Second edition Ritshidze report pinpoints reasons people with HIV stop treatment in Free State clinics

  • 2nd edition of State of Health report compares data over the last year of community-led monitoring in the Free State
  • The data, together with stories from people living with HIV, key populations and other public healthcare users, will be presented at a community meeting today
  • The meeting will be live streamed on vimeo, facebook and YouTube

Bloemfontein, 29 September 2022 — When Koketso* goes to the facility, she commonly waits the whole day without being attended to: “You will go in the morning and they’ll close while you’re still inside the clinic and tell you to come back the following day. You’ll sit there up until around 4pm… then they will tell you to come back the following day. It hurts me badly.”

While waiting times have improved over the last year in facilities monitored by Ritshidze — down from 5:30 hours to 4:31 hours after the clinic opens — this remains a very long time for people to wait for health services. Of 1,349 public healthcare users interviewed, 82% thought that waiting times were long, up from 57% reported in October/November 2021. People like Koketso continue to be frustrated by this, telling us that “these are the things that make us skip appointments. Thinking about going to spend the whole day there.”

Long waiting times are among eleven key issues outlined in the second edition of a new Ritshidze State of Health report. The report will be launched at a community meeting in Batho, Bloemfontein today. The report finds that while the province has marginally improved in certain indicators, it has worsened in many and too often Free State facilities are among the worst performing sites across all provinces monitored.

One area that needs improvement is the state of filing systems. Messy filing systems and lost files were observed in 50% of sites monitored, up from just 35% last year — and 60% of public healthcare users interviewed blamed lost files for the long waiting times. 

One community member told us that she stopped going to the clinic for over a year because her file went missing repeatedly: “It’s been a year and I have not been to the clinic because when we go, sometimes our files are missing. You will wait for a long time and the next thing they cannot find your file. Until it is late, then you are sent home. I decided I didn’t see a reason why I should go to the clinic.” When she returned a year later with a picture of her medicine bottle, she was sent to the back of the queue for having “defaulted”. 

The report calls for the Free State health department to take action to not just clean up filing rooms, but to organise systems to make this organisation sustainable so that people’s files can be easily and quickly located.

Extending the length of ARV refills is another key intervention called for in the report. While there has been limited improvement in the last year, facilities monitored in the Free State are performing worst across Ritshidze’s 400 sites across the country. Just 15% of people living with HIV interviewed reported getting a 3-6 month ARV refill. This compares to 59% in Mpumalanga — the province that is performing best — and 75% of people are getting 3-6 months supply in other PEPFAR supported countries. When we met with the Free State health department this week, they agreed with the need to extend supplies and committed to quickly develop a strategy to make this a reality.

Positively, facility and external pick-up points in the province were found to make ART collection quicker and people living with HIV are on the whole satisfied with them. The next step is for many more people to be given the option to use them, especially given that 68% of respondents said they would prefer to collect their ARVs closer to home. 

Ritshidze data revealed that only 41% of people thought that the staff were always friendly and professional (down from 44% last year) and 56% of people said staff sent them to the back of the queue if they missed an appointment. The fear of poor treatment only discourages people from ever going back to the clinic. Staff attitudes must be improved to ensure friendly and welcoming services for all people living with HIV and key populations, something that the Free State health department agreed with, alongside the need to implement the welcome back campaign strategy in all sites in the province.

For key populations, the experience can be even worse. Sam* — who identifies as gender non-conforming and is part of the LQBTQIA+ community — told us about their experience that has always been marked by judgment, probing questions and being made to feel unwelcome. 

“I started using the clinic in 2014 when I started taking ART. When you get there – from the security guard to the nurses right up to the clinic manager you find they are ignorant so they misgender you, call you names and ask you very personal questions. The nurses also like to bring their culture and their religion into the workplace, which is wrong,” they say.

Sam’s biggest concern is that the staff attitude will be so off-putting and offensive that key populations will simply stop seeking help at clinics and end up falling through the cracks, stopping treatment and even dying. The report calls for all staff, from security guards to clinicians, to provide respectful, safe, friendly, and confidential services.

Another key issue revealed in the data is on people living with HIV being denied ARVs because of not having a transfer letter. When Kelebogile* returned to Phuthaditjhaba Clinic having lost her job in Warden she was told that she could not be assisted until she brought a transfer letter: 

“I explained that I did not have money to travel to Warden and was told to sort myself out because that is not their problem. I begged them to help me because I had not been getting my treatment for 4 months… I sat and waited until 4pm until the clinic closed without receiving any help. I use ARVs. I don’t feel well. I’m losing weight. I just wish that they could help me.” Kelebogile only got her medicines following an intervention by Ritshidze and the Treatment Action Campaign after hearing her story.

Transfer letters are not required in the national adherence guidelines, yet 573 people in the Free State interviewed by Ritshidze had been denied access to services for not having one since we started collecting this data last October. This represents 16% of all public healthcare users interviewed, but given that most people interviewed are unlikely to have attempted to transfer services, it continues to point to a much larger problem regarding the communication and policies regarding transfer letters. 

“Through our community-led monitoring, we see and hear many challenges that make it hard for someone to access HIV and TB prevention and treatment. The Free State health department has been open to meeting with us to discuss the challenges in detail and make commitments on how to turn key challenges around. We will continue to monitor and engage to ensure that everyone can access the HIV, TB and other health services they need,” says Anele Yawa, from the Treatment Action Campaign (TAC).

* Identity withheld to protect the public healthcare user.

For more information or to arrange interviews contact:

Ngqabutho Mpofu | +27 72 225 9675 | 

Lotti Rutter | +27 82 065 5842 |

Note to editors:

This is the second edition of the Free State State of Health report; the first was published in September 2021. Like the earlier edition, the 2022 report identifies challenges that discourage people from going to the clinic for HIV, TB and other health services. The report focuses on the following critical themes: staffing; waiting times; infrastructure and clinic conditions; ART collection; ART continuity; treatment and viral load literacy; accessibility of health services for key populations; specific services for men; the implementation of index testing to find people living with HIV; and stockouts and shortages of medicines and other health products.

Today, Ritshidze is providing a platform for community members to raise their concerns directly to the Free State health department, district and national health departments, and PEPFAR partners working in the province, Right to Care and Wits RHI. To follow proceedings virtually please join at:

The full Free State State of Health report is available here

The full presentation is available here

A summary report is available here

A summary of recommendations is available here

The media alert is available here

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

About Ritshidze: 

With the establishment of 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+) — we have begun to more systematically document the failures in quality HIV, TB and other health service delivery at 29 facilities across the Free State: 1 in Fezile Dabi, 13 Lejweleputswa, 6 in Mangaung, and 9 in Thabo Mofutsanyana.

Ritshidze collects data through observations, as well as through interviews with healthcare users and healthcare providers. All monitoring tools are available here: 

Data in this report were collected between July 2022 and August 2022 (Q4 2022) (Table 1).

  • Interviews took place with 29 Facility Managers
  • Observations took place at 28 facilities 
  • Interviews took place with 1,349 public healthcare users
  • 54% (728) identified as people living with HIV
  • 71% (952) identified as women
  • 18% (246) identified as young people under 25 years of age

Additional quantitative data related to key populations was collected between August and October 2021. Data collection took place across two districts: Lejweleputswa and Thabo Mofutsanyana (Table 2). A total of 707 surveys were taken, combining 70 gay men, bisexual men, and other men who have sex with men (GBMSM), 321 people who use drugs, 262 sex workers, and 54 trans* people.

Follow Ritshidze on twitter, facebook and instagram for regular updates or go to 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.