TREATMENT ACTION CAMPAIGN - Special edition, Congress August 2017 - Spotlight

Special edition, Congress August 2017
                                             on the state of health in South Africa
                                             incorporating the NSP Review
                                             Edition #3 – August 2017
In this issue                                                                                                                                                                                                    

                                              THE STATE OF               MENTAL HEALTH AND                    SPOTLIGHT ON                                                                                                                                               @SpotlightNSP
                                               TAC IN 2017                  PILL-TAKING                       HEALTH MECS
                                                                                                                                     TRIBUTE                                                                                                                           Spotlight NSP
                                                                                                                                     MARK HEYWOOD
                                                                                                                                     Pledge for Prudence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  3
                                                                                                                                                                                                                                                                   Published jointly by the Treatment
                                                                                                                                     TREATMENT ACTION CAMPAIGN                                                                                                     Action Campaign and SECTION27
                                                                                                                                     The state of TAC in 2017. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  5          Editors: Marcus Low & Anso Thom
                                                                                                                                                                                                                                                                   Journalists: Ufrieda Ho, Ntsiki Mpulo
                                                                                                                                     LIVING WITH HIV
                                                                                                                                     PROFESSOR FRANCOIS VENTER                                                                                                     Contributors: Mark Heywood, Professor
                                                                                                                                                                                                                                                                   Francois Venter, Dr Michelle Moorhouse.
                                                                                                                                     Mental health and pill-taking: Getting beyond HIV. . . . . . . . . . . . . . . . . . . . . . . 9
                                                                                                                                                                                                                                                                   Ufrieda Ho, Marcus Low
                                                                                                                                     TREATMENT OPTIMISATION                                                                                                        Design: the earth is round
                                                                                                                                     DR MICHELLE MOORHOUSE
                                                                                                                                                                                                                                                                   Spotlight is produced with the
                                                                                                                                     Modernising ART. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12       support of the South African
                                        After funding shortfalls and   Professor Francois Venter on     Ufrieda Ho profiles the
  the state of health in South Africa

                                                                                                                                                                                                                                                                   Development Fund.
                                        a difficult restructuring in   dealing with the psychological   Gauteng and Limpopo          TREATMENT ACTION CAMPAIGN
  incorporating the NSP Review

                                        2014/2015, TAC heads to        impacts of living with HIV.      provincial Health MECs       Spotlight on TAC provinces. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
                                        its National Congress in a     Page 9                           in this Spotlight series
  Edition #3 – August 2017

                                                                                                                                                                                                                                                                   EDITORIAL INDEPENDENCE
                                                                                                                                     SPOTLIGHT ON HEALTH MECs
                                        much healthier state.                                           Page 20                      UFRIEDA HO                                                                                                                    The opinions expressed in Spotlight do
                                        Page 5                                                                                       Take two for Granny Gwen. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20                not always reflect the views of TAC or
                                                                                                                                     Building health infrastructure – and Brand Phophi. . . . . . . . . . . . . . . . . . . . . .  22                              SECTION27.

                                                                                                                                     NATIONAL STRATEGIC PLAN
                                                                                                                                     NSP in brief. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  24

                                             STATE OF SANAC                   STATE OF TB                     IN MEMORIAM            SOUTH AFRICAN NATIONAL AIDS COUNCIL
                                                                                                                                     State of SANAC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  27

                                                                                                                                     TUBERCULOSIS                                                                                                                  The Treatment Action Campaign
                                                                                                                                     State of TB . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  29   (TAC) advocates for increased access

                                                                                                                                                                                                                                                                   to treatment, care and support
                                                                                                                                                                                                                                                                   services for people living with HIV,
                                                                                                                                                                                                                                                                   and campaigns to reduce new HIV
                                                                                                                                     MARCUS LOW                                                                                                                    infections. Learn more about the
                                                                                                                                     TAC survey highlights poor infection control in clinics. . . . . . . . . . . . . . . . . . . 30                               TAC’s work at

                                                                                                                                     IN MEMORIAM                                                                                                                        @TAC

                                                                                                                                     Farewell to two powerful activists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  32

                                                                                                                                     Online highlights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  33

                                        We take a look at the trials   Ten things you need to           We pay tribute to the late
                                                                                                                                                                                                                                                                   SECTION27 is a public interest law
                                        and tribulations currently     know about the state of          Kholiswa Sondzaba, and                                                                                                                                     centre that seeks to influence,
                                        faced by the South African     tuberculosis in South Africa.    Thandiwe (TK) Sebeni.                                                                                                                                      develop and use the law to protect,
                                                                                                                                                                                                                                                                   promote and advance human rights,
                                        National Aids Council.         Page 29                          Page 32                                                                                                                                                    particularly the right to health.
                                        Page 27                                                                                                                                                                                                                    Learn more about SECTION27’s
                                                                                                                                                                                                                                                                   work at


                     Pledge for
                     Mark Heywood

                     One of the early TAC leaders and founders Prudence Mabele died
                     in July. Her death came as a shock, but even in death Prudence
                     has catalyzed discussions on resistance, treatment fatigue and
                     other challenges. Spotlight pays tribute to this giant of the
                     struggle via a heartfelt and powerful obituary delivered by
                     Mark Heywood at her memorial in Johannesburg last month.

