New Era

As World AIDS Day, December 1, 2009 is commemorated, there is a need to reflect on the Namibian HIV/AIDS situation with the intention of renewing commitment to the fight against this pandemic in the country.

Namibia made significant progress in fighting HIV/AIDS as observed in the reduction of the national HIV prevalence rate from 22.0% in 2002 to 17.8% in 2008.

Hopefully, a 10% or a single digit percentage will be achieved in 2010. The other major achieved in this regard is the enrollment of more than 40,000 people on the antiretroviral therapy (ART) programme in the public health sector.

These, and many more, achievements in fighting HIV/AIDS in the country are highly commendable.

However, what has been achieved so far should not give the country reason to be complacent as far as fighting HIV/AIDS is concerned. The country still faced major challenges in this area. More than 200 000 Namibians are HIV-positive and more people continue to be infected with HIV everyday. Therefore, the future does not yet look bright regarding HIV/AIDS prevalence in the country.

Some of those infected will require ARV treatment at some stage and the newly-infected will add another burden to the country's health system and resources, if the current situation is not reversed immediately.

Namibia is currently experiencing an imbalance between the commendable achievements in HIV treatment and the lamentable failures in HIV prevention.

The country is treating HIV very well, but is also, unfortunately, failing to prevent HIV very well at the same time. You have a situation where HIV clinics are full of those who qualify for HIV treatment, those who are being monitored and the newly-infected ones.

As a result, these clinics (which by the way are built behind hospitals for whatever reason, thereby increasing stigma and discrimination associated with HIV/AIDS) are becoming overcrowded. A situation that is likely going to compromise the quality of HIV care provided at these clinics, if this is not happening already.

There is, thus, fear that HIV treatment, which is successful currently, may actually crash if it is not matched with an equal measure of HIV prevention. That is to say that Namibia should not only treat HIV, it must prevent and prevent HIV more!

Otherwise, there is a real danger of compromising the quality of HIV treatment as well. There are already signs of strain in the HIV treatment process, including the overcrowding at HIV clinics that pressurises health workers leading to delayed start of ARV treatment, hesitation to treat HIV in cases of co-infections, especially TB co-infections, poor coordination between HIV and TB departments, to mention but a few.

Therefore, the current successful anti-HIV treatment programme is in danger of crashing if the country is not turning its focus to HIV prevention with the same vigour.

It is time to discard HIV prevention approaches that have not worked for the past 26 years of HIV/AIDS and promote those that are realistic and working, including the new ones. There is now consensus that piecemeal application of HIV prevention measures is useless. The advocacy nowadays is for the application of a package of HIV prevention strategies and actions to make a real difference in preventing new HIV infections.

This paper, informed mainly by the recommendations of the Mexico 2008 International AIDS Conference on HIV prevention, prescribes the following HIV prevention packages for application at all levels of the health system in Namibia from individual, community and country levels:

HIV prevention package for women

1) HIV test. Always the first important step is to know one's HIV status. Testing must always be done jointly with partners, where there are partners involved).

2) Have no concurrent partners. This must strongly be discouraged because it is recognised that it increases the chances of HIV transmission.

3) Use condoms correctly and consistently. They have been proven effective in preventing, not only HIV, but also other STIs and unwanted pregnancies.

4) Get on PMTCT. It prevents children from getting HIV from mothers; it must be remembered that if mothers get on ARV early in the pregnancy they will also be protected from AIDS, and probably their partners too in this way.

5) Get HIV treatment. Women who are not pregnant but are HIV-positive, must get HIV treatment when eligible. ARVs reduce infectiousness in HIV-positive people with a 95% adherence. Also treat other viruses and sexually transmitted infections without delay. It must always be remembered that HIV treatment, if adhered to, is in itself an effective prevention method.

6) Enjoy social justice and human rights. Women cannot be expected to prevent HIV infections if they have no equal rights as men in the homes, in the community and in the society, if they are unemployed and are as a result economically dependent and poor, if they have no say as to how and when sex should happen, e.g. cannot demand the use of condoms in the face of potential danger of HIV infection or if they are constantly subjected to abhorrent domestic violence. How can they be expected to protect themselves from HIV infections under such hostile conditions?

7) There must be leadership to fight HIV and AIDS. Women, especially HIV-positive women, must lead the struggle against HIV/AIDS from the front. They must lead like Emma Tuahepa, Anita Issacs, Hambeleleni Hainghumbi and many other Namibian women who have been leading the struggle against HIV/AIDS in the country by example. Thankfully, Namibian women, unlike their male counterparts, have been at the forefront of the fight against HIV/AIDS at all levels from the beginning. They must be encouraged to continue inspiring this way.

8) There must be community activism to fight HIV and AIDS. Trying to prevent new HIV infections without community, and especially HIV-positive people's involvement, is pointless. Therefore, women must mobilise, and they stand a good chance to do so, their communities to actively get involved in fighting HIV/AIDS. Here, as in leadership, the activism of HIV-positive women will bring desired changes.

HIV Prevention package for men

The HIV prevention package for men is similar to the HIV prevention package for women as described above, except that men do not get on PMTCT and they must: circumcise. Circumcising men gives them more than 65% protection chance from HIV infection.

But they must be reminded that they must still use condoms correctly and consistently even with the circumcision, because they can still get HIV infection.

Indeed this article dares, based on personal experience, to say that male circumcision also has the potential to protect female partners from HIV infection. This is, however, said without negating the need for research to confirm or refute this allegation.

The main weaknesses for Namibian men in the HIV prevention package are the leadership and activism elements.

Namibian men at all levels of society have been left behind by their women counterparts in terms of involvement and leadership in the fight against HIV/AIDS. Their only rescue is the Minister of Health, Dr Richard Kamwi, who of late has provided impressive leadership in this regard. Where are the other Namibian men to emulate him?

Therefore, for Namibia to bring the low level of HIV prevention to the same level of HIV treatment, which is high and pleasing, it must forget preaching the old-fashioned ABC approach alone.

It has been established by now that the A and B of this approach are not very helpful in preventing HIV. Who Abstains and who is Being faithful? Take the C and add it to the rest of the recommended measures in the packages as described above and implement them systematically and with vigour and expect to reap the fruits of the effort within five years.

In other words, the focus of prevention should be on behavioural change and biomedical prevention strategies as prescribed herein and elsewhere. The country's HIV/AIDS programmes must incorporate these prevention strategies. Obviously, some of these are being implemented already, such as the National HIV Testing Days, PMTCT and luckily the Minister of Health is vigorously promoting circumcision in the country now. But the country must be cautious not to implement HIV prevention measures in a piecemeal fashion â€" they must be implemented as a package or combination prevention to generate the desired impact in preventing new HIV infections and achieve a balance between HIV treatment and prevention that is currently lacking.

- C H Mwandingi is Chairperson of the Solidarity Community Care Organisation working in Ohangwena, Oshikoto, Khomas and Oshana regions of Namibia. He writes in his personal capacity.

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