Khayelitsha township in South Africa is about as bad as it gets” says Dr Nathan Ford, Medical coordinator for Médecins Sans Frontières' (MSF) Access to Essential Medicines Campaign.

“People in the slum lived in corrugated iron shacks, some of them built on top of each other. There was no running water, no sanitation, high unemployment and around one in three adults there were HIV positive. This was just 30km from the prime tourist destination of Cape Town,” he says.

Dr Ford set up MSF's first HIV project in South Africa back in 2001.

“HIV has a huge impact on people’s ability to work. There’s about a four year decline in productivity before treatment, then four years of steady improvement after treatment starts – so about eight years overall of being compromised.”

This often pulls the patient’s family with them into poverty. Being unable to work means property may have to be sold off to pay for medical treatment. Children sometimes have to leave school to care for a sick parent, which does little for their future job prospects.

“The way you get around that” says Dr Ford “is to diagnose and treat earlier so you get a shallower dip in productivity. Also, starting people on treatment early reduces the chances of them infecting others by 96%. One of the main reasons that people with HIV fail to get treatment however is travel costs.”

HIV treatment has traditionally been carried out only by doctors in hospitals. But for poor people in rural areas, travelling to an inner-city hospital every month to pick up their medication is impossible.

Dr Helen Bygrave is a London GP who worked with Dr Ford for several years. She explained how they worked around this problem in Lesotho – a landlocked country in the middle of South Africa. “We began decentralising HIV care to primary healthcare clinics in rural communities to increase the level of access. This model was taken up by the government and by 2011, 85% of clinics had begun to decentralise ART treatment.

“In Mozambique, they’ve formed community ART groups. A group of six takes it in turns to travel to pick up everyone’s medication. They all put a bit of money in the pot and pay for one person to go per month. The money is also used to pay for someone to go to hospital if they are sick so that treatment isn’t delayed.”

In Zimbabwe, patient support groups have taken this one step further. The Self Help Development Foundation trains groups of HIV/AIDS patients in income generating skills and projects like baking or crafts. The money is then used collectively for healthcare and transport costs.

In the South African fight against AIDS however, the poor transport system is not the only problem. There are roughly 100,000 immigrant miners in South Africa. Many are required to live in 'hostels' with other men for long periods and are banned from bringing their families with them. This takes its toll on marriages and causes high levels of divorce, with many men resorting to heavy drinking and using prostitutes.

Miners also view AIDS education from management with suspicion and AIDS is often blamed on the mines or other ethnic groups. Furthermore, studies have shown that neither miners nor sex workers regularly use condoms.

This is part of the reason why prostitution contributes to almost 20% of all newly HIV patients in South Africa. Prostitutes have less control over negotiating condom use and are more likely to live in poverty and inject drugs – all of which increase their risk of contracting HIV. However, the HIV charity Avert claims that organisations trying to deliver HIV programmes to prostitutes have often been met with police harassment.

The USA funded Presidents Emergency Plan for AIDS Relief (PEPFAR) is the largest international donor of HIV treatment for South Africa. Their ‘Anti-prostitution Pledge’ means that in order for a HIV/AIDS charity to receive funding, they must pledge to oppose prostitution. In effect, this cuts off help from the people who need it most. In April 2006, The Lancet called PEPFAR's strategy ‘ill-informed and ideologically driven’.

A different approach was tried in India in the early 1990s in a red-light district in Kolkata. Sex workers there – like in South Africa – were poor and marginalized. An intervention programme provided not just medical treatment and education but also looked to empower sex workers. This included vaccination and treatment services for the sex workers’ children, literacy classes for the women, political activism and advocacy as well as micro-credit schemes.

The sex workers created their own trade union, the Durbar Mahila Samanwaya Committee (DMSC) which negotiated better treatment by madams, landlords and local authorities. In 1999, the DMSC took over control of the programme, later expanding into 40 other red-light districts across West Bengal. It represents 65,000 sex workers and has created its own financial cooperative.

This new approach of empowering sex workers to negotiate their own living and working conditions has had a huge impact on reducing both HIV and poverty.

Lessons from India are relevant in today’s South Africa. During the apartheid years, it was common for births in rural areas to go unregistered – this was especially true for the children of sex workers. For people who lived far away from a registry office or who felt marginalised by the system, they saw no particular benefit in registering. In post-apartheid South Africa however, without a birth certificate you can’t get an Identity Document. Without that, the bureaucracy doesn’t recognise your existence.

This is the problem faced by Mercy, an AIDS orphan in South Africa (there are an estimated 1,900,000 in the country). She was adopted by Amos and his wife Gracious. Amos is a beggar and the family only barely scrape by, living in a small, unventilated shack with no running water. It’s freezing cold in winter and boiling hot in summer though this could easily be improved with a little work or a new home. Grants are available to people who care for children like Amos and Gracious, but only if they have an ID Book – which none of them do.