                     My dear friend and comrade Prudence
                     Thank you for honouring me as a ‘friend’     granted. Sometimes we activists are so        against corruption. Against those who are
                     to speak at your funeral. You have many      ‘busy’ that we pass each other like ships     parasitical on the response to AIDS. There
                     beautiful friends and comrades, so I am      in the night. But ‘busy’ with what, if we     are two streams in civil society: yours is
                     not sure why I am the one to speak.          don’t leave time for our friendships?         the stream that flows cleanly and clearly.
                     That is why, first, I must pay tribute to       I feel I did take you for granted –           Two years ago, you wrote to me to
                     your better friends and comrades, and        you had been a part of my life since          complain about people who stabbed
                     thank them for the support and love they     the middle of the 1990s. We in-ed and         you in the back. I am sorry that you died
                     have shown you during and after life.        out-ed conferences together, marched          still feeling betrayed. You said, “While I
                        Prudence, you were an activist – a        together, mourned together, mobilised         was at home sick with PCP and vertigo
                     warrior woman – a woman in a line of         together. I remember you in the earliest      … I was removed like Thabo Mbeki – at
                     activists; many of whom have passed,         days of the Positive Women’s Network,         SCF (SA AIDS Council) a motion was
                     some of whom are still larger than           of the AIDS Consortium, of TAC.               passed and my removal happened;
                     life. I think of Charlene Wilson, Sarah         This week I found a picture of you         mostly friends nominated each other,
                     Hlahlele, Yvette Raphael, Vuyiseka           with Vavi, Zackie Achmat and me,              and without a quorum.” You told me
                     Dubula, Sipho Mthathi, Vovo Gonyela,         celebrating the victory of TAC over           that “there’s a lot you do not know that
                     Anso Thom, Bev Ditsie, Phindi Malaza,        the Pharmaceutical Manufacturers’             makes me disagree with my chair, and
                     Phumi Mtetwa, and Sharon Ekambaram,          Association in 2001. If we could              because of that I am now victimised”.
                     to name a few in a long line.                excavate my memory, I’m sure we               The people who undermined you now
                        Indeed, the best leaders that I           would find pictures of you when we            preach unity. But unity means we must
                     know in the response to oppression           won over PMTCT; when we protested             be silent about their transgressions.
                     and violence – of which HIV is just          at the International AIDS Conference in          We will build unity. Yes we will! But
                     a part -- are the women who have             Toronto; when we re-established the SA        it will not be a fake unity. It will be
                     risen to fight in solidarity with other      National AIDS Council. Recently, I saw        unity with the poor, the marginalised,
                     women; honest women, incorruptible,          a picture of you marching to demand           the violated and discriminated against.
                     self-sacrificing, principled.                the resignation of Jacob Zuma.                Unity with sex workers. Unity with the
 #16 – August 2017

                                                                                                                                                              #16 – August 2017
                        Prudence, at your funeral I have to          A book should be written about your        vulnerable. What we won’t do is build
                     decide whether to speak like you – always    life. We need to tell your story – not just   unity with thieves and murderers.
                     principled, brave, bold, sometimes rude      for those who know it, but for those who         Remember, one of the oldest slogans
                     – or like me: more shy, careful, cautious,   don’t; because it is a story of courage       of the AIDS movement was ‘Silence =
                     scared about speaking truths to power.       and hope. It is the story of a heroine.       Death’. Today, once again, there is far
                     You seemed never to be scared.                  One truth about you, Prudence, is          too much silence. Once again there is
                        I will try to be something in between.    that you were not a hypocrite. At the         too much death. We have to stop the

                        Your death on Monday 10 July left         time of your death, I hear people lament      silence. We have to stop the death.
                     me numb. It left me feeling neglectful;      that civil society is divided. People tell       Prudence, I want to finish my
                     wanting. I had suddenly lost someone I       us we must ‘overcome our divisions’,          tribute by making a pledge to you.
                     loved (I realise now that I did love you),   but you never had any truck with that.        I ask those reading this to repeat
                     but whose life and presence I took for       We were always divided. We are divided        my words to themselves.

