The COVID-19 outbreak has been placing unprecedented strains on sophisticated health systems in Europe and Asia, with overstretched medical staff struggling to treat their patients and intensive care facilities overwhelmed in rich countries.

The UNAIDS China Office and the UNAIDS Kenya office, in collaboration with WeDoctor—a Chinese medical service platform—held an online session with more than 70 doctors from Kenya to share China’s experience responding to COVID-19.

In March 2020, a stock-taking exercise led by UNAIDS, UNICEF and UNFPA, together with the Ministry of Health and Wellness of Botswana and the Central Medical Stores, assessed the availability of antiretroviral medicines, condoms and other contraceptives in the country in anticipation of the COVID-19 restrictions.

The First Lady of Botswana and UNAIDS special ambassador for the empowerment and engagement of young people in Botswana, Neo Masisi, has partnered with UNAIDS, young people and people living with HIV to produce a series of videos on COVID-19. The videos have been broadcast on Botswana national television.

In Dar es Salaam, Tanzania, the COVID-19 pandemic has amplified the struggle for those who are already marginalized and vulnerable. In densely populated areas and informal settlements, where many of the cities’ people who use drugs reside, social distancing is difficult and running water and sanitation infrastructure is sparse.

It is no surprise that Birknesh Teferi’s first name means “revolution” in Amharic, the language spoken in Ethiopia. She exudes passion and self-pride; she’s the picture of health and well-being.

Her journey to this point in her life is indeed revolutionary—a story of resilience, hope and transformation. She has beaten tuberculosis (TB), survived cervical cancer and is living positively with HIV.

Ms Teferi was diagnosed with HIV and TB in 2003, a time when information about HIV, TB and sexual and reproductive health in Ethiopia was scarce and stigma and discrimination high.

According to the World Health Organization (WHO), Ethiopia is one of the 48 high-burden TB countries globally. In 2018 in the country, 165 000 people fell ill with TB and there were 27 000 deaths; 2200 of which were among people living with HIV.

After waiting 15 days for her test results, while the health-care worker went on leave, Ms Teferi was told that she was “positive”.

“I thought it was good news. I hugged the nurse in relief, only for her to tell me that being HIV-positive meant I had the virus,” she said.

Ms Teferi successfully underwent the WHO recommended treatment for TB—directly observed treatment short-course (DOTS)—which cured the TB but did not help her with her struggle to accept her HIV status.

“What followed was a period of hurt and heartbreak … Waiting for death,” she recalled of the aftermath of her diagnosis.

She describes herself then as a “drifter.” She did not disclose her HIV status because of stigma and worked as a sex worker to make ends meet.

“If a client had a condom, we would use it. If he didn’t, we didn’t. I tried to use them, but I had no money to buy them. That’s how I developed a sexually transmitted infection.”

During the treatment of the infection, Ms Teferi was diagnosed with cervical cancer and was referred from one health facility to the next, often in different towns.

She eventually found a “caring” doctor and had an operation to treat the cancer. “I was in so much pain, I couldn’t sit. I was miserable,” she remembers.

But when Ms Teferi started to take HIV treatment in 2008, her life slowly changed. She started to look after herself more. She insisted on condom use with her clients.

She met a group of women living with HIV from the Tilla Association of HIV-Positive Women in Hawassa, Ethiopia. The association focuses on capacity-building and training and support of women living with HIV. It runs an embroidery centre as an income-generating activity for women living with HIV, where Ms Teferi now works.

“I am now free of drifting. Life is so much better. If people feel that it is possible to live, possible to work, then life can change,” she said.

For the first eight months of her time at the centre, the manager assigned her a volunteer to help her with her physical recovery from her operation. For the first time, she had support from other women who understood what it was like to be her.

The women at the centre invited her to watch a film about living positively with HIV. “That movie gave me hope,” she says. “I started to learn more about HIV from my manager. I gradually got relief, better medical services and Tilla supported me financially and emotionally.”

While Ms Teferi is on HIV treatment and has been cured of TB, there are millions of people worldwide who still lack access to prevention and treatment for both conditions. TB is the leading cause of death among people living with HIV globally.

In 2018, there were an estimated 1.2 million TB deaths, 251 000 of which were among people living with HIV—this is a 60% reduction from 620 000 in 2000. Between 2000 and 2018, TB treatment alone averted an estimated 48 million deaths among HIV-negative people and TB treatment supported by antiretroviral therapy averted an additional 10 million deaths. However, progress is slow and needs to be accelerated in order to end TB by 2030 as part of the Sustainable Development Goals.

