- 4th edition of State of Health report compares data over the last four years of community-led monitoring in KwaZulu-Natal
Umlazi, 26 November 2024 — “I decided to be honest when I have STIs… I told them that I’m a sex worker. In return they’d come to the waiting area and expose me. They’d say that I’m at the clinic for clients. I lost faith in public facilities. I’d rather default than go back.”
For people who use drugs, sex workers, and the LGBTQIA+ community, going to the clinic in KwaZulu-Natal can mean facing insults, discrimination, and at times deliberately poor treatment. Instead of finding staff who are sensitive to and knowledgeable of their health needs, people can be faced with judgement and disrespect.
“The nurse shouted at me saying ‘hey you girl, are you a boy or a girl’ come here. People laughed and I never went back… I was not expecting to be mistreated at the clinic,” explained one trans woman who went to the clinic to collect her ARVs. One person who uses drugs told us how the nurses only attend to him outside the clinic. “The nurse won’t even come close to me. She would say I smell and ask in the open why I was there. I have to explain what I need with everyone listening.” One gay man recounted a nurse ignoring him and moving on to see the people behind him in the queue. “When I complained, she responded that she hates gay people because we are demonic and spread diseases. I ended up not getting medication. It was a traumatic experience”.
While positively 80% of public healthcare users said staff are always friendly — in contrast only 20% of trans people, 19% of people who use drugs, 18% of gay, bisexual, and other men who have sex with men (GBMSM), and 14% of sex workers thought they were. Most members of key populations surveyed did not feel safe or comfortable at the facility — with many reporting major privacy violations.
Many had also been refused access to health services. 6% of sex workers, 10% of trans people, 11% of GBMSM, and 37% of people who use drugs we surveyed had been denied services in the last year. One person who uses drugs described how he has gone back to the clinic many times without help: “They told me I don’t bathe and that I am a ‘para’. They don’t even want to examine us. At the moment I have no treatment (ARVs). Sometimes I ask my friend but two weeks can go by without me seeing him”. Of those who had been denied services, 36% of trans people, 70% of people who use drugs, 81% of GBMSM, and 88% of sex workers reported they never ended up getting the services they needed.
14% of people who use drugs also reported having been denied access to their ARVs in the last year — often in the face of longstanding and unfounded myths around the addition of ARVs to heroin based substances (such as nyaope/whoonga). A nurse told one sex worker: “you must stop acting like you want ARVs for yourself” going on to say that sex workers take ARVs and sell them so they can make whoonga — as “no sex worker can work without it”.
Being denied services is a humiliating, painful, and unjust experience to go through — and a violation of the Constitutional right to health, equality, and human dignity. While some people may suffer the indignity of trying to get services another time, others can be pushed out of care altogether.
The ill treatment of members of key populations is among ten key issues outlined in the fourth edition of a new Ritshidze State of Health report in KwaZulu-Natal.
On a more positive note the report reveals that KwaZulu-Natal continues to have the shortest waiting times out of all provinces monitored by Ritshidze — at 2:23 hours. The average waiting time was under 2 hours in King Cetshwayo, Zululand, and uThukela. In order to bring the provincial average down further, the health department should focus on districts and facilities with longer waits, including in Ugu where it is over 3 hours.
Another positive is that more people living with HIV reported getting a 3 month supply of ARVs this year, up to 72%. “They are currently giving me three bottles of my ARVs. I am happy about that” one person living with HIV told us. Getting a 3 month supply of ARVs is the new standard of care. This means people living with HIV have to go to the clinic less often, making it easier to collect ARVs and also reducing congestion at clinics.
While this is a welcome improvement in the province, we do expect this to be closer to 85%-90% by now. One person still getting a 2 month supply wished it could be extended because “at times there are delays when you go to the clinic and they can’t find your file. At times it’s difficult because transport money is a problem”.
In addition to longer refills, people should be able to collect their ARVs through easier and quicker pick-up points, either externally or at the facility. Positively 75% of people reported using pick-up points. “I collect my treatment from the pharmacy which is nice. I only come to the clinic for my prescription,” one person living with HIV explained.
