through peer programmes and that there must be action to empower key populations on human rights. She also recommended to involve the police in HIV programmes to better sensitized them on key populations.

Giving an expert client worker perspective, Nompilo Gwebu (SNAP, Kingdom of Eswatini) commented on what should be implemented to reduce internal stigma amongst people living with HIV and indicated that integration of services was imperative. She also suggested there was a need to change tags like “People living with HIV” to “Recipients of Care” in order to reduce stigma attached to this term. She said it was essential that chronic care be treated the same. She said expert clients need to be recognized at facility level as they currently struggle with logistical issues such as space. She also called for increasing the number of support groups available.

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Gcebile Ndlovu (PLWH, Kingdom of Eswatini) also called for comprehensive policies for healthcare providers in order to reduce the impact of stigma. She also said that caring healthcare providers were important in order to be able to care for others. She advised that all policies should be inclusive and input should be sought from those who the policies are being designed for. She indicated that policies should be put in place to ensure all services are accessed under one roof – there should be no special places for people with certain ailments. She emphasized that respect and dignity for all was imperative.

Sharing a clinician’s view to the discussion, Thabiso Alphone Lekhotsa (Elizabeth Glaser Pedriatric AIDS Foundation, Lesotho) talked on initiatives needed to be implemented and strengthened to counteract stigma for children born with HIV. He said capacity building of service providers was very important and that privacy and confidentiality should be ensured. He also warned that service providers should not bring their parental values to clients as that discouraged some from approaching them for help as they are castigated. He said there is a need to understand adolescents and their different backgrounds and challenges in order to programme for them accordingly. He highlighted that service providers need to be empowered to know their rights and added that there was a need for more champions of care.

Speaking on behalf of the youth, Tanaka Chirombo (IAS Youth Champion, Malawi) explained the role that can be played by young people to empower each other to face stigma and discrimination in order to boost confidence. He pointed out that it was critical for youth to have access to information and that peer education create more open environments. He also encouraged the involvement of youth in the policymaking processes emphasizing that there must not be anything for youth without youth involvement.

After the panel discussion, participants formed working groups to discuss and bring forward recommendations for a call to action based on the background of the region and previous discussions.

Key recommendations

• Establish a stigma and discrimination monitoring body

• Advocate to engage and involve everyone in policy, programming, and service delivery for HIV in particular for key populations and people living with HIV

• Call for a reduction of stigma and discrimination by building capacity and sensitizing healthcare workers, community and families more on stigmatization

• Decentralization of services is essential at all levels including grassroots. This must also come with flexible hours to access health services and increased outreach programmes

• Stakeholders must address and amend legislations and policies that end up promoting stigma and creating fear for key populations to seek services

• Develop policies that will protect key populations and people living with HIV from discrimination

• Provide and mobilize for resources in the fight against HIV, which could include setting up a National HIV Fund for drugs, services and human resources.

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10. Conclusion

The IAS Educational Fund meeting in the Kingdom of Eswatini successfully achieved its objectives to present key scientific and policy content from the AIDS 2018 conference. The meeting provided a platform to discuss ways of how to translate effectively science into local policies and practices in the Southern Africa context. This was achieved through meaningful recommendations developed through interactive panel discussions and group work from the rich pool of experts and various representatives of society including key populations and vulnerable group representatives.

Attendance to this two-day workshop was high with more than 150 participants attending, and provided comprehensive perspectives from the various actors working in the HIV response in the region and beyond. NERCHA Director, Dr Khanya Mabuza, attested to this saying that every speaker and presenter demonstrated a great deal of commitment and dedication when participating. He also thanked the participants for their recommendations on the key topics and promised that their implementation will be encouraged. He added, in particular on the issue of stigma, that everyone should step up their efforts towards its eradication.

In a few months, the IAS will follow up with participants to encourage them to share concrete actions and activities that they will have been able to implement from the meeting’s recommendations. Next steps for the region will be to encourage the networks of advocates, researchers, programmers, implementers and policymakers to take these key recommendations and, with a collaborative vision, include them in implementation programmes in countries and communities.

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11. Acknowledgements

The IAS and NERCHA would like to acknowledge all participants and stakeholders in Southern Africa for their contributions towards making the IAS Educational Fund meeting at the Royal Swazi Sun’s Convention Centre in Ezulwini, Eswatini, from 26 to 27 March 2019, a resounding success.

The commitment and participation of international, regional, national and local HIV scientists and researchers, policymakers, implementers, community representatives, relevant stakeholders who attended was greatly appreciated and recognized.

The IAS also extends its appreciation to the Swiss Agency for Development and Cooperation, ViiV Healthcare and Merck Sharp & Dohme for their financial support for the meeting and to the Kingdom of Eswatini Ministry of Health and UNAIDS for endorsing the meeting.