“TB is curable and preventable,” said Aeneas Chuma, the Director for the UNAIDS Regional Support Team for Eastern and Southern Africa, a.i. “It is critical in this moment of history, in the context of the global COVID-19 pandemic, that we ensure that people living with HIV who are diagnosed with TB have uninterrupted access to HIV and TB treatment. UNAIDS is working with governments and community partners to ensure that we adapt to a rapidly changing health context, with kindness, compassion and humanity.”

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Pumza Mooi is worried. A resident of Port Elizabeth, South Africa, she is one of 2.5 million people in the country living with HIV but not currently on antiretroviral therapy.

“I’ve decided that I have to start,” said Ms Mooi. “No matter how strong my CD4 count or how low my viral load, it will never be as good as on HIV treatment. It is something I must do for myself, for my children and for those who look up to me. I am scared of getting sick,” she said.

Ms Mooi’s decision to start HIV treatment comes at a time of uncertainty for people with a compromised immune system, owing to the risk of a severe COVID-19 infection. There is currently no evidence that people living with HIV have any greater risk of acquiring COVID-19, but there is concern that a COVID-19 infection could be more severe for people living with HIV who are not taking antiretroviral therapy.

South Africa is under a 21-day lockdown to try to slow the spread of COVID-19 and Minister of Health Zweli Mkhize has urged everyone to take precautions to prevent infection, emphasizing the importance of everyone knowing their HIV status, getting tested and immediately starting treatment should they test positive.

“The thought of catching COVID-19 frightens me,” said Ms Mooi. “It is scary to think that I already have one virus [HIV] that my body is dealing with. I am asking myself, is my body strong enough, is my immune system strong enough?”

Ms Mooi acquired HIV many years ago, when the prevailing advice was to commence treatment if the patient experienced a reduction in their CD4 count, thus falling ill. She has been monitoring her status ever since. In 2016, the World Health Organization published new guidelines recommending lifelong antiretroviral therapy for all children, adolescents and adults, including all pregnant and breastfeeding women living with HIV, regardless of their CD4 cell count. In other words, anybody diagnosed with HIV should start treatment straight away.

UNAIDS is actively monitoring the impact of COVID-19 and working with networks of people living with HIV, the government and development partners to ensure that the concerns of people living with HIV are heard and reflected in the COVID-19 response. This includes identifying constraints on health services, encouraging longer, multimonth prescriptions of antiretroviral medicine and helping communities to provide solutions.

Social networking

Life under lockdown is especially difficult for people living in informal settlements and UNAIDS has recognized the challenge of achieving self-protection, social distancing and containment in such areas. Added to this are fear-inducing and inaccurate reports about the coronavirus. “There is a lot of information going around but not all of it is true,” Ms Mooi said. “I am reminding people that the government has given us a WhatsApp number where we can get good information, and not to worry about other information. If it is true, the government will tell us.”

Luckily, Ms Mooi has a robust support network after she shared her HIV status online many years ago. “I know I will be looked after,” she says. She moderates Facebook and WhatsApp support groups for people living with HIV that have dozens of members, ranging in age from a 16-year-old born with HIV to a woman of 62 who has lived with HIV for many years.

Over the past few years, many in the group have shared their experiences of living with HIV and their experiences of taking HIV treatment, confronting stigma and discrimination and staying motivated. Their consensus is that taking and adhering to HIV treatment is the best option, Ms Mooi said.

Right now, there is a new topic in the groups. “They are worried about COVID-19,” Ms Mooi said. “I tell them don’t worry, stay home and practice good hygiene.” For the time-being, everyone knows they will have to sit tight and take care of each other remotely, to get through extended isolation.

The group fosters discussion mostly among women, although men are listening in. “I get messages from men asking why we don’t discuss issues affecting them, but if they don’t disclose they won’t always get the help they need,” she says. “I encourage men to share their stories and let us help each other.”

Looking ahead

Like most, Ms Mooi is already looking forward to being able to move about more freely again and to start HIV treatment. She is doing what she can to look after her family and to encourage her networks of people living with HIV. “We are doing the things we are told to do, like washing our hands and keeping away from other people, and just praying and hoping for the best,” she said.

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“Peace is not merely the absence of war—it is when people have access to resources that enable them to meet their basic needs so they can live their life with dignity. If people have no nutritious food, if children do not go to school, if there is a conflict, then they are not at peace. COVID-19 came to remind us about it,” said Karambu Ringera, the founder and President of the International Peace Initiatives in Kenya.