  2                                                                                                                                                            3

                                                                                                                 The state of
                                                                                                                 TAC in 2017
                     For you, Prudence, we will:
                                                                                                                 In August 2017, the Treatment Action Campaign (TAC) will have
                     ++Ensure that all young women have access to PrEP and other ways of protecting
                                                                                                                 its five-yearly National Congress in Johannesburg. At the
                       themselves, in the same way that we fought for Nevirapine for pregnant women with HIV.
                                                                                                                 Congress, delegates from TAC branches across seven of South
                     ++Campaign for the resources and political will to stop violence and
                       murder against women and the LGBTQI+ community.                                           Africa’s nine provinces will agree on TAC’s priorities for the next
                     ++Ensure the decriminalisation of women, men and                                            five years, and elect the organisation’s national leadership.
                       transgender folk who engage in sex work.
                                                                                                                 After funding shortfalls and a difficult       and on the radio, TAC has been well-      treatment available to people living
                                                                                                                 restructuring in 2014/2015, TAC heads          represented by its current leadership.    with HIV, but government did not
                     For you, Prudence, we will:                                                                 to its National Congress in a much             In particular, Yawa has refused to be     want to. In 2002 TAC took the matter
                                                                                                                 healthier state. Under the leadership          intimidated on international platforms,   to the Constitutional Court, and won.
                     ++Never steal                                                                               of TAC General Secretary Anele Yawa,           and has consistently and forcefully       Yet even after that victory in the
                                                                                                                 donors have been reassured and the             represented the poorest of the poor in    Constitutional Court, government
                     ++Never manipulate
                                                                                                                 organisation has been stabilised; and          meetings and at conferences. Under his    still did not want to make treatment
                     ++Never deceive or lie                                                                      focus is again where it should be –            leadership, TAC has been given moral      available. It was only after the fall
                                                                                                                 on the urgent work of fixing South             authority and a sharp political edge      of former President Thabo Mbeki
                     ++Never take advantage of AIDS, TB or any other cause of ill health, for our own benefit.   Africa’s public healthcare system.             – something it will need to maintain,     in 2008 that things changed, and
                                                                                                                    In this regard, TAC has had a major         if it is to remain relevant in South      government committed to rolling out
                                                                                                                 success in the Free State, where a long        Africa’s current political context.       ARVs. Under the leadership of Minister
                     For you, Prudence, we will:                                                                 campaign resulted in the removal                   Yawa – with the support of others     of Health Dr Aaron Motsoaledi, there
                                                                                                                 of former MEC for Health Benny                 such as Deputy General Secretary          followed a massive scale-up of ARVs –
                     ++Recognise the intersectionality of AIDS with ensuring quality                             Malakoane, and a court victory for             Sibongile Tshabalala, Chairperson         something which has been so effective
                       education, employment, and stopping corruption. Fighting AIDS                             the #BopheloHouse94 (a group of                Nkhensani Mavasa and Deputy               that life expectancy in South Africa
                                                                                                                 wrongfully convicted community                 Chairperson Patrick Mdletshe – has        has gone up from 54 to over 62.
                       means fighting for human rights and social justice.
                                                                                                                 healthcare workers), which clarified           had to lead TAC not only through             Government now has mostly good
                     ++Call on our country’s’ leaders to wake up again to HIV                                    the law regarding the right to protest         severe financial difficulties, but also   health policies, and says that all people
                       and TB. It’s not over. It’s not half over.                                                in South Africa. In the Free State, TAC        through major changes in the context      with HIV should have access to ARVs.
                                                                                                                 has shown that it is possible to hold          within which we find ourselves. These     Yet while the policies are good, many
                     ++Call on Deputy President Ramaphosa and the honest members of                              underperforming MECs accountable.              leaders have recognised that the TAC      are not implemented. Policy says we
                       the ANC to remove President Zuma from power, because we cannot                               TAC has also been hard at work in the       needed today is not the same as the       should have ARVs and other medicines,
                                                                                                                 Eastern Cape, Gauteng, KwaZulu-Natal,          TAC that was needed ten years ago.        but often we have medicine stockouts.
                       have a good response to AIDS in a corrupt government.
                                                                                                                 Limpopo, Mpumalanga and the Western                Together they have guided the         Policy says clinics should have good
                                                                                                                 Cape – often advocating for better             organisation through change               TB infection control, but many clinics
 #16 – August 2017

                                                                                                                                                                                                                                                       #16 – August 2017
                                                                                                                 healthcare services at facility level. While   in at least three key areas:              do not have good infection-control
                     Prudence, we will remember you for as long                                                  much of this community-level work                                                        measures in place. Good policies are
                                                                                                                 never makes the headlines, it remains                                                    drawn up at national level, but in

                     as we live. Your life was not in vain.                                                      one of the key things that differentiates
                                                                                                                 TAC from other organisations working on
                                                                                                                                                                1. From a policy
                                                                                                                                                                   struggle to an
                                                                                                                                                                                                          many clinics and hospitals across the
                                                                                                                                                                                                          country those policies are nowhere
                                                                                                                 healthcare. Particularly impressive was           implementation                         to be seen. Due to mismanagement
                                                                                                                 a TB infection-control survey conducted                                                  and corruption, our healthcare system