Yet 24% still continue to collect through standard medicine dispensing, having to consult with a clinician at the facility to get rescripted on each visit. “Sometimes others are sent home or are given another day to come back to the clinic. It would be better if all of us who collect treatment get it at the Pelebox. It will be better for the clinic staff.. because sometimes there are 20 of us who are just there to collect treatment.. It can help with the overcrowding at the clinic,” one person living with HIV told us. 25% had never been offered the option to use a pick-up point or club — and 37% of all people living with HIV surveyed said that they would like to collect ARVs closer to their home if it were possible.
The province also scored highly on ensuring people taking ARVs understand the benefits of taking their pills every day. 92% of those surveyed understood that having an undetectable viral load means treatment is working well — and 84% understood that having an undetectable viral load means a person cannot transmit HIV. The health department should focus on facilities and districts with poorer results — identified in the report — to ensure that everyone understands these benefits.
One area that remains a challenge in the province is the low availability of lubricant at clinics. Despite being a basic HIV prevention tool, only 50% of clinics monitored had lubricant freely available. “Condoms are on display in different parts of the clinic, but no lubricants exist. Once I asked for lubes during a consultation, and the nurse said she did not know what that was” one gay man told us.
For those who did ask for lubricants, some people were not given as much as they needed and others were met with disrespect. A sex worker told us: “you will have to ask in the consultation room and they will only give you three packets”. A gay man explained how nurses have told him that he doesn’t “deserve” their help because they accuse him of sleeping with their husbands. “They will never give me condoms or lubes when I ask for these and they are always rude,” he explained.
Overall it is clear that KwaZulu-Natal is outperforming other provinces across several Ritshidze indicators — however there is still room for improvement in scaling up 3 month supply of ARVs, getting more people into pick-up points, and ensuring lubricants are made available. Critically there must also be a drastic improvement in the friendliness and availability of services for members of key populations. We simply cannot get everyone on HIV treatment while denying people who are queer or trans, people who use drugs, or sex workers entry to clinics or access to services, or by making conditions intolerable. “They don’t treat us right at the clinic… we should be treated with compassion. How we are treated makes people not want to return to the clinic” one person who uses drugs summed it up.
For more information or to arrange interviews contact:
Ngqabutho Mpofu | +27 72 225 9675 | ngqabutho.mpofu@tac.org.za
Lotti Rutter | +27 82 065 5842 | lotti@healthgap.org
Note to editors:
This is the fourth edition of the KwaZulu-Natal State of Health report; the first was published in November 2021, the second in November 2022, and the third in November 2023.
The full State of Health report for KwaZulu-Natal is available here
The full KwaZulu-Natal presentation is available here
A summary report is available here
A summary of recommendations is available here
About the report:
The report has been developed using data from Ritshidze — a community-led monitoring system developed by organisations representing people living with HIV, including the Treatment Action Campaign (TAC), the National Association of People Living with HIV (NAPWA), Positive Action Campaign, Positive Women’s Network (PWN), and the South African Network of Religious Leaders Living with and affected by HIV/AIDS (SANERELA+).
Ritshidze monitoring takes place on a quarterly basis at more than 450 clinics and community healthcare centres across 25 districts in 8 provinces in South Africa — including 129 facilities across KwaZulu-Natal: 65 in eThekwini, 11 in King Cetshwayo, 14 in Ugu, 14 in uMgungundlovu, 15 in uThukela, and 10 in Zululand. All monitoring tools are available here: https://ritshidze.org.za/category/tools/
Data in this report were collected between July 2024 and August 2024.
- 129 facilities were assessed
- Surveys were carried out with 128 Facility Managers
- Observations took place at 129 facilities
- Surveys were carried out with 7,184 public healthcare users
- 51% (3,665) identified as people living with HIV
- 10% (746) identified as young people under 25 years of age
Additional quantitative data related to members of key populations were collected between July and September 2023. Data collection took place across five districts: eThekwini, King Cetshwayo, Ugu, uThukela, and uMgungundlovu. A total of 2,992 surveys were carried out, combining 496 gay, bisexual, and other men who have sex with men (GBMSM), 1,485 people who use drugs, 712 sex workers, and 299 trans people.
Follow Ritshidze on twitter, facebook and instagram for regular updates or go to www.ritshidze.org.za for more information.
