People who belong to, what is referred to in HIV jargon as, key populations (KPs) including men who have sex with men (MSM), people who use drugs (PWUD), sex workers, and transgender people often report that it is difficult for them to access healthcare services.
This could be for a variety of reasons, ranging from negative staff attitudes to the unavailability of services meeting the needs specific to certain groups.
While Spotlight and other publications have often reported on such issues, the reporting has mostly focussed on individual cases. Now, a large survey has given a glimpse into how big the problem is and provided some insights into the particular ways in which services for people belonging to KPs fall short.
The report, titled State of healthcare for key populations, was launched last week by community healthcare monitoring group Ritshidze.
Collecting the data
Ritshidze used “more than 50” people (all from key populations) to collect the data by surveying 5 979 people belonging to KPs from 18 districts in seven provinces. The Western and Northern Cape were excluded from the survey. Ritshidze’s monitoring generally focusses on facilities supported by PEPFAR (United States President’s Emergency Plan for AIDS Relief), of which there are none in the Northern Cape. They did not have permission from the province’s health department to do monitoring in the Western Cape.
Among the people surveyed, 1 476 were men who have sex with men, 2 397 people who use drugs, 1 344 sex workers and 762 transgender persons. “Some individuals with multiple identities (e.g. a trans* sex worker or a sex worker who also uses drugs) engaged in more than one survey to reflect multiple identities,” the report states. The majority of those surveyed were over the age of 25.
The survey participants were identified through snowball sampling. This means that participants could refer others who they know, who then, in turn, refer those they know to participate. “Compared to a facility-based sample, this methodology allowed us to find more ‘hidden’ KPs who may not use the facility in addition to those more regularly accessing services,” the report states. They used both quantitative (from August to October last year) and qualitative (from March to November 2021) data collection methods.
What the data tells us: ‘not receiving care’
According to the report, 20% of respondents were not receiving services anywhere. By province, the highest proportion of people not receiving services was in the Eastern Cape (43%) and the lowest proportion was in Mpumalanga (3%).
Explaining this, the report states “this data could point to the fact that the province (Eastern Cape) remains one of the poorest and most isolated in the country, with many challenges plaguing the public health system. Community members often travel long distances that are not always safe to get to public health facilities that service multiple communities.” Citing challenges such as poor roads and the inability to attract and retain health workers to help service remote areas, the report states that these challenges are likely also “impacting the uptake of services in the province by KPs”.
In Mpumalanga, however, data collectors focused more on urban communities of KPs. “More urban sites could point to better sensitisation than deep rural communities and therefore a higher uptake of services,” the report states.
The data shows that “KPs with more than one KP identity were the most likely to not be receiving services anywhere, suggesting that overlapping marginalised identities are making it more difficult to get healthcare. “The proportion of people who use drugs who also identified as transgender women were most likely not to be receiving services (36%), followed by those who also identify as transgender men (33%),” the report reads.
Receiving ‘not so friendly’ careAmong those respondents who access and receive healthcare, the majority said they use a public health facility (clinic). Some also access health services through drop-in centres (a community-based facility usually run by NPOs to provide certain services), mobile clinics, or private doctors. The data shows that many KPs, however, were not aware of drop-in centres or had to travel long distances to get to one. Even though most KPs use public health facilities, they are the least satisfied with the service in the clinics, compared to other means of accessing health services. Some of the reasons as cited by KPs include unfriendly staff, fears for safety, verbal abuse and privacy concerns.
The data shows that KPs in Mpumalanga cited better experiences with health staff than in other provinces (although this may partially be due to the sample in this province being mostly urban). Around 74% of men who have sex with men in Mpumalanga stated that staff members were friendly and professional but elsewhere, in provinces such as KwaZulu-Natal, only 17% of MSM surveyed said the staff was friendly and professional.
According to the report, KwaZulu-Natal provided, on the whole, the worst services for KPs alongside North West and the Eastern Cape, where mainly men who have sex with men, people who use drugs, and sex workers reported poor service.
In Gauteng facilities, it was particularly difficult for people who use drugs and in Limpopo, sex workers and transgender people indicated that they are treated badly at facilities.
Access to lube, methadone and hormone therapy
The report also contains some notable findings relating to people’s access to specific products or services. The findings in this regard suggest that apart from staff attitudes at facilities, availability of specific products is also a problem.
Only 26% of men who have sex with men, 19% of people who use drugs, 28% of sex workers, and 25% of trans people reported that lubricant is available at the facility. According to the report, out of 131 sites that say they offer services for men who have sex with men, only 88 sites offer lubricant to men who have sex with men. Water or silica-based lubricants are particularly important for helping to reduce the risk of condom breakage during anal sex. Broken condoms increase the risk of HIV transmission.
Only 24% of respondents who use drugs said methadone was available at drop-in centres. According to the report, out of 80 sites that say they offer services for people who use drugs only 16 sites offer methadone and only 7 offer new needles. Methadone/buprenorphine maintenance therapy is the current gold standard treatment for opioid dependence.