                                                                                                                 by TAC members earlier this year (see                                                    is in a state of crisis – a crisis for
                                                                                                                 page 30 for more on that survey).              For much of TAC’s history, they           which poor people pay the highest
                                                                                                                    In meetings with the Minister of            campaigned for government to              price. TAC’s struggle has thus shifted
                                                                                                                 Health and UNAIDS, in speeches at              change its HIV policy. They wanted        from fixing the policies, to fixing the
                                                                                                                 International Conferences, on television       government to make antiretroviral         implementation of the policies.

  4                                                                                                                                                                                                                                                     5
2. From an HIV struggle                      recent initiatives is that all TAC branches     must decide to what extent it wishes to
                        to a healthcare                           were mandated to adopt a clinic. In this        remain an HIV organisation, or whether
                        system struggle                           way, TAC will increase accountability           it will become an organisation for all
                                                                  on the front lines, where people                poor people who are dependent on
                     For most of TAC’s history, the focus has     interact with the healthcare system.            the public healthcare system. To some
                     been on HIV and related opportunistic           More broadly speaking, however, there        extent, this shift has already taken
                     infections. TAC’s biggest struggle so        has been a shift in focus in the last five      place in TAC’s work; but hopefully the
                     far, after all, was the struggle for ARVs.   years from national to provincial, as           Congress will make the shift explicit,
                     The T-shirts that made TAC famous            TAC’s struggle has moved from a policy          and make it clear that TAC is open
                     say ‘HIV positive’ on the front. Most        struggle to an implementation struggle.         to all – irrespective of HIV status.
                     importantly, TAC is a membership-            In South Africa, the National Department           The second issue, and one that is
                     based organisation, and most of our          of Health decides on policies, but              probably even more important, is
                     members are living with HIV – so HIV will    the provinces are responsible for               what decisions the Congress will make
                     always be a critical part of our work.       implementation. Thus when TAC sees              regarding the current political crisis in
                        Yet though we have won the battle for     the policies are good, but the clinics are      South Africa. While it is tempting to
                     HIV treatment, the healthcare system is      still in crisis, it is the provinces TAC must   keep TAC’s focus on health care only,
                     falling apart. And the healthcare system     hold accountable. In recent years, for          the reality is that corruption and state
                     is falling apart not only for people         example, pressure from TAC has helped           capture are impacting the healthcare
                     living with HIV, but also for people         to unseat underperforming MECs for              system. For example, the economic
                     with tuberculosis, diabetes or cancer.       Health such as Benny Malakoane in the           crisis has meant that health budgets
                     Thus when TAC campaigns for quality          Free State and Sicelo Gqobana in the            have been unable to grow as one
                     healthcare for all, the organisation         Eastern Cape. It is critical that this kind     would hope – which has contributed to
                     is not just campaigning for people           of provincial-level work continues.             posts in the public healthcare system
                     with HIV, but also for all brothers and                                                      being frozen and left vacant. While
                     sisters with other diseases. We all stand                                                    provinces lack the money to employ
                     in the same long queues. We are all          Looking ahead                                   more healthcare workers, the country is
                     harmed by medicine stockouts. In this                                                        losing billions of Rands to corruption.
                     new phase in TAC’s history, TAC has          The 2017 National Congress will set                Though TAC has taken a stance
                     the opportunity to be a home for all         the direction for TAC over the next five        against corruption and state capture
                     poor people who need healthcare,             years. Much of TAC’s success in the years       in a few media statements (TAC has
                     not just people living with HIV.             to come will depend on the quality of           endorsed the Save SA movement, for
                                                                  the national leadership elected at the          example), these statements do not carry
                                                                  Congress. More than ever before, TAC            the same weight as a firm and clear
                     3. From the national                         needs brave and dedicated leaders who           Congress resolution. A critical question
                        to the provincial                         can think and act strategically in the          for the 2017 TAC National Congress is
                        and the local                             interests of TAC’s members. The good            thus whether the organisation will take
                                                                  news is that in someone like Anele Yawa,        a clear resolution against state capture
                     TAC has always done its work on all          TAC already has a very strong leader.           and call for the removal of President
                     levels, from local to national. The heart    However, it remains an open question            Jacob Zuma – given that he is at the
                     and life-blood of TAC has always been        whether Yawa will be re-elected, and            centre of most state-capture allegations.
                     its branches. The national victories we      who the rest of the leadership team             If TAC sidesteps or fails to be firm and
                     have won were only possible because          would be. One would also expect at              clear on this issue, its political relevance
                     of the power of TAC’s branches. Now          least half of the national leadership           will be much diminished. TAC’s attempts
                     more than ever, it is important that         positions to be taken up by women.              to fight corruption at provincial level
                     TAC’s branches remain strong, and that          In addition to the leadership question,      will simply ring hollow if TAC can’t take
                     TAC’s work is driven by its members          there are at least two critical issues that     a strong resolution on state capture
                     and its branches. One of the important       the Congress must resolve. Firstly, TAC         and corruption at the highest level.
 #16 – August 2017

