Ritshidze survey of more than nine thousand people reveals ongoing crisis in health system for key populations

  • 2nd edition of State of Healthcare for Key Populations report reveals little change in the crisis that sees key populations continue to be ridiculed, abused, and even chased away from clinics. 
  • The data, together with stories from people who use drugs, sex workers, and LGBTQIA+ community members, will be presented at a community meeting today.
  • The meeting will be live streamed on vimeo, facebook and YouTube.

Mamelodi, 6 February 2023 — “They treat us badly, they judge us… Some of the people that I work with have stopped going for their HIV medication because of the type of attitude that they get when you get there. They should treat us like human beings, the same way they treat other people.

New Ritshidze data collected from over nine thousand people reveal ongoing abuse towards key populations — including people who use drugs, sex workers, and LGBTQIA+ communities in South Africa. 

Both clinical and non-clinical staff like security guards continue to be unfriendly and discriminatory, be it at the clinic gate, in waiting areas, or even during medical consultations. Just 37% of respondents reported that facility staff are always friendly towards gay, bisexual, and other men who have sex with men (GBMSM), just 24% towards people who use drugs, just 46% towards sex workers, and just 41% towards trans* people. 

Where the attitudes of clinic staff have become unbearable, some people have stopped going to the facility altogether. One sex worker explained: “Whenever I go to the facility it is only that sister that gives me a bad attitude. She will always embarrass me and treat me like an animal. Which is why I stopped going to that clinic and taking my medication.

Unfriendly and discriminatory services are among a number of key issues outlined in the second edition of a new Ritshidze report. The report will be launched at a community meeting in Mamelodi today. The report reveals the ongoing crisis of key populations being ridiculed, abused, and even chased away from clinics.

Disgraceful privacy violations continue to occur that destroy people’s right to privacy and make clinics feel unsafe and uncomfortable to be in. This year 42% of GBMSM, 45% of people who use drugs, 38% of sex workers, and 35% of trans* people did not think privacy is well respected at clinics. 

“Clinic staff are known to disclose people’s HIV status, or the fact that they are queer, trans*, a sex worker, or someone who uses drugs, in front of other healthcare users, or to invite other clinicians into private consultations in order to laugh at or judge people’s symptoms,” said Londiwe Khuzwayo, a Ritshidze Key Population Organiser. 

One sex worker told us: “After I disclosed to a nurse that I am a sex worker, she called in her colleague to tell her and they were both mocking me” — and one trans* woman explained how a fear to open up can mean that you can not access the services needed: “I am not comfortable in that facility at all, and when you are not comfortable with the staff, you are not able to open up and tell them exactly what is wrong with you because you are afraid of being judged.

Only 14% of GBMSM, 10% of people who use drugs, 19% of sex workers, and 14% of trans* people actually felt “very safe” using the facility. 

Shockingly, significant numbers of key populations reported being refused access to services in the last year because of being someone who uses drugs, is a sex worker, or is a part of the LGBTQIA+ community — including 5% of GBMSM, 19% of people who use drugs, 12% of sex workers, and 9% of trans* people. This is absolutely unacceptable and goes against Section 27 of the Constitution. 

One person who uses drugs pointed out: “anytime I go there, the security would chase me away, saying that I need to go take a bath because I stink. They are rude towards us drug users.”

The nurses and security guards discriminate against us, they see us as thieves because we use drugs and make accusations… Sometimes they chase you out of the facility and you end up not getting the services we need,” another person who uses drugs disclosed.

One sex worker told us: “Once the nurses realise that you are sex worker, they treat you very badly, they are very judgmental towards us and sometimes deny us services.

Where key populations do continue to suffer the daily indignities of using the public health system, specific services remain unavailable for the most part. 

Lubricants, for example, are only freely available in 27% of facilities monitored. “We don’t get lubricants there. They have condoms but the staff will always complain about us taking too much”, “they deny us the amount of condoms we need. There’s hardly any lubricant, they always say they’ve run out of stock”, “If you ask for condoms, they will laugh at you, ask many questions like what are you going to do with it, how much are you going to use” explained some of the sex workers we interviewed.

