A region in crisis
Southern Africa is the epicentre of the HIV epidemic. It is the region most affected by HIV and AIDS in the world, which has witnessed a significant deterioration of health and development of the region’s population. Despite bearing the brunt of the epidemic, a common voice for southern African civil society has been lacking significantly in all international and regional fora.

It was recognised that there is a need for more meaningful contribution, adequate consultation and preparation among civil society organisations in southern Africa. Therefore, as organisations representing diverse sectors of the Civil Society in Southern Africa, we met to reflect, review and dialogue on a common position in preparation for the upcoming UNGASS meeting (June 2008).

The primary specific objectives of the meeting were to:

• Share country experiences and CSO perspectives on the progress of HIV and AIDS responses
• Identify and capitalise on advocacy opportunities where southern African civil society can help lend their voices to the debates
• Consolidate southern African perspectives ahead of UNGASS meeting
• Agree on an southern African Common Position Paper for UNGASS review based on our experiences from country reports
• Develop a comprehensive advocacy strategy for civil society organisations in southern Africa

From the 10 southern African countries that have formally submitted UNGASS country reports, we have noted with appreciation that there has been substantial progress to scale up essential HIV prevention, treatment, care and support services for those who need them. Numerous governments in southern Africa have demonstrated greater commitment and leadership, as evidenced in newly established strategic frameworks and improved coordination of national responses to HIV. In addition, financial resources for national multi-sectoral HIV responses have continued to increase. Despite this progress, civil society groups participating in the southern Africa pre-UNGASS meeting have identified the following challenges / gaps that hamper the achievement of universal access in the region.

• Limited Involvement of Civil Society in UNGASS Monitoring Processes

Since the 2006 UNGASS High Level Review meeting, a number of southern African countries strengthened the involvement of civil society in the review, analysis and writing of the UNGASS country reports. In particular, Zambia and Zimbabwe took strategies to enhance open consultation between relevant government ministries and civil society. However, a number of countries felt that civil society continues to be sidelined in national processes for reporting on UNGASS indicators. It was recommended that:

• Civil society needs to build its own capacity to monitor, analyse and feed into national M&E mechanisms.
• All countries should have a civil society technical working group to support the country reporting process for UNGASS and a representative on the National AIDS Council to support the country reporting process for UNGASS.
• There should be a stronger voice of HIV positive people on National AIDS councils to ensure that civil society data is adequately fed into the national M&E process and UNGASS reports.
• There is a need to strengthen partnership forums to enhance coordination and engagement of CSOs.
• Stronger links between CSO and parliamentarians need to be formed to enhance information flow, awareness creation and oversight/monitoring of policies.
• Governments and civil society should link and co-ordinate associated international plans and treaties that have been signed and inform all stakeholders well in advance of reporting dates, processes,etc (i.e. Ungass, CEDAW, MDGs, Maputo Plan of Action, VAW)

• Prevention

The year 2006, was identified as the year of prevention in the southern African region. Government and civil society organisations committed themselves to enhancing a focus on prevention, while maintaining the emphasis on access to treatment.  Although some countries are showing a decline in HIV infection rates, the participants of the southern Africa pre-UNGASS meeting highlighted that existing prevention strategies are failing to have the desired impact. There is an urgent need to scale up and deliver prevention interventions that have impact. Beyond abstinence and condom provision, there is a need to provide a range of prevention strategies which increase faithfulness, reduce intergenerational sex and multiple concurrent partnerships. Many countries are exploring additional strategies such as male circumcision. From CSO in southern Africa, the following are key recommendations to strengthen the prevention aspect of the response in the region:

• Scale up HIV and TB prevention programmes at the same pace as treatment initiatives. Prevention programmes need to be comprehensive and include a range of strategies.
• There is a need to identify comprehensive HIV prevention programmes and services that address gender inequalities and focus on the needs of women, youth and older people.
• This includes conducting more research on male circumcision and its impact on women, identifying more prevention methods that are female-controlled, and working with health professionals to eliminate stigma associated with youth, women and older people who seek HIV prevention and sexual reproductive health services.

• Information about HIV and TB prevention needs to be widely accessible in relevant languages and formats (including Braille, sign language, and vernacular). An overall fatigue to HIV and TB messages has been noted therefore HIV information and messages need to be developed together with target audiences.
  

• Violence, rape and sexual assault of women need to be addressed in the strongest terms to address HIV and AIDS. There is a need to put legislation and policies into real practice to protect women’s rights and safety. 
• All countries need to make a national commitment to developing targeted HIV prevention programmes for vulnerable and ‘at risk’ groups. In addition, governments should address the legislative barriers to effectively addressing the HIV prevention and sexual reproductive needs of these groups.