                                                                                                                                                                  #16 – August 2017
                     TAC leaders 1998-2017
                     YEAR                  GENERAL SECRETARY                  CHAIRPERSON

                     1998 - 2003           Mark Heywood                       Zackie Achmat

                     2003 - 2005           Siphokazi Mthathi                  Zackie Achmat

                     2005 - 2007           Vuyiseka Dubula                    Zackie Achmat/Nonkosi Khumalo

                     2007 - 2010           Vuyiseka Dubula                    Nonkosi Khumalo

                     2010 – 2013           Vuyiseka Dubula                    Nonkosi Khumalo/Anele Yawa

                     2013 - 2017           Anele Yawa                         Nkhensani Mavasa

  6                                                                                                                                                                7

                     Mental health
                     and pill-
                     taking: Getting
                     beyond HIV
                     Professor Francois Venter, Wits Reproductive Health and HIV Institute, University of the Wiwatersrand

                     Recently, I took part in a chat show on Radio 702 to discuss how to
                     disclose one’s HIV status to one’s sex partners. Hosted by Eusebius
                     McKaiser, the show was vibrant, entertaining and challenging
                     – made more so by the other guest, Thula Mkhize. Thula is an HIV-
                     positive, heterosexual man in a discordant relationship (his
                     wife is HIV-negative). Thula speaks openly and passionately
                     about his sex life, and we chatted about the ethics of disclosing
                     on the first or second or third date, among other things.

                     Dating when HIV-positive can be very         behaves as if he were doing her a huge        HIV field and beyond, and generates
                     tricky. When do you disclose your            favour, despite her being completely          a lot of chatter on social media.
                     status to a new sex partner? How do          non-infectious on treatment. These               Pill fatigue is a difficult concept to
                     antiretrovirals impact on your sex life?     little and not-so-little indignities can be   swallow, as a health professional. The
                     Why do we sometimes take risks that          devastating, and can prick holes in your      daily tablet we use for HIV is small
                     don’t seem rational? Relationships           self-esteem. Getting reliable support         and getting smaller, has very few
                     are hard, but can be so much harder          after disclosure is far from guaranteed.      side effects, and is becoming safer all
                     when you have a background condition             A few weeks ago we lost Prudence          the time. Public health guidelines in
                     that is sexually transmitted.                Mbele, a beloved long-time activist           South Africa recommend that a huge
                        The show went well; but I found           living openly with HIV, who died of           proportion of our population need
                     some of the callers talking about their      TB. Prudence was famous for her ‘pill         tablets for diabetes, hypertension and
 #16 – August 2017

                                                                                                                                                             #16 – August 2017
                     experience of disclosure surprisingly        holidays’ – a big no-no in HIV-land, as       cholesterol, among other ailments,
                     moving and upsetting. People were            it leads to further immune damage.            especially as people get older. Pills are
                     calling in, talking about the enormous       The idea of someone stopping their            a part of normal life for everyone as
                     impact of HIV on their sex lives, and of     life-saving tablets – even temporarily        they get older – so why should HIV-
                     partners slowly pushing them away due        – boggles the minds of most health            positive people complain of pill fatigue?
                     to their status. This was not the violent,   providers. Her death triggered an intense        Some of those reasons relate to
                     ignorant stigma that we easily identify      media and Facebook/Twitter reaction,          anxiety and depression and stigma, now

                     and loudly denounce, but a more              filled both with criticism at her choices     strongly linked to delayed presentation
                     subtle, much more personal rejection.        as well as empathy, as people shared          for treatment, as well as adherence to
                     It reminded me of a good friend who is       their own hard stories about taking           their meds. Sadly, mental health issues
                     HIV-positive, who when she is about to       antiretrovirals. Yet this notion of ‘pill     are more associated with medical hot
                     engage in sex with a guy, says he often      fatigue’ affects lots of people in the        air than with any content; very few

