By the time the schools in New York City had been closed and a shelter-in-place order was imminent—or not, depending on the hour—COVID-19 had not yet hit sub-Saharan Africa in earnest. The steady drip of articles warning that it was a matter of time were like media coverage of the 1990s AIDS epidemic run on warp speed. The epidemic gained attention first in America and Europe; Africa was, for longer than it should have been, a “powder keg” of undifferentiated countries.
Within hours, Africa caught up. South African President Cyril Ramaphosa declared a “state of disaster” in a clear, firm 90-minute address days before a spike in cases, including several cases of community transmission. Ramaphosa’s state of disaster speech earned him high marks in comparison to U.S. President Donald Trump and UK Prime Minister Boris Johnson; it also rattled people living with HIV, including activists like South African AIDS activist Yvette Raphael, one of the leaders of Advocacy for Prevention of HIV and AIDS (APHA).
“One of the things that really has us worried is this whole direction of social isolation and distancing,” she remarked. “It works from an elite point of view. If I do get the virus and I stay [in] an informal settlement with 12 other people, how do I self-isolate?”
In Uganda, President Yoweri Museveni issued many of the same edicts, larding them with anti-Western sentiments and declaring that everything except for petroleum would be imported for the time being. The directions reminded Lillian Mworeko, the Uganda-based leader of the International Community of Women Living with HIV, about the early days of the HIV epidemic, when the only prevention was a condom, and women were supposed to practice safer sex to save their lives.
“I see countries taking action that are not taking into consideration the reality of vulnerable groups, of women, of children,” she said. “When you isolate, what is it that you put in place to help this woman who is going to be on the front line to be sure that they will be able to respond to the call, that their needs and priorities will remain taken care of?”
For Mworeko, Raphael, and many other people living with HIV (PLHIV) worldwide, UNAIDS head Winnie Byanyima is the leader they have been waiting for to bring a bold, feminist analysis to the AIDS response and to health in general. TheBodyPro worked with Mworeko and Raphael to come up with questions for Byanyima, who did this interview—her first full-length conversation since COVID-19 started—from her Geneva apartment during a chaotic week that saw the office shifting to “tele-working” and the news shifting every day.
Emily Bass: What should HIV program preparedness look like in sub-Saharan Africa and AIDS-endemic countries that are also now dealing with COVID-19, and what is UNAIDS thinking about in terms of providing guidance?
Winnie Byanyima: Coronavirus is very serious, it’s totally unprecedented. We have not seen anything like this in our lifetime, and it’s hitting countries really hard, from the richest to the poorest, and it’s going to hit countries with the highest burden of HIV quite soon. We are watching and seeing them heroically try to keep it out, but when it does hit—and it will hit—we can expect huge health and economic impacts. We are concerned, for example, about the possibility of severe disruption to [HIV] services, prevention, testing, treatment services. We are concerned about the welfare of 24 million people who are on treatment today globally, many of them in the poorest countries. We are concerned about 15 million others who are living with HIV but who haven’t yet accessed HIV treatment. That is a category I am particularly concerned about, because they are most likely having compromised immune systems, so they are more likely to be vulnerable. We don’t know. But it’s likely.
So, what are we doing? We are taking action in the countries where we work, we are working with our partners, we are first of all assessing the information needs, we are assessing medication and access to services. We are trying to establish the facts of what is happening on the ground for PLHIV, people on treatment. We are trying to find out whether countries are moving towards multi-month dispensing of ARVs [antiretroviral medications]. This is important. We are advising it, and we are checking to see if it is happening. We are trying to see whether services are being interrupted, and we are helping to develop contingency plans across those services. Is there a plan B, should it be interrupted? We are looking at travel restrictions and the different isolation quarantine measures and seeing whether these are affecting the services for PLHIV or not. If you are going to be quarantined, you’ve got to be with your ARVs or you’re in trouble.
What are we recommending to PLHIV? We are not asking them to panic, because if they are on treatment and they are virologically suppressed, there is no evidence they will be at a higher risk than anybody else, so we are saying, take precautions to reduce your exposure just like everybody else. We are also saying, reach out to your health care provider, be assured that there are adequate stocks of your medicines when you need them, so check and don’t be surprised.
Governments must look at [HIV] services as ones that are essential that must be continued, that cannot be suspended as other services have been suspended, and these include condoms, opioid substitution therapy, clean needles, syringes, PrEP [pre-exposure prophylaxis]—all these things that tend to be seen as being for groups that are discriminated, that are marginalized, but that are essential, lifesaving services that need to be kept going.
EB: As you are working through country offices to monitor, have you heard anything that’s concerning?
WB: To the extent that it affects the health systems and therefore how it delivers to PLHIV, we are hearing of countries trying very hard to protect their economies. I am talking of developing countries really kind of posturing, putting out there a sense that they are on top of the situation in terms of screening, testing, isolating, and all that, and yet when the systems have been tested … stories of just how weak the system is. If this virus is now transmitted locally, it could spread like fire. That is worrying, so we are getting some stories of the weaknesses in the system, so that makes me worried. We have not heard any alarming stories [about HIV services] yet. Where there are shortages, they were already there.
EB: Some European groups are saying, “Return your Kaletra,” so it can be used for treating COVID-19. What should be done, and by whom, to clarify and address this?
WB: People with HIV know that global solidarity is critical in fighting an epidemic such as HIV, and now coronavirus. They also know how important it is to make treatment available and make it available quickly. It’s a matter of life and death. They know that speed is important, and they know that formal systems don’t always work.
