Bonang Moleleki, who represents Bong Jwa Tlhago Trans, a North West-based non-governmental organisation that works on transgender issues, tells Spotlight in her experience the transgender community feels left out of the health system.
"We often encounter rudeness from nurses, especially when you come with the topic of Hormone Replacement Therapy (HRT) because nurses don't know or don't want to know about transitioning."
Moleleki says when they ask for other medication that is not HRT but related to family planning like Depo-Provera and Nuristerate (both forms of birth control), many are told that they are out of stock only to see another patient receiving it.
"We get asked questions like why do we have to do family planning when we are men? That means in their head because we said we are trans, then automatically we are men who want to look like ladies," says Moleleki. "Nurses make fun of our names or our identity documents because the person on the ID doesn't match the person standing in front of them. They will call other nurses to come and see as if there's something wrong with your ID."
Moleleki says the medication they require is often not available in public facilities. "We always have to travel far and wide to get medication and pay ridiculous amounts of money just to get one or two boxes of medication, which will last you for like a month or so, then you have to go back again. Imagine travelling from Mahikeng (in the North West) or Potchefstroom to Pretoria, Soweto or Joburg CBD every month just for one box of pills. It's very exhausting and strenuous to some of us," says Moleleki.
Such accounts of challenges key populations encounter at public health facilities are not new. But the latest data published by the community-led monitoring group Ritshidze in its second report on key populations provides systematic documentation indicating that such problems are widespread in the public healthcare system.
New data that Ritshidze released earlier this month shows, among others, that many transgender people who were interviewed said they don't access services at a public health facility because staff is not friendly and their privacy is not respected.
Some improvement
Still, Ritshidze's second report on the State of Healthcare for Key Populations reveals a slight improvement for people at high risk of HIV when they are trying to access public healthcare facilities to get help.
Last year, Ritshidze's benchmark report on key populations revealed that 20% of the people in key populations who were interviewed could not access health services anywhere. This year, the report shows an improvement where 12% (1 135) of those interviewed revealed that they were not receiving services anywhere.
The report shows that the proportion of gay and bisexual men who have sex with men who are not getting the services they need was highest in Gauteng and Mpumalanga.
For its second report on key populations, Ritshidze collected data across 21 districts in seven provinces (excluding Northern and Western Cape) from a total of 9 137 people, which included 2 349 gay, bisexual, and other men who have sex with men, 3 353 people who use drugs, 2 290 sex workers, and 1 145 transgender people.
The report shows that the proportion of gay and bisexual men who have sex with men who are not getting the services they need was highest in Gauteng and Mpumalanga. Those in Limpopo were seemingly better off with only 2% of this group indicating they were not getting services.
People who use drugs in KwaZulu-Natal were seemingly worse off compared to other provinces, with 24% of them saying they are not getting services anywhere.
The Free State had the highest number of sex workers who said they were not receiving services.
In the Eastern Cape, it was transgender people who had the highest number among the key populations, indicating that they are not getting services.
'Must do more'
Despite some improvement, the report again highlights that sex workers, people who use drugs and LGBTQIA+ community members are still discriminated against when trying to access public health facilities, which often leads to treatment interruptions and stopping their clinic visits.
According to Professor Linda-Gail Bekker, Director of the Desmond Tutu Health Foundation, key populations make up half of the new HIV infections in our region. "Key populations are a critical population to reach in terms of treatment and prevention. We have more than one key population and it is expensive for government to set up tailored services for these groups like, for example, clinics for men who are sleeping with men," she says. "Peer-to-Peer counselling is also important as we have seen how it has worked in South East Asia where a sex worker will offer another sex worker PrEP because they understand each other's needs."
Ritshidze data shows 12% of sex workers interviewed said that healthcare workers refused to offer them services. "This is absolutely unacceptable and goes against Section 27 of the Constitution that states 'everyone has the right to have access to health care services', the report states.
Bekker says public-private partnerships are important in getting resources to key populations, who are particularly affected by social and structural barriers and experience stigma, discrimination, and other rights violations in many settings.
"There is value in donor-funded programmes which have assisted with the HIV response because some NGOs have managed to tailor solutions according to the needs of each key population. It is important to rope in NGOs into the public health system to assist with resources," she says.
Systemic challenges
The report found that many people who belong to key populations didn't feel safe and protected from abuse, harassment, or risk of arrest at public facilities. "Only 14% of gay and bisexual men who have sex with men, 10% of people who use drugs, 19% of sex workers, and 14% of transgender people felt very safe using the facility," the report states.
"This," according to Professor Francois Venter, who heads up Ezintsha, a research centre at the University of the Witwatersrand, "stems from a number of reasons ranging from negative staff attitudes to the unavailability of services meeting the needs specific to a certain group."
Venter says working with key populations requires specialised training because the needs of each group are different. "Working with key populations requires nuanced training and most of the time, health workers only get two-hour training or are trained for one day. We need ongoing training to ensure that health workers are equipped to deal with individual needs of each group amongst the key populations."