  8                                                                                                                                                           9
resources are allocated specifically to
                     this area in either the public or the
                                                                                                                about your mood; and if you are feeling
                                                                                                                low or anxious, it can be enormously
                                                                                                                                                                 Just as with HIV, every single one of us knows
                     private sector, despite tons of data
                     suggesting they are important. We have
                                                                                                                helpful just to tell someone about it.
                                                                                                                   So pay attention to your friendship
                                                                                                                                                                 another person who is experiencing mental ill health.
                     some very spirited and smart mental                                                        circle, family and community; and invest
                     health professionals trying to change                                                      time and energy in these relationships.          and helpful, competent staff. This will    to take mental health seriously, and be         strategy encompassing talking
                     this, but there is an inertia in the current                                                                                                help you stay mentally healthy too.        bold about opening conversations with           therapies, good lifestyle interventions,
                     health system. This is also coupled with                                                                                                       If you are persistently depressed,      your friends and family about mental            removing stress, treating other
                     harsh societal views around mental                                                         Speak to your health                             it might also be possible to obtain        health. The World Health Organisation           health conditions, and prescription
                     health – depressed people are told to                                                      professional                                     anti-depressant medications on             estimates that one out of every four            medications. Compassion, empathy and
                     pull themselves together, think positive                                                   It is likely that you will receive very little   prescription. Primary healthcare clinics   people suffers mental illness at some           the ability to ask the patient questions
                     thoughts, be grateful – which are less                                                     clinical help concerning your mental             have access to anti-depressant drugs,      point in their lives, so you are not alone.     about their unique experience of living
                     than helpful to people experiencing                                                        health. Many health professionals are            and these can be a valuable addition          You might find useful mental                 in their own body are crucial. The last
                     sometimes devastating physical                                                             woefully under-trained around mental             to other counselling support. If you       health information and support                  thing you should be doing is adding
                     symptoms as a result of mental ill             people without HIV. Disclosing your         health, and you might find yourself              have the means, shop around for a          through one of the smartphone apps              to stigma by putting your foot in your
                     health. The truth is that mental ill health    HIV status can be scary, but it can         brushed off if you try to talk to your           professional you relate to – one who is    or personalised telephonic support              mouth. It is not a moral failing to suffer
                     is probably just as stigmatised as HIV.        also keep you healthy. Similarly, if you    doctor, nurse or even counsellor                 sympathetic to mental health issues.       lines that are becoming increasingly            mental ill health, just as it is not a
                        What does all of this mean,                 notice your mental health is wobbling,      about this. If you feel strong enough,              There are many similarities between     available. These may involve a cost,            moral failing to be HIV-positive, or have
                     for someone with HIV? There                    disclosing this to your friends and         you can ask questions and insist that            taking anti-depressants and taking         but there have been enough studies              any sexually transmitted infection.
                     are no magic bullets; but this is              family can help keep you healthy.           your health worker answer them; or               antiretrovirals. You need to take your     to show that they can be valuable.                 As South Africans, there are many
                     the best advice I can offer:                      Of course, this does not hold true for   if they can’t, that they do their own            meds consistently, without interruption,   Watch this space to learn more about            things that grind us down: corrupt
                                                                    everyone. The world can be brutal and       research and come back to you.                   in order to achieve the best results.      which ones are reliably effective.              politics; lack of jobs; increasing living
                                                                    violent, families may use stigmatising          You have a right to mental health            You may experience some side effects;         What should HIV-negative people              costs; high rates of violent crime;
                     Identify your mental                           diseases to play out internal politics,     care, even though the reality is that            but these can often be mitigated by        and healthcare workers be doing? I              poverty and poor service delivery;
                     health symptoms                                and not every spouse is going to be         South Africa is very under-resourced             changing the dose slightly, or just        guess trying to avoid the trite ‘support’       alcohol abuse; and family and
