PrEP As HIV Prevention - An Intersectional Lens On Access

A reflection from the 2016 International AIDS conference

02/12/2016 05:55 SAST | Updated 02/12/2016 05:55 SAST
Siphiwe Sibeko / Reuters
A child wears a cross over a top featuring the image of the late Nkosi Johnson, one of the youngest victims of the HIV epidemic and died in 2001 from the disease, during the launch of the 5-Day countdown ahead of the AIDS2016 International Conference, at the orphanage Nkosi's Haven, which was named after Johnson, in Johannesburg, South Africa July 13, 2016.

It is the year 2016 and we are reflecting on the progress made on HIV/AIDS globally and nationally. More significantly, South Africa hosted the International AIDS conference for the second time this year (the first having been in 2000, around the time when Thabo Mbeki raised a question of whether or not HIV causes AIDS), and I was still finding my way out of primary school, and bombarded with the "AIDS KILLS!" stigmatised messaging on billboards! Now we're here, and it is quite interesting how the conversation has changed since then, and maybe how one may argue that the prospect of "Getting to Zero" should not be lost.

According to the UNAIDS 2016 GAP report, there are 7 million people living with HIV in SA, and we are leading in HIV rates globally. To address this, the South African National AIDS Council (SANAC) Global AIDS Response Report (2015) tells us that the government invests approximately R1.5 billion annually to its HIV/AIDS programmes. The question is, where are the gaps in HIV prevention? Studies are being done, solutions are being put forward, but the pace of eradicating the virus is not very impressive. So, the focus of this article will mainly be on Adolescent Girls and Young Womxn (AGYW), and the prevention approaches thereof.

A 2012 survey found HIV prevalence among South African womxn was nearly twice as high as men. Rates of new infections among womxn aged 15-24 were more than four times greater than that of men the same age, and this age group accounted for 25% of new infections in South Africa (South African National HIV Prevalence, Incidence and Behaviour Survey, 2012). However, if you unpack the demographics attached to these numbers, you will note that it is predominantly black humans in poor communities that are mostly infected and affected. I echo the words of Charlize Theron on her opening speech at the conference, when she said "The real reason we haven't beaten the epidemic boils down to one simple fact: We value some lives more than others. We value men more than womxn. Straight love more than gay love. White skin more than black skin. The rich more than the poor. Adults more than adolescents". So, I see these dynamics being overlooked even in the attempts to prevent HIV.

Pre-Exposure Prophylaxis (PrEP)

I was very involved in conversations around rolling out PrEP to AGYW in South Africa during the conference, and my main role was to discuss some of the factors to consider when rolling out this drug.

So, PrEP is an ARV, but it serves as a prevention drug, which means it is usually taken by "at-risk" humans such as sex workers, Men who have Sex with Men (MSM), and based on the stats, AGYW. It comes in 3 forms: an injectable, the pill or the vaginal ring. Now a lot of trial studies have been done over the last couple of years with young womxn, with the aim to find out whether AGYW like this PrEP, issues around adherence etc.

So, I have interacted a couple of times with the people running with these studies and big organisations working on biomedical technologies, and I've met some of the participants of the study (all of them black womxn). What are some of the factors to consider when rolling out PrEP to AGYW. I have listed a couple below:

• Acknowledging that women, particularly young women, have sex and they enjoy it!

I was workshopping a policy brief by Catriona McLeod and Jonathan Glover on Comprehensive Sexuality Education- zooming in on the Life Orientation subject in schools. One of the key themes that came up in the research was messages of disease, danger, and damage when it comes to adolescent sexuality education. There is this problematisation and pathologising of young people's sexuality- and this builds on the stigma around having sex, which affects communication on prevention and fuels a particular attitude amongst parents, healthcare workers and teachers, which in turn affects access. So, if we want to reach out to young people regarding them having safe sex, we must acknowledge that they are having sex for pleasure and that really it is ok!

• This "we're doing it to empower womxn" statement must stop!

We know that there's money going into this, and although there might be an element of meaning well, let us not fool ourselves by telling each other that we want to empower womxn and for them to take control and not rely on someone else for their protection. We are not being realistic because we do have such an approach already, and that is the female condom! We hear very little to none about it, some womxn don't even know it exists and some are freaked out by it- because it was never normalised! There is very little knowledge around it and very limited access. So, if we are going to use black bodies for these trial studies, we need to make damn sure that these services are available for these women post these studies! With friendly services that cater to intersectional aspects of womxn's lives and also recognises this as their basic human right! The vaginal ring is inserted the same way as a female condom, so what makes it better?


A lot of young women struggle to access Sexual and Reproductive Health Services like the pill, abortion, etc. How will they easily access another pill (PrEP truvada) or the ring (dapirivine) as those too, are telling of the fact that they are having sex and they want to take charge of their bodies? Therefore, one needs to ask themselves that as well. Young girls are being chased away from clinics when they visit wearing their school uniform, and yet clinics close early so they cannot go home, change and go back. Those are factors we HAVE to consider.

• Training of healthcare workers &Teachers

There is a huge challenge in communicating with young people around their sexual health. "Youth-Friendly Services" is just a buzz word to look good. Some of the healthcare workers and teachers themselves are womxn and experience some form of oppression of lack of autonomy around their bodies if one zooms into their narratives. They are socialised in a particular way, and have fears that they transfer into the AGYW they work with. They become gatekeepers and barriers to access and indirect agents of patriarchy, but really that has to do more with the bigger societal challenges which can sometimes put too much pressure on them as well. So sensitising them around sexualities and gender as well as understanding their narrative is very important.

• On the issue of gender

There is a strong need for support structures for women in SRHR and HIV prevention. The pill alone will not remedy an unjust system. If I decide to take PrEP, I tick all boxes of privilege from where I'm standing in this context. I am educated and knowledge on the issue, I have access and it will be a choice that I make on the grounds of undisputed autonomy. Now, a 16-year-old lesbian womxn from a violent community who takes PrEP because of fears of being raped for who she is needs a different kind of attention. There is more support needed and for her it's not choice, it is lack of justice! How will she be supported? If we are in the same waiting room, it would be stupid to address us in the same manner!

All in all, the efforts are impressive, but we are dealing with more than that. We need to have an intersectional lens at all times! We need a reproductive justice approach! Working in silos is pushing us back and it is very selfish!

Like they say "World AIDS DAY goes beyond, far beyond, December 1".