Ritshidze survey of nearly 14,000 people using drugs, sex workers, & LGBTQIA+ community members exposes crisis in public health system

Mamelodi, 29 February 2024 — “They must treat us as human beings… they should stop calling us names but treat us with respect. They are there to help us, not judge us”.

New Ritshidze data collected from interviews with 13,832 people reveal people who are queer or trans, use drugs, or engage in sex work, often face uncaring, disrespectful, cruel, and even abusive treatment at public health facilities. 

Very few people reported that facility staff were always friendly: only 35% of trans people, 33% of gay, bisexual, and other men who have sex with men (GBMSM), 26% of sex workers, and 17% of people who use drugs. Numerous people said they were treated worse (or feared they would be) when staff found out they were a member of a key population. 

Unfriendly services are among a number of issues outlined in the third edition of a new Ritshidze report. The report will be launched at a community meeting in Mamelodi today

Further findings include that disgraceful confidentiality violations remain common. 57% of GBMSM, 61% of trans people, 65% of sex workers, and 74% of people who use drugs did not think privacy was respected. One trans person told us: “There is no privacy at all… they shout in the waiting area in front of other patients asking if that is you in the ID. So now everyone knows you are trans”.

This results in only a handful of people feeling truly safe and comfortable when trying to access healthcare at the facility. Alarmingly, many people told us they had been refused health services at the facility within the last year because of being queer or trans, using drugs, or engaging in sex work: including 8% of GBMSM, 10% of trans people, 11% of sex workers, and 31% of people who use drugs. 

“I was sick and never got to set foot inside the facility because I use drugs”, one person told us. “I was chased away by the security guard, who told me the clinic is not a place for “addicts””.

Others had been denied ARVs, STI treatment, or contraceptives. Being denied services is humiliating, unjust, and a violation of people’s Constitutional right to health.

For those who are not deterred by these daily indignities, the services they need might still be unavailable. While GBMSM, people who use drugs, sex workers, and trans people are more at risk of getting HIV, prevention tools are not always accessible. 

While most sites had external condoms, lubricants were only available at 28% of sites monitored — and just 29% of GBMSM, 23% of trans people, 19% of sex workers, and 12% of people who use drugs had been offered PrEP at the facility. Many did not even know what PrEP was. 

Untreated sexually transmitted infections (STIs) are a significant enhanced risk for HIV transmission and contraction, yet STI services are not always available. People even report being refused STI treatment because they are queer, trans, use drugs, or do sex work. 

Harm reduction services are life saving but are almost entirely unavailable in public health facilities. Even getting information can be a challenge. Only 9% of people who use drugs told us they could get information on where to get new needles — despite the benefits to reduce HIV and hepatitis transmission, the risk of wounds and endocarditis, and syringe litter in public places. 

“I went there to ask for new needles… they asked me who taught me drugs? That I cannot come to the clinic to ask for needles so that I can inject drugs… I felt my heart ache”, one person explained to us.

Methadone is an important treatment to help people safely reduce or stop taking opioids, yet it is unavailable at the facility level. Only 10% of people who use drugs could even get information about where to get methadone. 

Public health facilities should respect trans and gender diverse people and ensure they feel comfortable, but only 32% of trans and gender diverse people told us that facility staff were always respectful of their gender identity. One trans person explained how they feel at the clinic: “they see us trans people as a clown. When a trans woman walks into the clinic, they would all be laughing”. 

39% of trans women had even gone through the indignity of being told to use a service point just catering to men, like a Men’s Corner. This is reckless and dangerous.

Trans and other gender diverse people may also want hormone therapy — a life saving treatment for those experiencing gender dysphoria, and in a country rife with transphobia. Yet hormone therapy is not available at primary level, and 25% of those who asked were confronted with a staff member that did not know anything.

“In our clinics we are frequently laughed at and judged. It forces some people to stop going to the clinic entirely,” said Philimon Twala, the national Key Population Sector representative from the Treatment Action Campaign (TAC). “It is critical that our public health facilities treat people who use drugs, sex workers, and the LGBTQIA community with dignity and respect, so that we can protect our own health and lives.” 

This year’s report finds that drop-in centres (often run by NGOs) were found to provide much friendlier and safer care than public health facilities. However, there are just too few drop-in centres across the country to help everyone. Instead, accessible, acceptable, and quality services within the public health system are urgently needed.

“As Ritshidze we have been calling for specialised services at public health facilities. The department and PEPFAR’s response was to turn a handful of sites into Centres of Excellence to provide services for key populations. In order for this to work, they have to be more accessible than drop-in centres and offer the clinical services, expertise, transport, and referral pathways that key populations really need,” said James Oladipo, from Ritshidze. 

“As it stands though, COEs are being launched without any additional staffing and resources being put in place nor does there seem to be any public awareness campaign about their existence or outreach to key populations who might wish to access them. There needs to be a culture change in those facilities, or else the ill treatment and hostility will persist.” 

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:

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. A docket of 195 testimonies will also be handed in to duty bearers pertaining to the challenges members of key populations face in the public healthcare system.

To follow proceedings virtually please join at: 

Vimeo | YouTube | facebook

The full report is available here

The full presentation is available here

The summary report is available here

The docket of testimonials 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 two data collection efforts and reports published in 2022 and 2023, Ritshidze undertook a third large-scale quantitative and qualitative data collection effort across 24 districts in 7 provinces of the country. The data collection took place between July and September 2023. 

This year 13,832 surveys were collected combining interviews with: 

  • 2,612 gay, bisexual, and other men who have sex with men (GBMSM)
  • 6,097 people who use drugs
  • 3,700 sex workers
  • 1,423 trans people

As the third edition of this report and data collection effort, we do compare current results to those from the two prior rounds. All raw data, tools/surveys used, and prior year reports are available on the Ritshidze website at www.ritshidze.org.za 

About Ritshidze

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

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.