                     It’s a good idea to pay attention to your      supportive. Use common sense, and           in this field. Your raising it could be          waiting for your body to get used          statements – from ‘Well, at least you’re        relationship break-ups. If you also take
                     mental health, as well as your physical        choose your support network carefully.      helpful in transforming your own health          to them. Many people take anti-            alive’, to the hideous ‘We will all die one     into account the reality that too many
                     health. The first step is noticing whether     Equally, this does not mean you need        worker’s understanding, too, and could           depressants for months or years in         day’ – would be a start. I have been at         of us experienced trauma because of
                     you are feeling different – do you have        to rush out and disclose to everyone        contribute towards changes in broader            order to keep their mood stable and        dinners in white, middle-class suburbia         the brutalising effects of apartheid,
                     feelings of hopelessness, persistent           the moment you get your diagnosis –         mental health policy for everyone,               enhance their mental health. There is      where someone is loudly opining                 it is no wonder that mental ill health
                     sadness, a lack of energy to get through       I’ve seen quite a lot of people treating    over time. Also, challenge people on             nothing to fear from these drugs.          about morality and its connection               is so prevalent in our society. Sadly,
                     your normal routine, or disrupted sleep        this period as a kind of confessional.      social media and in public, when they                                                       with HIV, not knowing that the couple           we have been slow to acknowledge
                     or eating patterns? If so, and if these        Learning you are HIV-positive can be        post trite messaging on mental health                                                       across from me are my patients. The             this and implement adequate policies
                     persist for more than a couple of weeks,       a huge shock; give yourself time to         issues (the most annoying I have seen            Get activated                              same holds for mental health issues             to help mitigate mental illness.
                     you may be becoming depressed.                 think it through, and decide when           is a meme saying that people with                Use activism to get behind                 – think before saying some stupid,                 Just as with HIV, every single one
                        Do you have persistent and repetitive       and who you want to disclose to.            depression don’t need tablets – just             organisations advocating for better        stigmatising thing. There needs to be           of us knows another person who is
                     thoughts, worrying about your life                American sex therapist Dan Savage        a pair of running shoes and a forest).           health services, for both HIV and          much more community awareness                   experiencing mental ill health. However,
                     or other problems? Do you notice               famously says that disclosure on a          They will be more careful next time.             mental health. In a recent study we        about the importance of unconditional           this may be hidden – due to stigma,
                     physical symptoms such as shortness            date (or in any other situation) tells                                                       did on truck drivers (most of whom         acceptance and support of people                shame, lack of understanding, and lack
                     of breath, churning stomach or nausea,         the other person only a small thing                                                          were HIV-negative), rates of anxiety       on any kind of chronic medication.              of adequate treatment. As a country,
                     dizziness or rapid heartbeat, fear of new      about you; whereas their reaction           Take your medication                             and depression were very high; we             If you’re a health professional, the         we achieved a lot when we started
                     situations or people? If so, and these         tells you everything you need to know       Taking tablets every day for ‘conditions’        see similar prevalence among carers,       best thing you can do is to educate             taking HIV seriously: through activism,
                     persist for more than a couple of weeks,       about them. While it can be a shock         when you’re healthy is fast becoming a           low-income families living in poor         yourself around mental health –                 scientific research, transformed health
                     you may be experiencing anxiety.               to hear from a friend or loved one          fact of life for everyone, for everything        housing, and inner-city dwellers. If       and learn, firstly, how to accurately           delivery systems and a lot of hard
                                                                    that they have HIV, or depression, or       from high blood pressure to diabetes.            you can, donate money to help them         diagnose someone with depression or             work at all levels, we managed to
                                                                    any other scary condition, there is no      Getting onto antiretrovirals, developing         campaign, and to hire good staff.          anxiety; and secondly, how best to work         turn the epidemic around and make
                     Get support                                    excuse for casually offensive opinions      habits around swallowing tablets and             Become a vocal supporter of better         out a treatment plan. Mental ill health         HIV a manageable condition. We can
                     The best thing you can do is ask for           or hurtful comments. You do not have        staying on treatment, and finding the            mental health initiatives, wherever they   is rarely healed only through drugs, but        do the same with mental health,
                     support. It is sometimes very hard to          to stand for it, and you can be clear       easiest system possible for getting your         exist. Challenge your health provider      more usually involves a comprehensive           if we are motivated to do so.
                     reach out, especially when you may             in deciding whether to continue a           tablets, will move this aspect to ‘habit’
 #16 – August 2017