In addition only between 15% and 28% of eligible key populations had ever been offered PrEP, despite it being widely available in facilities monitored by Ritshidze. “No, they don’t tell us about PrEP, this is the first time I am hearing about it. And from how you have explained it, this is what a sex worker should be on because of the risk of our job.

Widespread access to harm reduction services (like methadone and unused needles) or gender affirming care (including hormones) remain outside the reach of most of the people they are meant to serve. “When you go to the clinics, they treat you like a thief. I need to be able to get new needles and methadone from the clinic but they don’t take you seriously,” one man illustrated about the familiar story of lack of harm reduction services. “They do not offer hormones or even refer us to where we can go get it,” explained one trans* person about the reality people face in trying to access gender affirming services.

While drop-in centres can be friendlier and have better access to services, many key populations have never even heard of them (79% of GBMSM, 75% of people who use drugs, 74% of sex workers, and 71% of trans* people were not aware of a drop-in centre) — and certainly cannot afford the taxi fare or overnight accommodation needed to get to them. 

“The truth is that most key populations are trying to access healthcare at a public health facility — yet clinic visits can be oppressive. Being mocked, treated with open hostility, or even denied services leaves deep scars,” said Philimon Twala, the Key Population Sector representative from the Treatment Action Campaign (TAC), speaking from personal experience.

67% of GBMSM, 81% of people who use drugs, 57% of sex workers, and 59% of trans* people interviewed were using a public health facility not a drop-in centre or mobile clinic. Further, the majority (>92%) of the people interviewed this year had not engaged in the Ritshidze survey in 2021 — showing that more public health facilities must be specialised to meet the needs of key populations in South Africa.

“While we commend commitments to ensure one key population designated clinic per district, we know districts are often vast. This year, among other recommendations, we again call for at least two key population specialised clinics per district, per key population group, at a minimum — and that planned patient transport or resources for transport be made available so that people can actually get to those sites,” said James Oladipo from Ritshidze. 

Only with urgent and drastic improvement to the public healthcare system will people who use drugs, sex workers, and people from the LGBTQIA+ community be treated with dignity and respect and will be able to protect their own health and lives. Our public healthcare system needs to do much better, much faster.

For more information and interviews contact:

Ngqabutho Mpofu | +27 72 225 9675 | ngqabutho.mpofu@tac.org.za 

Lotti Rutter | +27 82 065 5842 | lotti@healthgap.org 

About the community meeting

Today, Ritshidze is providing a platform for community members to raise their concerns directly to the National health department, PEPFAR and agencies (USAID and CDC), and the Global Fund. To follow proceedings virtually please join at: https://vimeo.com/event/2850765/ae988c64e5 

The full report is available here

The full presentation is available here

A summary report is available here

The media alert is available here

A recording will be available after the event on the Ritshidze website, Facebook, and YouTube channels.

About the report

Building on our first data collection and first edition of our State of Healthcare for Key Populations report published in 2022, Ritshidze undertook a second large-scale quantitative and qualitative data collection effort across the country. 

Key populations who took part were identified through snowball sampling where initial participants were asked to refer those they know, who in turn refer those they know, to participate in the survey. Compared to a facility-based sample, this methodology allowed us to find more “hidden” key populations who may not use the facility as well as those more regularly accessing services. All tools/surveys used are available on the Ritshidze website: https://ritshidze.org.za/category/tools/ 

A team of more than 146 key population data collectors across the 21 districts were recruited to support the data collection effort, including mobilisation, implementation of tools, analysis, and reporting. 

A total of 9,137 surveys were taken, combining 2,349 gay, bisexual, and other men who have sex with men (GBMSM), 3,353 people who use drugs, 2,290 sex workers, and 1,145 trans* people. The quantitative data collection took place between July and September 2022 across 21 districts in 7 provinces. Qualitative data collection took place from May 2022 to December 2022.

About Ritshidze

Ritshidze is a programme of the PLHIV Sector made up of the National Association of People Living with HIV (NAPWA), Positive Action Campaign, Positive Women’s Network, the South African Network of Religious Leaders Living with HIV (SANERELA+), and the Treatment Action Campaign (TAC).

Follow Ritshidze on twitter, facebook and instagram for regular updates or go to www.ritshidze.org.za for more information.


“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.

CLICK HERE to read more and see where we work.