Some good news in KZN — but serious threats could erode gains in the province

A community member is a bright pink tshirt reads the Ritshidze State of KwaZulu-Natal Health report at the community accountability meeting in November 2021. Photo by Rian Horn.

KwaZulu-Natal gets the thumbs up in the latest Ritshidze State of Health report for making strong progress towards the UNAIDS 95-95-95 targets and in ensuring that treatment literacy scores in the province are the highest in the country. 

According to the National Department of Health: 94% of people living with HIV (PLHIV) know their status; 85% of PLHIV who know their status are on treatment; and 89% of PLHIV on treatment are virally suppressed.

“At least there is some good news coming out of KZN, but there is also room for improvement,” said Sibongile Tshabalala, who chaired the launch of the report on Thursday. Tshabalala is the National Chairperson of Treatment Action Campaign (TAC), which is one of the Ritshidze partners undertaking community-led monitoring in 400 facilities throughout the country. The other partners are the National Association of People Living with HIV (NAPWA), Positive Action Campaign, Positive Women’s Network (PWN) and the South African Network of Religious Leader Living with and Affected by HIV/AIDS (SANERELA+).

In KZN, 3447 public healthcare users were interviewed along with 136 Facility Managers and observations took place at 135 facilities in August and September 2021. The data, together with collected community stories, form a body of evidence to compel authorities to act and do better. The Ritshidze report and analysis also gives targeted recommendations as a tool and guideline to help government and PEPFAR make appropriate interventions and to stick to timeframes.

Tshabalala added at the launch that Ritshidze’s community-led monitoring aims are to not just fulfil a watchdog function but also to work with government “to respect each other” in working to improve services in the public healthcare sector to ensure that fewer public healthcare users fall through the cracks. 

The report noted that there continues to be serious threats that could erode the gains in the province. These include poor staff attitudes and behaviour that have in some places turned clinics into near-battlegrounds between nurses and public healthcare users and threatens to lead to people living with HIV interrupting treatment or disengaging altogether.

Another major impact came from COVID-19 lockdowns. In the higher lockdown levels there were fewer people coming forward for HIV and TB screening, testing and treatment. In some cases HIV and TB was overlooked completely as resources and attention were redirected to cope with the crisis of pandemic.

But a community member, whose story was shared at the report launch, told how the COVID-19 emergency also showed a lack of sensitivity and professionalism by nursing staff. She said that she was admitted to hospital in August after her COVID-19 test returned a positive result. But having to be immediately isolated after diagnosis she didn’t have her ARVs and hypertension tablets with her.

She said nurses scolded her when she asked for medication, telling her she should have bought them from home. Her brother tried to bring them to her in hospital but he wasn’t allowed access to her and wasn’t allowed to drop off her medication. She went eight days without her pills and she said nurses just didn’t care.

“In the hospital they make you feel so small in the way they talk to you. They said to me ‘this is a COVID ward, don’t think that we have ARVs just waiting for you’,” she said of the disregard they had for her even as she was scared battling COVID-19 and also worried that she was defaulting on her treatment.

Patients wait outside Ntuzuma Clinic. Photo by Rian Horn, Ritshidze September 2021
Patients wait outside Ntuzuma Clinic. Photo by Rian Horn, Ritshidze September 2021
Patients wait in a make shift tent outside Nseleni CHC. Photo by Rian Horn, Ritshidze September 2021
Patients wait in a make shift tent outside Nseleni CHC. Photo by Rian Horn, Ritshidze September 2021

The report outlines several key issues and aspects of clinic care that are being monitored by Ritshidze. Among these issues, problems of staffing and long waiting times show up significantly as what adds to deepening dysfunction in the province’s clinics — as it does throughout the country. When it comes to unfilled vacancies, KZN fairs the worst in the country and also reports an average waiting time of around three and a half hours per appointment. The province reported the highest proportion of vacancies with a shortage of professional nurses at 60 facilities. The data also shows that 81% of Facility Managers interviewed said they are understaffed. Only 35.2% of patients interviewed said that they were satisfied that there are always enough staff members at their facilities.

Recommendations include filling 80% of vacancies by May 2022; putting in place transportation for community health workers (CHWs) so they are able to find and reach out to people living with HIV and TB who have disengaged from care; and also ensuring that all PEPFAR supported sites have at least one male nurse and one male counsellor employed to improve health seeking behaviour among men.

The province can also improve in giving more people living with HIV multi-month scripts. With 54% of individuals still receiving a two-monthly supply of ARVs, and only 15% getting a three-month supply. Ritshidze’s recommendations are for the province to supply all people living with HIV who are eligible with a three-month ARV supply by May 2022 and that this should be extended to a six-month refill by December 2022.

Removing these stable people living with HIV from clinic queues is a key way to lessen patient loads in the clinic and saves people’s time and money wasted in travelling and waiting to make collections.

Another major barrier to reaching and keeping more people on treatment comes from discrimination of key populations of people like sex workers, people who use drugs, men who have sex with men, and transgender people. Many key populations interviewed in the report said that they are humiliated and insulted by nurses and clinic staff and some say the ill-treatment has been off-putting enough for them to prefer to go without ARV treatment.

The report found that only 23 facilities offer lubricants to sex workers, only 10 offer outreach services for men who have sex with men, and only two facilities offer hormone therapy for trans people.

A transgender woman who spoke at the report launch told of the difficulties in trying to get circumcised — not so much because of the medical procedure she was seeking, but because of the demeaning manner in which she was treated. She said: “The nurses take it as a joke that I’m a woman with a penis”. She added that at her clinic she’s repeatedly referred to as “Mr”, she believes it’s a deliberate slight as she dresses as a woman. When she speaks to nurses about her sexual health they pry about her sex life and even challenge her choices.

“What these nurses must know is that there are trans people, there are intersex people, there are bisexual people – they need to be sensitised because we all need services,” she said. 

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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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