Ms Ringera says that peace is holistic—even though her organization focuses on women living with HIV and AIDS-related orphans, she believes that it is also working for peace.

Her work started back in the early 2000s, when Ms Ringera was a student in the United States of America. When she returned to her home town in Kenya, Meru, for the summer holidays, she met a group of women, some of whom had recently lost their husbands. Most of the women didn’t know the cause of death of their husbands, but since AIDS-related deaths in Kenya were at their peak then, Ms Ringera suspected the reason. She encouraged the women to find out their own HIV status so as to not follow in their husbands’ footsteps.

Moved by the plight of many of the women she met, many of whom couldn’t afford to send their children to school or access HIV treatment, when back in the United States Ms Ringera arranged a cultural event, at which Kenyan food was served and people could learn about African culture. She collected US$ 400—enough to send seven children to school.

“I love the proverb about not just giving a person a fish, but teaching them how to fish,” she said. She wanted to help more children at home in Kenya, but, said Ms Ringera, “I wanted to go beyond just being someone who came to study poor women, create a solution for them and ask them to implement it.” For her, it was important for the women to understand that they could help themselves.

The women decided that they would make jewellery, which could be sold at her cultural fundraising events. At the same time, women started developing more skills, such as weaving and catering, so they could start their own businesses and support themselves.

Nearly two decades later, Ms Ringera runs a nongovernment organization that provides sustainable initiatives for orphans, women living with HIV, survivors of violence and communities with the tools and resources they need to move on from violence, poverty and crisis to stability and self-reliance.

In the beginning, many of the women who work at the International Peace Initiatives couldn’t afford a US$ 3 school uniform for their children. Today, Ms Ringera is proud that many have put their children through university. “People even in vulnerable circumstances can transform their lives. We have women and children, young people, to show that this is possible. We need to create interventions that inspire people to save themselves,” she said.

In the time of COVID-19, though, Ms Ringera is worried.

“We will need a good strategy to survive as a family,” she said. “Since 2009, when our children’s home was opened, this is the first time that we closed its doors to visitors. We did this immediately after hearing the news about the new coronavirus.”

The children’s home is home to 76 children, who need to be fed three times a day. Ms Ringera thinks that sustainability is key—Ms Ringera and her team are planting crops, keeping chickens and trying to collect a store of food for at least three months. “I feel that more and more, people need to create their own sustainable systems where they are, so that during challenges like this, at least they can have their own food locally,” she said.

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The United Nations agencies in South Africa have launched a joint flash appeal to support 9.9 million people to cope with the COVID-19 response.

The United Nations Country Team in South Africa, under the leadership of the Resident Coordinator, was joined for the launch of the appeal on 30 April by government ministers and others.

The Emergency Appeal on the Impact of COVID-19 in South Africa calls for US$ 136 million to support government efforts to reach vulnerable and marginalized communities to address the impact of COVID-19. It aims to raise funds for health, including HIV/tuberculosis, food security and nutrition, gender-based violence protection and response, education, water and sanitation, coordination and governance.

The United Nations Resident Coordinator, Nardos Bekele-Thomas, said, “Helping South Africa especially at this time makes development sense and it also makes business sense. We focus on the most vulnerable groups. They have potential to be producers and, with disposable income, they will become consumers, investors and productive assets for the economy,” she said.

The Minister of Health, Zwele Mkhize, welcomed the United Nations plan, which will complement national efforts and focus on the needs of vulnerable communities, including people living with HIV and tuberculosis, migrants and refugees, vulnerable women and children, key populations and millions affected by poverty, unemployment and the impact of national restrictions on trade and movement since 26 March. “We have various issues of inequality, unemployment, poverty and densely populated areas and chronic overcrowding in our metros, which are the most affected by COVID-19. We have already started to see local transmissions in these areas, which has given us cause for concern,” he said.

Mr Mkhize said the appeal would also help to ensure that the AIDS response continues unabated, including scaling up testing and treatment for people living with HIV. “We had already started a programme to achieve our 90–90–90 goals in 14 of the 52 districts and we cannot allow this pandemic to disrupt all these efforts and the successes and achievements we have already scored,” he said. “We appreciate the focus on people living with HIV, given the burden of disease.”

The Minister of Health told the launch that it was important to work with communities, civil society and other stakeholders already in place. The COVID-19 response would strengthen South Africa’s resolve to achieve universal health coverage, he said.

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United Nations entities in South Africa, including UNAIDS, are working closely together to support government and community responses to the COVID-19 pandemic. The United Nations in South Africa has jointly engaged with civil society, the private sector and key affected communities, including people living with HIV and tuberculosis, to rapidly respond to the impact of a national lockdown that commenced on 26 March.

