Who are the Key Populations
Current Key Populations
Key populations in HIV are groups burdened with disproportionately high rates of contracting and transmitting HIV. These most vulnerable groups are men who have sex with men (MSM), sex workers (SW), and people who use drugs (PWUD). (7)
The Desmond Tutu HIV Foundation (DTHF) Key Populations Division is committed to researching and reaching these most-vulnerable populations. Our research is directed to provide a platform for action. We have developed training programmes and community engagement programming to conduct the most meaningful studies.
- Men’s Health
The Key populations division is researching new biomedical HIV prevention strategies. This includes rectal microbicides – a gel that is applied directly to a high HIV transmission risk area to prevent infection. There are currently no clinically significant results on microbicides. Additionally, we explore other prevention strategies such as PrEP, the daily pill taken by HIV-negative people to reduce risk of HIV infection if exposed to the virus. Knowing how communities use the pill and its effectiveness is essential for forming prevention strategies.
Additionally, the site oversees the HPTN 075 study; recruiting and retaining a cohort of MSM over a year. The aim is to ascertain the feasibility of HIV prevention in MSM over Sub-Saharan Africa. The division is also overseeing the HPTN 083 trial. This involves examining the safety and effectiveness of a long-acting injectable PrEP as opposed to a daily pill. A successful PrEP injection would reduce human error when taking PrEP (forgetting to take a pill every day) and reduce social pressure. Some individuals want to hide pill-consumption from their peers due to the stigma around sex and HIV.
- The MSM Community Programme
In addition to our medical research is our community outreach programme. We support 12 communities of MSM in Cape Town, providing education, fostering community growth and providing education and HIV supplies. Our volunteers support the communities in organising their own activities, such as netball, debates, drag shows, hiking and pride parades.
- Vidi Kids – Child Health
There have been studies that suggest a link between Vitamin D consumption and an increased immune response to TB infection. Vidi Kids is a trial that started in 2017 and will last three years. Children who test negative for TB between 6-11 will receive a weekly dose of vitamin D or a placebo. After three years the team can compare the rates of infection in the Vitamin D and placebo group and determine whether Vitamin D helped block tuberculosis.
Primary school children have a TB infection rate of 20%, and at the end of their school career there is a 70% infection rate. If vitamin D shows to be effective in reducing new infections then this will be grounds to campaign for new school meal regulations, for example. (E.g. fortified bread served at school).
- Female SW and Maternal Health
In order to reduce HIV/AIDS orphans and child mortality, the Maternal and Child Health (MCH) Division developed the following goals.
- Preventing HIV infection in women of reproductive age;
- Preventing unintended pregnancies in HIV-infected women;
- Preventing mother-to-child transmission of HIV; and,
- Ensuring long-term care and treatment for HIV-infected children and mothers.
To achieve these goals, the team is researching immune response after an antimicrobial peptide infusion in young women and female SW.
The stats worldwide vs the stats in South Africa
In 2015, there were roughly 2.1 million new HIV infections worldwide. In South Africa, the estimated HIV prevalence rate is around 11.2% of the total population: over 6 million people.
Most new cases of HIV amongst children were in Sub-Saharan Africa. In these instances, most children were infected from their mothers; from pregnancy, childbirth or breastfeeding.
Amongst the male population, it is MSM who are particularly at risk of HIV infection. MSM have the highest rates of HIV of any group in South Africa. MSM are particularly vulnerable in South Africa due to social stigma around homosexuality and fear of being open about their sexual choices. (11)
Female SW in South Africa have HIV prevalence of 40-88% (varying studies in different locations). This puts female SW at greater risk of transmitting and catching HIV than women in the general population. (1,2)
Whilst the number of new infections are still high, there has been significant global effort to make treatment accessible. Yet, the number of people on treatment is still less than half of people who are HIV-positive. (9) There is still an urgent need to double our efforts and access these populations.
Need for specialised attention, sensitivity training, and reduction in the stigma and discrimination that is still so widely prevalent
DTHF has created a specialist sensitivity training manual for healthcare workers who regularly meet these key population.
These key populations are all stigmatised and discriminated against in some capacity. As a result, there are increased HIV infection/transmission risks in the form of physical and sexual violence, isolation and discrimination. These negative environmental conditions support misinformation, and vulnerable people may be too scared to seek help.
South African legislation does not criminalise sexual choice. However, there are still many accounts of police discrimination based on sexual orientation. (11) This stigmatisation breeds mistrust amongst vulnerable people who may be fearful to seek assistance after incidences that put them at risk of contracting HIV.
It is estimated the 360,000 children (0-14 years of age) were living with HIV in South Africa in 2013. (4) ARTs in pregnant women and other prevention methods are critical for reducing the number of children born with HIV and HIV orphans. More than 2.3 million children in South Africa have been orphaned due to HIV. (5)
A pregnant woman taking ARTs can reduce the chance of HIV transmission to her infant during pregnancy and natural childbirth. However, breast milk contains the virus and whilst the risk of adults being infected orally with HIV is small, the risk is larger for breastfeeding infants. Formula milk and clean, boiled water are not always accessible for mothers, putting these children at risk of infection.
When the unit was established in 2008, there was little information about HIV among MSM in South Africa. Health care providers with sensitised services were nearly non-existent, and stigma was pervasive across the country. This put MSM at risk; both from contracting and transmitting HIV.
Our division conducted the first HIV surveillance study of MSM in Cape Town and has advocated for MSM rights in the South African National Strategic Plan for HIV, STIs, and TB 2011-2016. Since then, the division extended into research into SW and PWUD, as well as a sensitivity training manual adopted by five other African countries.
Through advocacy and research, the division introduced PrEP to the South African National Department of Health as a prevention intervention tool. Additionally, the National Strategic Plan for HIV/AIDS, STIs and TB (2012-2016) Key Populations, Key Solutions, recommends PrEP.
PrEP licensure since 2010 had been problematic. In 2012, through advocacy, policy engagement, the leadership of Prof Linda-Gail Bekker and team, the clinician’s society put together MSM Guidelines. The team lead advocates who worked on this issue and in 2015 PrEP was licensed.
Now, we can provide our participants with PrEP through our partners. This allowed clinicians to prescribe PrEP off-label and put together the Southern African guidelines on the safe use of pre-exposure prophylaxis in March 2016.
- 16.UCSF, Anova Health Institute & WRHI (2015) ‘South African Health Monitoring Study (SAHMS), Final Report: The Integrated Biological and Behavioural Survey among Female Sex Workers, South Africa 2013-2014‘
- 17.Human Sciences Research Council (HSRC) (2014) ‘South African National HIV Prevalence, Incidence and Behaviour Survey 2012‘
- UNAIDS (2014) ‘South Africa HIV Epidemic Profile‘
- Kaiser Family Foundation ‘Children Orphaned by AIDS (<18 Years Old)‘ [accessed December 2015]
- Population Council (2007) ‘Identify. Investigate. Act.‘
- Men who have sex with men and HIV/AIDS in sub-Saharan Africa.Smith AD, Tapsoba P, Peshu N, Sanders EJ, Jaffe HW Lancet. 2009 Aug 1; 374(9687):416-22.
- UNAIDS (2016) ‘Fact Sheet 2016’
- Statssa https://www.statssa.gov.za/publications/P0302/P03022015.pdf
- The Marang Men’s Project http://www.hsrc.ac.za/uploads/pageContent/5338/MarangMSMLaunchPresentationNovember2014.pdf