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12. Appendices

12.1 Programme

Chairs: Dr Vusi Magagula, Director Health, Kingdom of Eswatini

Ms Keratile Thabana, National AIDS Commission, Lesotho

Day 1, 26 March 2019:

08:00-09.00 Registration and networking

09:00-10:00 Welcome, official opening and keynote addresses

Speaker: Prof Kenneth Ngure, IAS Governing Council representative, Africa

10:00-11:00 Key messages from AIDS 2018

Speaker: Prof Kenneth Ngure, IAS Governing Council representative, Africa

HIV Cure

Speaker: Prof Caroline Tiemessen, National Institute for communicable diseases, South Africa

11:00-11:15 Coffee break

11:15-12:00 Overview of HIV in Southern Africa

Speaker: Dr Lawrence Mashimbye, UNAIDS, Kingdom of Eswatini

12:00-13:00 Lunch

13:00-14:30 Panel discussion: HIV prevention for adolescent girls and young women – Innovative ways forward

Keynote speaker: Ms Ellen Mubanga, National AIDS Commission, Zambia

Panel moderator: Mr Khanyakwezwe Mabuza, NERCHA, Kingdom of Eswatini

Panelists: Mr Mohasoa Lehlohonolo, Phelisanang Bophelong, Lesotho

Ms Zandile Masangane, WHO, Kingdom of Eswatini

Ms Thobile Dlamini, SWABCHA, Kingdom of Eswatini

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Ms Mandisa Zwane, SAFAIDS, Kingdom of Eswatini

Ms Keratile Thabana, National AIDS Commission, Lesotho

14:30-15:50 Group work

Lead group moderator: Mr Muziwethu Nkambule, NERCHA, Kingdom of Eswatini

Group moderators: Dr Rudoh Kuwengwa, SNAP, Kingdom of Eswatini

Mr Eddy Mkhatshwa, Kingdom of Eswatini

Ms Tengetile Kubheka, MTAD, Kingdom of Eswatini

Mandzisi Mkhonto, CANGO, Kingdom of Eswatini

Dr Raymond Bitchong, RFM, Kingdom of Eswatini

15:50-16:00 Closing remarks and evaluation

Day 2, 27 March 2019:

Chairs: Ms Nokwazi Mathabela, NERCHA, Kingdom of Eswatini

Prof. Kenneth Ngure, IAS Governing Council member, Kenya

08:00-08:30 Registration

08:30-08:45 Opening comments and overview of the day

08:45-10:15 Panel Discussion: HIV, Non-communicable diseases and Tuberculosis - The path forward for treatment and prevention

Keynote speaker: Dr Nomthantazo Lukhele, WHO, Kingdom of Eswatini

Panel moderator: Dr Monde Muyoteta, TB Programmes Director, Centre for Infectious Disease Research, Zambia

Panelists: Dr Velephi Okello, MoH, Kingdom of Eswatini (NCDs &TB)

Ms Ntombi Ginindza, MoH, Kingdom of Eswatini

Dr Welile Sikhondze, TB programme, MoH, Kingdom of Eswatini

Duncan Moeketse, GNP+, South Africa

10:15-10-30 Coffee break

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10:30-11:45 Panel discussion: Regional action to reduce HIV stigma and discrimination

Keynote speaker: Mr Emmanuel Ndlangamandla; Director, Coordinating Assembly for Non-Governmental Organisation, Eswatini

Panel moderator: Ms Tobile Dlamini, SWABCHA, Kingdom of Eswatini

Panelists: Mr Melusi Simelane, Rock of Hope, Kingdom of Eswatini

Ms Sindy Matse,SNAP, Kingdom of Eswatini

Ms, Nompilo Gwebu, ENAP, Kingdom of Swaziland

Ms, Gcebile Ndlovu, PLWH, Kingdom of Eswatini

Thabiso Alphone Lekhotsa, Elizabeth Glaser Pedriatric AIDS Foundation, Lesotho

Tanaka Chirombo, IAS Youth Champion, Malawi

11:45-12:00 Rapporteur summary

12:00-13:00 Lunch

13:00-15:45 Group work

Group work lead moderator: Dr Munyaradzi Pasipamire, PEPFAR, Kingdom of Eswatini

Ms Zodwa Nxumalo, Hospice at Home, Kingdom of Eswatini

Mr Mandzisi Mkhonto, URC, Kingdom of Eswatini

Mr Bongani Masango, SNAP, Kingdom of Eswatini

Mr Sandile Ginindza, PSI, Kingdom of Eswatini

Mr Eddie Mkhatshwa, CANGO, Kingdom of Eswatini

15:45-16:00 Closing remarks, next steps and evaluation

Mr Khanyakwezwe Mabuza (NERCHA)

Prof Kenneth Ngure (IAS)

Ms Nokwazi Mathabela (NERCHA)

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