Key populations face ill-treatment, compromised healthcare, and even outright abuse

Key populations (KPs) aren’t asking for special treatment, just to be treated with dignity and basic professionalism by clinic nurses and staff.

A Ritshidze report released at the end of January reveals that discrimination against KPs — including gay, bisexual, and other men who have sex with men (GBMSM), people who use drugs, sex workers, and trans* people — is rampant, widespread and disgraceful.

Around 6,000 KPs were interviewed during 2021 in a large-scale survey that formed the basis of the report. It involved community-led monitoring together with a team of 50 KP data collectors working in 18 different districts in the country, interviewing thousands of KPs about their experiences at public healthcare facilities.

Some of the key findings from the report are that 20% of KPs interviewed were not receiving any kind of health services anywhere. There was also a significant percentage of KPs who said they were flat-out turned away from facilities — most noticeably 38% of people who use drugs in Limpopo surveyed said they had been refused access to clinic services. 

The majority of KPs interviewed were also unaware of drop-in centres. Drop-in centres are aimed at KPs, making these facilities better geared to give sensitised and friendly healthcare. The report noted however, that even as drop-in centres and mobile clinic services are considered to offer more satisfactory services they too have limitations. This included a limited package of services and in some cases inconsistent or disrupted services when mobile clinics weren’t able to access perceived unsafe areas. Some KPs also expressed dissatisfaction of having to be separated from general population healthcare users (through drop-in centres) in order to receive a degree of dignified healthcare.

Many of those interviewed described that they had at some point suffered ill-treatment, compromised healthcare, or outright abuse. Personal accounts shared included stories of sex workers being laughed at or scolded at in front of other healthcare users for “taking too many free condoms”. Sex workers being refused help after being severely assaulted by their clients because clinic staff say they are “sleeping with our husbands then coming to us for help”, and denied PEP (post exposure prophylaxis). 

People who use drugs told of being dismissed at facilities and made to sit separately from other healthcare users while having to hear nurses make derogatory quips about having to keep their valuables safe because “all drug users are thieves”. 

Trans* people interviewed told of being asked prying, demeaning questions such as “are you a woman or a man or a what?” or nurses refusing to recognise and record their pronouns correctly. 

Queer men said they were questioned about why they needed lubricants or had to suffer the indignity of being made a spectacle of during consultations.

Another serious issue highlighted in the report was that patient confidentiality is not respected. In some cases it was deliberately violated. KPs surveyed told of having consultations take place with several nurses in the consulting room. Some KPs interviewed said non-medical staff are allowed to walk in and out of consulting rooms at will.  Sometimes cleaners chatted to nurses during consultations and security guards had access to patient files or questioned patients about their medical issues before being allowed entry, interviewees said.

KPs surveyed also spoke about incomplete packages of care at their facilities. Trans* people for example, have limited access to hormone therapy and gender affirming care at facilities close to where they live. Harm reduction services including methadone treatment or access to unused needles for people who use drugs were only available at 24% of drop–in centres. 

Community members and representatives from the Department of Health, PEPFAR, CDC, USAID, and the Global Fund were invited to the public launch on 27 January in Mamelodi. KPs present on the day relayed experiences that matched the issues reflected in the report. 

The overarching problem circled back to poor staff attitude as the primary hurdle in making services and facilities more KP-friendly in order for more KPs to feel safer and comfortable enough to access HIV, STI and other health services. 

Ultimately, the consequences of KPs being turned away from care, ridiculed, harassed or simply ignored at clinics means more people fall through the cracks and the goals of getting people on to ARVs, long-term retention, and preventing new HIV transmission keeps losing ground. 

UNAIDS sums up why KPs need to be at the centre of strategies to achieve targets towards being able to end the AIDS epidemic by 2030. “Key populations constitute small proportions of the general population, but they are at elevated risk of acquiring HIV infection, in part due to discrimination and social exclusion”. 

Ritshidze’s State of Healthcare for Key Populations report released in Mamelodi comes therefore as an urgent call for the Department of Health, PEPFAR, and the Global Fund to take seriously the needs of KPs. These duty bearers have to sensitise and hold staff accountable to create more welcoming facilities. As a first step, two public health facilities in every district should be identified as sites to provide KP friendly and specific services — and at the same time, drop-in centres and mobile clinics should be scaled-up to provide friendly, safe, well communicated, and quality services that KPs need. 

“The reality is that public health facilities remain the entry point for most KPs to get the healthcare they need … yet KPs are too often treated poorly by clinic staff who show a lack of compassion and professionalism.  If KPs are shouted at, humiliated, scared or even refused entry to the clinic, then why would they keep going back?” the Ritshidze report states plainly about the crisis in clinics.

“The barriers KPs face in getting healthcare services are dire and unacceptable. Urgent and drastic improvement to the healthcare system is critical to ensure that KPs can protect their own health and lives,” the report concludes.

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“Ritshidze” — meaning “Saving Our Lives” in TshiVenda — has been developed by people living with HIV and activists to hold the South African government and aid agencies accountable to improve overall HIV and TB service delivery.

Partner organisations include 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+)—in alliance with Health Global Access Project (Health GAP), the Foundation for AIDS Research (amfAR), and Georgetown University’s O’Neill Institute for National and Global Health Law.

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