Only 5% of trans people said hormone therapy was available at drop-in centres. According to the report, out of 73 sites that say they offer services for trans people, only 14 offer hormone therapy.
'Go in for help, come out offended'
One of the survey participants mentioned that consultation at the health facilities is difficult. “There is never a time for one to consult with the nurse. There is always another nurse in the consultation room or another nurse comes in and they start chatting about their own stuff and you have to wait.
"There is no privacy, their attitude is bad and you can’t express yourself or ask for help because you don’t get a chance to connect with the nurse. You go there for help but come out offended because you are not even treated like a human.”
Nkhensani Mavasa, a KP organiser with Ritshidze says their report confirms the persistent and unaddressed crisis KPs face in accessing healthcare in South Africa. “Often clinic staff are unfriendly, openly hostile, and especially abusive to KPs. At times, people are even chased away from using facilities altogether.
"Together with shameful privacy violations, this ill-treatment drives KPs away from using our clinics,” Mavasa says.
Sibongile Tshabalala, national chairperson of the Treatment Action Campaign (TAC) says the report provides important insight into the treatment and services key populations receive at health facilities.
“It is also vital to ensure that those most at risk of getting HIV can access the treatment and prevention tools needed to meet the UNAIDS 95-95-95 targets and move South Africa towards epidemic control. If these people are ill-treated, chances are they will not come back to the facility, which will impact on their health as well as our aim to get them to use these services,” Tshabalala says.
Plans to improve KPs’ experiences of health services
Addressing the launch through a pre-recorded video, Deputy Minister of Health Dr Sibongiseni Dhlomo in response to the findings said, “We do pick up in the report that the majority of key populations use our public health facilities, because of that we need to improve them (health facilities) as this is their only hope. Some have nowhere else to go to. It’s unaffordable for them to go to private health facilities,” he said.
In a previous article, Spotlight reported that the health department was currently revising its Key Populations programme, which will be accompanied by a Key Populations Health Implementation Plan as well as plans to establish Key Populations Centres of Excellence.
Health spokesperson Foster Mohale at the time said the department has developed a comprehensive Key Populations Competency and Sensitisation Toolkit and it is being rolled out to as many public health facilities, regional training centres, and to many health workers as possible.
Spotlight enquired about the progress of the programme and its plans in lieu of the Ritshidze report, but the department failed to provide a response by the time of publication.
View from SANAC
Nelson Dlamini, spokesperson for the South African National AIDS Council (Sanac), told Spotlight that they have been a part of the development of the KP Health
Implementation Plan. He said this plan addresses the needs of key populations, aligned with the National Strategic Plan for HIV, TB and STIs, 2017-2022.
“It focuses on the five key populations (sex workers, men who have sex with men, transgender people, people who use and inject drugs, and inmates).
"It includes revised programme tools and standard operating procedures, a new set of NIDS Indicators (2019) to track progress, also includes district and provincial population size estimates (PSE) to improve target setting and guidance for access to services through self-care options and includes sensitisation elements,” he says.
Dlamini says staff (nurses, security guards, doctors and other clinical staff) sensitisation is aimed at improving access to appropriate and non-judgemental health services to key populations.
“Sensitisation training can challenge negative beliefs and shift attitudes through providing factual information. It enables individuals to engage emotionally, reflect upon and examine their personal attitudes and beliefs, and encourage positive behavioural intentions through role play and practical exercises,” he says. Dlamini says this is provided for in the Healthcare Provision for MSM, Sex Workers, and PWUD: An Introductory Manual for Healthcare Workers in South Africa, which was developed in 2013 and is used across South Africa.
Invest in sensitisation training
Dlamini says more investments must be made with regards to sensitisation of health care providers. “… [W]e need to identify, strengthen and support civil society, community-based and key population-led organisations and networks to provide large scale programming,” he says, adding that such organisations can be well placed to create trusted, safe platforms for service delivery.
Elma de Vries from PathSA (an interdisciplinary health professional organisation) says all staff at health facilities, including security staff, need sensitisation training. “Basically (sensitisation) is for staff to understand what different key populations are (e.g. the difference between sexual orientation and gender identity) and how to treat all people with respect.
"There is a need to create an affirming space. Staff training is key, and consistent availability of preventative measures such as condoms and lube, and availability of medication such as PrEP and hormone treatment. Some NPOs have been providing sensitisation training. There is clearly much more that needs to be done if one reads the Ritshidze report,” says de Vries.
She says accountability mechanisms need to be in place. “The department of health has a compliments and complaints mechanism as part of the Ideal Clinic Initiative, but this is not uniformly implemented throughout the country.
"If individuals are refused access to care, it would be difficult to lay a complaint at the facility itself, in such cases a complaint can be made at the district office or provincial health department as outlined in this national guideline.”
This article was produced by Spotlight - health journalism in the public interest.