Data collected by Ritshidze shows that over half of the people in key populations interviewed reported poor staff attitudes.
Venter stresses that healthcare workers are working under difficult conditions due to a health system that is collapsing. "Health workers are understaffed and faced with medicine shortages. Nurses are not intrinsically horrible people but the system forces them to be these people who are horrible to patients. The system turns them into people who are not friendly to key populations. There are a lot of white papers that are not going anywhere. Policies have to be attached to management strategies and there must be a budget allocation," says Venter.
Gaps in support - the numbers
According to Ritshidze's findings this year, 63% of the 1 145 transgender people who were interviewed wanted access to HRT at public health facilities. However, HRT is mostly only available in big cities.
Only 11% of people who use drugs who were interviewed were given information on where to get methadone and only 8% were given information about drug dependence support. The report also found that only between 15% and 28% of eligible members of key populations had ever been offered pre-exposure prophylaxis (PrEP), which can reduce your chance of getting HIV from sex despite it being widely available in facilities monitored by Ritshidze. Accessing basics such as lubricant also remains challenging. Of gay and bisexual men who have sex with men, only 45% indicated that they could access lubricant, and 40% of people who use drugs, 53% of sex workers, and 59% of transgender people using public healthcare facilities said they could access lubricant.
What government is doing to assist key populations
The South African National AIDS Council's (SANAC) Key Populations Technical Lead, Jabulile Sibeko says SANAC alongside the national health department has developed a Key Populations Competency and Sensitisation Toolkit and it is being rolled out at public health facilities, regional training centres, and to as many health workers as possible.
"However, with the current system, when data is being collected at clinics the register does not ask whether a person is a member of the key populations, for example, whether they are a sex worker or drug user so it's hard to track their data."
Sibeko says greater investment is needed for capacitating healthcare workers on working with key populations and providing for their needs.
"We do know, for example, that the department of health should be providing HRT, but at the moment the department of health is not providing HRT for everybody," says Sibeko. "Only donor-funded agencies are ensuring that it is provided. Harm reduction for drug users," he says, "is also not provided at public health facilities and needles are only provided at agencies funded by the Global Fund.
Government is also not providing Opioid Substitution Therapy (OST) at clinics, which reduces cravings for drug users that use heroin. We are only now discussing policy that will make provision for this therapy at clinics. As we know, most drug users don't have places to shower, as most of them are homeless. When they go to a health facility they are mistreated because people think they will steal from them or nurses tell them that they stink."
Sibeko says at present, only the Global Fund is providing needles for those that are using injectable drugs.
The country's National Strategic Plan (NSP) for HIV, TB and STIs (2023-2028) is expected to be launched in March this year. In the latest draft of the NSP that was published for public comment, many of these challenges are acknowledged with specific goals on how to address them.
The draft document also acknowledges that key populations have the "highest prevalence and incidence of HIV in the country due to multiple reasons, including inadequate efforts to reach these populations, stigma and discrimination and punitive laws". For example, the "Thembisa model 4.5 reports 57.9% HIV prevalence in female sex workers, followed by transgender people with 51.9%, and MSM with 29.9% prevalence". "People who inject drugs (PWID) and people in prisons report 21.8% and 17.5% HIV prevalence, respectively."
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So, according to the draft document, "HIV epidemic control hinges on how well we include key populations in the national response. Modelling shows key populations and their sexual partners will contribute over 40% of new infections in the next five years."
Among the strategic interventions planned range from legislative amendments such as "advocating for decriminalising drug possession for personal use" to "including a gender-affirmation package of services in all levels of care for transgender persons, mental health services and targeted sexual health screening based on the biological body". Other plans to improve access to services for men who have sex with men, for example, are to facilitate access to internal and external condoms with compatible lubricants and to offer voluntary medical male circumcision for men in this group who have female partners.
Meanwhile, at the launch of the new Ritshidze report in Pretoria, Deputy Minister of Health Dr Sibongiseni Dhlomo said the department will work on having dedicated health workers at clinics to assist key populations.
Public health facilities already bear the brunt of huge staff shortages with government saying there is little money to appoint new staff. Spotlight asked the department's spokesperson, Foster Mohale, for clarification on this and progress on other undertakings it made last year following Ritshidze's first report on key populations but did not receive a response by the time of publication.
Dhlomo, at the launch, admitted that the department has failed in training some of their staff, but promised that government will work with Ritshidze data to improve the delivery of healthcare services to key populations.
Spotlight previously reported that the health department was revising its Key Populations programme, which will be accompanied by a Key Populations Health Implementation Plan as well as plans to establish Key Populations Centres of Excellence.
NOTE: Professor Francois Venter is quoted in this article. Venter is a member of Spotlight's Editorial Advisory Panel. The panel provides the Spotlight editors with advice and feedback on the quality and relevance of Spotlight's public interest health journalism. The Spotlight editors, however, remain editorially independent and solely responsible for all editorial decisions. Read more on the role and purpose of the panel here.
