Last week Ritshidze launched a detailed report into the state of the public healthcare system in the Eastern Cape. The report was based on the results of data collected through Ritshidze’s community-led monitoring. It was presented to the at a community accountability meeting in Mdantsane, outside East London. You can read the summary presentation here and watch the full recording below.
Improving the quality of services provided in public clinics is vital to ensuring enough people are accessing HIV and TB prevention services, are getting tested, and are starting and staying on treatment. It is key to achieving the UNAIDS new scaled up 95-95-95 targets that now aim for 95% of people living with HIV knowing their HIV status; 95% of people who know their status on treatment; and 95% of people on treatment to have suppressed viral loads.
Yet in the Eastern Cape, while 91% of people living with HIV know their status, only 72% of those people are on HIV treatment, out of which 88% are virally suppressed. This translates to just 66% of all people living with HIV receiving ARVs in the province and only 58% of all people living with HIV being virally suppressed. The failure to make sufficient progress towards the 95-95-95 targets, most especially keeping enough people on treatment, can be directly linked back to the crisis in our clinics in the Eastern Cape.
Ritshidze data collected in Eastern Cape reveal significant staff shortages that are undermining the quality of services provided at clinics. Ensuring access to quality healthcare services and ensuring everyone living with HIV and TB gets access to medicines and care depends mainly on having enough qualified and committed staff. 89% of Facility Managers said they do not have enough clinical and non-clinical staff at the facility to meet the needs of patients, and patients agreed: just 29% of patients interviewed report that there are always enough staff at the facility. These shortages are worsened as too many vacancies remain unfilled — with 133 vacancies reported across 28 facilities monitored.
The proportion of men who know their HIV status and are accessing ART is much lower compared to women in South Africa. While men only account for a third of new infections, they account for more than half of the HIV related deaths, pointing to a major challenge in men’s uptake of HIV treatment services. Men’s corners and male healthcare workers are interventions that encourage men to uptake services at the facility.
The challenge of long waiting times is further compounded by poor filing systems. 32% of Ritshidze respondents think that the queues are long because “it takes too long to find files, the filing system is messy or files get lost”. Ritshidze observations reported filing systems to be in a bad condition in 58% of sites monitored. Messy and disorganised filing systems increase the delays to healthcare users being attended to, and increase the burden on already overstretched healthcare workers.
Unnecessary trips to the clinic just to collect an ARV refill adds both a burden on PLHIV and to the already overwhelmed clinic and healthcare worker staff. This inefficiency can also contribute to PLHIV disengaging from care directly impacting the province’s attainment of 95% of PLHIV on treatment. Extending treatment refills, also known as providing “multi-month dispensing” or MMD, is one strategy to reduce unnecessary burdens and support both PLHIV and the health system to be more efficient. Ritshidze data reveals that 61% of PLHIV reported receiving 2 month ART refills. However just 15% of PLHIV reported 3 month ART refills, which is low, and 21% of PLHIV still reported refills of 1 month — which is very problematic considering that South Africa’s national policy standard is for two months.
People living with HIV lead complicated lives and may miss appointments and even miss taking some pills. When they do, meeting them with support when they return to the clinic helps ensure long term adherence. But those who return to the clinic and are treated badly, or who fear they will be, will often not come back.
Treatment literacy improves linkage and retention rates as people understand the importance of starting and remaining on treatment effectively. By becoming as informed as possible, people living with HIV are empowered to take control of their own health and sex lives. However, Ritshidze monitoring revealed major gaps in knowledge about what an undetectable viral load test means. Only 70.6% agreed with the statement; “having an undetectable viral load means the treatment is working well”. Further just 67.2% agreed with the statement “having an undetectable viral load means a person is not infectious.” Only 80.8% of them said that a healthcare provider had explained the results of the viral load test results.
While index testing has the ability to help identify individuals who may have been exposed to HIV earlier, if implemented in ways that cause harm to individuals, undermine their rights to consent, privacy, safety and confidentiality, it erodes communities’ trust of healthcare providers.
One significant barrier to access HIV services for key populations like sex workers, transgender people, people who use drugs or men who have sex with men, is being discriminated against at the facility. For key populations to receive quality services, they need spaces that are safe enough to disclose that they are key populations without fear of poor attitude, discrimination and/or arrest. Yet staff are not sensitised at primary healthcare facilities — the entry point for most key populations to access HIV, TB, and other health services — to provide key population friendly services. At times key populations can be shouted at or even chased away from the clinic without getting the services needed.
This is just a snap shot of the issues discussed in the community accountability meeting. It was a space for public health users to talk directly to those in power. Community members reported their challenges and sought rapid interventions by the Eastern Cape Department of Health and PEPFAR implementing partners in the province. Follow Ritshidze on twitter, facebook and instagram for regular updates or go to www.ritshidze.org.za for more.