• As a prevention strategy, there is a need to place an emphasis on economic empowerment of women, children and the older people through social protection policies, micro-finance, property rights or cash transfers.

• Greater emphasis on mainstreaming HIV prevention and behaviour change strategies into other development areas (i.e private sector, education..etc).
• Treatment and Care

In southern Africa, there has been an overall increase in access to treatment for adults living with HIV. However none of the countries have reached the target they set. There remains a significant portion of people without sufficient access to treatment and care, as evidenced by the ongoing high mortality rates in the region. Of particular concern, is the need for treatment and care for children and older people (adults above 50 years of age) who are HIV-positive.
From CSO in southern Africa, the following are key recommendations:

• Scale up access to the continuum of care required by people living with HIV, regardless of their age or sex. The continuum of care is understood to include relevant tests, prophylaxis for OI and TB, anti-retroviral treatment, and psychosocial support.
• A key component of comprehensive care for people living with HIV is access to good quality food. However the region has high food insecurity which directly compromises effective treatment of people living with HIV and AIDS. There is a need for treatment approaches to include nutritional support

• Regional strategies need to be established as a matter of urgency to ensure sustainability of ARV and treatment supplies in the southern African region. Governments in the region should make better use of the flexibilities within TRIPS agreements.
• There is an urgent need for a harmonised protocol on ART for the entire southern African region, as mobile population, migrants and refugees have the right to greater access to treatment
• Scale up treatment literacy initiatives in the region through greater involvement of people living with HIV as peer educators and community health workers.
• All countries need strategies that support households headed by older persons and /or children.

4. Vulnerable and Marginalised Groups
Among southern African countries, there was no data on indicators related to vulnerable and ‘at risk’ groups, including MSM, prisoners, IDUs, and CSW. As a result, significant populations are not being reached with HIV prevention, care or treatment.

From CSO in southern Africa, the following are key recommendations:

• All countries in southern Africa need to recognise sexual diversity among its populations address legislative barriers and develop programmes that reach LGBTI groups.

• All countries in southern Africa need to establish strategies for addressing intravenous drug use

• More specifically, young people, women and the elderly who use drugs or are sexual minorities need access to HIV-related services

• All countries need to establish programmes for older persons, and there is an urgent need to review key indicators in UNGASS (in particular indicators 7, 16, 17) to incorporate older populations.

• All countries should reject legislation and policies that criminalise HIV and AIDS.

• Integration of Sexual and Reproductive Health and Rights

In many of southern African countries, HIV and AIDS have been addressed separately from other sexual and reproductive health services and programmes. This has created an artifical separation of health care services. A key recommendation is to enhance programmes focused on comprehensive sexual and reproductive health services for men and women. This would include:

• Ensuring that all HIV positive women have access to SRH services which offer high quality counselling and support to enable them to make informed decisions about family planning.

• Strengthening adult women's treatment guidelines that include a focus on women particularly dealing with the continuum of care and respecting women's choices to parenthood in treatment regimes  (specifically with regard to first line regimen drugs being contra-indicated in pregnancy)

• All women in southern Africa, irregardless of HIV status should have the right to decide to become pregnant or to terminate a pregnancy.
• VCT and STI services need to screen and refer for risks of Violence Against Women
• Screening and coverage for cervical cancer need to be increased
• Need for increased funding to develop sexual and reproductive health services, with specific attention to fertility aspirations of HIV positive couples.  

• Regional programmes are needed to provide  HIV and AIDS / SRHR related services for commercial sex workers and mobile populations

6. Health Systems strengthening

To achieve the impact required to effectively address the HIV epidemic in southern Africa, there is an overall need to increase funding and strengthen health systems, including training of health professionals and community health workers. Resources and systems need to be developed to enhance the links between formal and community prevention, care and treatment services. From CSO in southern Africa, the following are key recommendations:

• Resources are needed to strengthen communities and the AIDS response to address issues of women, youth and elderly
• Address health care workers crisis by strengthening community resources to help fill the gap through task shifting.
• Southern African countries need to be more vocal in advocating for compensation for trained health care workers who immigrate to developed countries.  A regional strategy is needed mitigate the migration of health workers.
• Invest in the future- in order to have an impact, Development  partners need to consider long tern funding of HIV and TB programmes

As civil society organisations in southern Africa, we are committed to working in partnership with governments and other stakeholders to ensure the achievement of universal access.