With Kaletra, there have been several studies, the first one is coming from China, and it is coming soon. We at UNAIDS are also looking forward and awaiting the results of those trials. [Editor’s note: One trial was published after this interview was conducted, showing Kaletra was not more effective than standard of care in treating COVID-19. Check our sources below.] We are now also hearing about “compassionate use” of Kaletra for COVID-19 because we don’t yet have the certainty that Kaletra is an effective treatment. There is some use of it in Switzerland and Western Europe, but in those countries, Kaletra is not the most commonly used antiretroviral, so many people have other, safer, more effective [HIV] treatments.
Any call to change one’s ARVs has to be based on evidence, and until evidence is there, they should stay on what is given. No one should be pressurized to change their treatment. It’s a bit early to say whether Kaletra is going to be a good treatment for COVID-19. We thank all of those who are working very hard to put out a treatment as soon as possible. The HIV community is waiting to hear what is coming out of that. We have to be ready always to jump into difficult situations, to help, to make everything possible to save lives. Where [Kaletra] is being tested and used compassionately, we have no objection, but no one should be pressurized—the rules of respecting human rights of people with HIV are important.
EB: It is hard to do intersectional work, and it is even harder to do in emergency times. The reality is that some of the COVID-19 social distancing precautions sound, to many African women I have spoken to, about as feasible as using a condom for every sex act did during the early days of HIV, in terms of the trade-offs you have to make to survive, to get food for your family, to get the water from the tap. So what does a feminist, intersectional response look like to COVID-19? What can we expect of ourselves and the response?
WB: It’s really challenging to governments that have been designed by men and continue to be run and led by men. Their approach to issues is always really siloed. You have built-in competition between siloes. The systems drive incentives for being visible achieving in a narrow line, not for intersecting, not for being crosscutting. The challenge is that it’s about being able to work at many levels at the same time. Feminists and feminist groups who are on the ground who are leading HIV responses have so much to offer in that sense, in the sense of knowing how to solve problems that are multi-faceted, in terms of being able to build trust across different groups of people, to break down power and work with different groups of people well. This is the strength of feminist groups and organizations. They reach the most vulnerable, and they insist on non-discrimination. In this response, I believe the only way to succeed is for government to empower communities with information and tools they need to be able to prevent. If you empower communities, I can tell you, they will find innovative, creative ways of prevention. They know everybody, they know who is vulnerable and who is not, and they will find creative ways for prevention even in those settings where social distancing is impossible.
EB: So does it follow in these settings where we have an informal economy, poverty, that these governments, part of their preparedness is civil society funding and engagement?
WB: Definitely, it is important to localize the response. It’s no good even pretending there is one solution. You will find that in the market, market women will organize themselves to isolate immediately. They will find ways to do the hand washing, to make sure that all the advice that is important is complied with in their setting. But you need to empower them, to give them resources.
EB: What could happen to the AIDS response as COVID-19 spreads in sub-Saharan Africa?
WB: You can make some comparisons with the global financial crisis. It broke out in America, quickly spread to Europe, then to other capitals where financial markets are connected, Hong Kong, some parts of Asia. Africa was for some time untouched, because it was not so connected in the financial market and in the global supply chain, but it was affected in a third phase, like two years late it started feeling hurt, there was less foreign direct investment. There wasn’t so much going there, but the little there was started drying up. Then aid started drying up. In a year or two, we are likely to see aid budgets coming down, and for Africa that will be a disaster, because already most, except for South Africa, their HIV responses are heavily aid dependent. In the context where most sub-Saharan African countries now are either highly indebted or under debt distress or at risk of being in debt distress, they have already been cutting health budgets in order to make debt repayments.
When there are huge pressures on budgets, that is when you see who is valued and who is not. Governments choose to discriminate people with HIV because many are criminalized and stigmatized. Sex workers, gay men, men who have sex with men, people who inject drugs—they were already not a priority. Now, with pressure on health systems, I can see some of them may choose to cut those services in the name of, “We have a problem.” I also see another challenge of human rights deficits. I am afraid about restrictions that countries that are already not democratic will impose in a way that hurts those with a small voice.
We may be faced with that argument—for me, it is a false argument—for me, we need to do system strengthening, not investing in a vertical disease. There will be some resources for preparedness of the health system to deal with outbreaks, and then there can be a divestment from one struggle that isn’t over yet. That would be a real mistake.
EB: You have this remarkable ability to speak directly to some of the heads of state, and you have been using it to great effect. Have you been making calls, getting ready to make calls to work with heads of state in sub-Saharan Africa as this unfolds?
WB: I need to. I need to do so. And I need to plan how to do this, because HIV is a revealer. It shines a torch on inequalities in society, on who matters and who doesn’t matter. We now have to tell these leaders that, “Please, don’t come in to find a solution for yourselves, for political and economic elites. This time, tackle the inequalities and where they intersect, because you are not safe when they are not safe. This is one equalizer about [COVID-19]. If you want to rout it out, you have to tackle these inequalities, look at them, see who is crushed the most, and start there, instead of trying to start with yourselves as you always do, you elites. That is the message I would like to take to them.
EB: Speaking of messages, is there anything else you have as a message for people living with HIV, women living with HIV who are doing their own preparedness work?
WB: I want to say to them, don’t see yourself as victims, and don’t be frightened. In the Pan-African movement, we used to have our slogan, “Don’t agonize, organize.” So, I am saying, mobilize, you’ve been able to mobilize against a killer epidemic, HIV, and you have saved your lives and millions of others. This is one other epidemic. You are tested, you are grounded, you know how to fight and how to use collective power of communities to prevent, to test, and to treat in the most respectful, human rights–focused approach. So go out there and fight, use your voice to demand and take action for your communities.