Using the World Health Organization eight-pillar approach, the United Nations in South Africa has developed a multisectoral plan centred on the immediate health and other needs of people, including access to medicines, HIV prevention and testing services, food security, education, social protection and community resilience.

On 30 April, the United Nations in South Africa launched an emergency flash appeal for US$ 136 million to support close to 10 million people in need. The appeal will help fund the civil society response and ensure that the needs of key populations and vulnerable communities are met in the response to COVID-19, including continued health support to people living with HIV, migrants and refugees, women and children affected by violence and communities facing shortages of food and other essentials.

UNAIDS has worked with partners to coordinate the United Nations in South Africa plan, providing support to strategic information, community engagement and communication. Funds already available to the United Nations Joint Team on HIV/AIDS are being reprogrammed to ensure that civil society, people living with HIV, key populations and vulnerable communities continue to be supported in the AIDS response while also addressing new challenges from COVID-19.

United Nations staff, including UNAIDS staff based in provinces with a high HIV burden, are working in the national and provincial COVID-19 command centres and supporting community health workers actively engaged in screening, contact tracing and voluntary testing. South Africa has massively scaled up screening for COVID-19.

Supporting community innovation

The United Nations has actively engaged with civil society organizations through sector networks, some of which have been established to coordinate responses to the pandemic, such as the C19 People’s Coalition and the COVID-19 Front, and long-standing networks, including the South African National AIDS Council (SANAC) Civil Society Forum and the National Economic Development Council Community Constituency. Their plans include a strong emphasis on advocacy, communication and social mobilization around issues such as medical care, shortages of food and fresh water, crowded housing conditions, homelessness and loss of income. The United Nations Country Team is providing technical support to civil society and resource mobilization through its emergency flash appeal.

UNAIDS has also supported organizations representing people living with HIV to survey and document the needs and challenges of people living with HIV in accessing essential health and social services, antiretroviral therapy and safety and hygiene services committed by the government. The survey results will inform a dialogue led by people living with HIV to find joint solutions.

Working with the government and other partners

Under the leadership of the United Nations Resident Coordinator in South Africa, Nardos Bekele-Thomas, the United Nations in South Africa is fully supporting the all-government, all-society COVID-19 response led by the National Command Council, chaired by the President, with a cutting-edge Ministerial Advisory Council that provides the science and evidence for decision-making.

The United Nations has jointly consulted the government, including the Department of Health and the Department of Social Development, to explore response needs, including support to the National Solidary Fund set up by the President for resource mobilization. The United Nations also briefed the diplomatic corps, the business sector, private foundations and philanthropies on how the United Nations is responding to support the government, civil society and communities. Consultations were also held with the World Bank, which is currently developing a post COVID-19 strategy and possible support to the national response.

The UNAIDS Country Director for South Africa, Mbulawa Mugabe, emphasized the importance of using lessons from the AIDS epidemic to put people at the centre of the COVID-19 response and encourage communities to identify issues and develop solutions. “We need to make sure that we act with purpose and speed,” he said. “Communities have mobilized themselves and are determined that people who need services have access to them. We remain concerned that COVID-19 may impact differently on the 5 million people in South Africa who are living with HIV and on treatment and the 2.5 million people who are not currently receiving antiretroviral therapy. It is important to protect the progress in the AIDS response to date and continue achieving the HIV prevention and treatment targets for 2020.”

The Joint Team on HIV/AIDS in South Africa is working with the Department of Health, primary recipients of the Global Fund to Fight AIDS, Tuberculosis and Malaria and the United States President’s Emergency Plan for AIDS Relief in an effort to safeguard access to HIV services and promote multimonth dispensing of antiretroviral therapy.

UNAIDS is working with the United Nations Office on Drugs and Crime, the Department of Social Development, SANAC and other partners to address disruptions for homeless people, including those who use drugs, so they can access essential services, including antiretroviral therapy, replacement needles and syringes and methadone, even after they were relocated to emergency shelters. The Office of the United Nations High Commissioner for Human Right is monitoring the impact of the lockdown regulations and enforcement procedures on marginalized people and key populations and is advocating to end stigma and prevent punitive measures. The social protection cluster in the United Nations team is working with government and civil society to address humanitarian challenges.

The World Health Organization and UNAIDS are working with the Department of Health and SANAC to develop communication materials directed at communities, including podcasts to be made available through WhatsApp and community radio stations.

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