                                                                                                                                                                                                                                                                                                          #16 – August 2017
                     be afraid of people’s reactions. My            relationship with an individual who         rather than being a constant reminder
                     experience though is that families             is rejecting or judgemental about           of the virus. If you acknowledge
                                                                                                                                                                                                            For more information and resources
                     and friends can be remarkably                  your physical or mental health.             to yourself that pill fatigue might              Professor Francois Venter is
                     compassionate; and studies have shown             You can often find support groups        actually be systems fatigue – weariness          a medical doctor who has
                                                                                                                                                                                                            on mental health, go to:
                     that people who are open about their           through local churches, NGOs and            around a health system that remains              been involved in HIV patient               ++ Mental Health Infaormation Centre of Southern
                     HIV status tend to get more support,           community organisations. These don’t        largely inefficient and unfriendly, and          care, as well as guideline                    Africa, at
                     have fewer issues with adherence, and          work for everyone, but can be of huge       wastes so much of your time – this               development and studies on                 ++ South African Depression and Anxiety Group, at www.sadag.

                     generally appear to be happier. In one         benefit. You might find that sharing        might help you to address your own               new HIV treatments, for many                  org. Toll-free suicidal emergency number: 0800 567 567
                     study, people with HIV who had good            your experiences and finding out more       negative thought patterns about                  years. He had lots of support              ++ South African Federation for Mental Health, at
                     social support mechanisms reported             about HIV will be empowering, and           taking your meds, and help you to                from work colleagues and                   ++ Lifeline, at or phone 0861 322 322
                     the same quality of life, once they            this will help keep you both physically     stick to the regime. If you can, try to          friends in editing this article.           ++ AIDS Helpline: 0800 012 322
                     were on successful antiretrovirals, as         and mentally well. Also, you could talk     find a clinic that has good systems

10                                                                                                                                                                                                                                                                                                       11

                     Modernising ART
                                                                                                                                                                                                                                                    in pregnant women as yet, but these
                                                                                                                                                                                                                                                    studies are under way. Once we have a
                                                                                                                                                                                                                                                    better understanding of this, TAF is set
                                                                                                                                                                                                                                                    to be a favourable option to replace
                                                                                                                                                                                                                                                    TDF, on account of its better safety
                     By Dr Michelle Moorhouse, Wits Reproductive Health and HIV Institute,                                                                                                                                                          profile and lower dose, which will
                     and Southern African HIV Clinicians Society                                                                                                                                                                                    result in significant reductions in cost.
                                                                                                                                                                                                                                                       And in fact, if DTG, FTC and TAF
                     Antiretroviral therapy (ART) in South Africa seems set for                                                                                                                                                                     are co-formulated, potentially we are
                                                                                                                                                                                                                                                    looking at a future first-line regimen,
                     a revolution, with a new drug combination that is highly                                                                                                                                                                       to quote Prof Francois Venter, “smaller
                     effective and involves only one pill a day that is smaller than                                                                                                                                                                than an aspirin”, which is incredibly
                                                                                                                                                                                                                                                    potent, incredibly robust, incredibly
                     an aspirin. One of South Africa’s top HIV clinicians explains.                                                                                                                                                                 well tolerated, all while being
                                                                                                                                                                                                                                                    incredibly cheap – incredible, isn’t it?
                     South Africa, like many lower- and            living with HIV (PLWH) will receive
                     middle-income countries, follows the          a combination of efavirenz (EFV),          Alternatives to EFV
                     World Health Organisation (WHO)               tenofovir (TDF) and emtricitabine (FTC)    So how do we improve on EFV? There          there may be some side effects, which        inexpensive pill – looks promising.          ART does not exist
                     recommended public health approach,           or lamivudine (3TC) as first-line ART.     are a number of alternatives to EFV to      include dizziness and anxiety. But this is      Then there are also other future          in a vacuum
                     using standardised drug regimens to           FTC and 3TC, which are structurally        consider that are currently available       coming mainly from European cohorts,         third-drug options which are not             All of this is very important, while we
                     treat HIV. This, along with tasks shifting    almost identical, really contribute very   in South Africa. Rilpivirine (RPV) is one   which do not have the genetic diversity      available in South Africa (or indeed         have such tough targets to chase –
                     from doctors to NIMART (Nurse Initiation      little in the way of toxicity generally,   option, from the same class of ARVs as      of African populations. Currently a          anywhere else) as yet. These include         the famous 90-90-90. And to achieve
                     and Management of Antiretroviral              and are usually continued through          EFV, and is dosed at 25mg (compared         massive study called ADVANCE that            doravirine and bictegravir. Doravirine is    that third 90, we need to modernise
                     Therapy) trained nurses, has enabled          subsequent lines of therapy, so I am       to 600mg of EFV which contributes           compares DTG to EFV is under way in          from the same class of drugs as EFV and      treatments so that PLWH can adhere
                     more than 3.9 million people living           not going to say much more about           significantly to the size of the FDC).      South Africa, and includes screening         RPV. It is still in phase 3 of development   to them. When there are so many
                     with HIV (PLWH) to access life-saving         them here; I’m going to confine my         RPV is much better tolerated than           for these types of symptoms. DTG             (registrational studies), and whether        other challenges to overcome within a
                     antiretroviral therapy (ART) since            deliberations to EFV and TDF.              EFV and is incredibly cheap, which is       is also available in SA already co-          or not it will ever hit our shores is        healthcare system, optimising ART to be
                     2003. ART is undeniably one of the               What is great about this                always good news in a drug which could      formulated with abacavir (ABC) and           unknown. Bictegravir, also in phase 3,       as simple, safe, efficacious and robust
                     biggest successes of modern medicine,         combination is that millions of PLWH       potentially be used to treat millions       3TC; but it is not practical to roll out     is a drug which is very similar to DTG       as possible facilitates safer task-shifting
                     along with vaccines and antibiotics.          around the world have been treated         of people. The downside is that it is       this particular FDC programmatically,        and is co-formulated with tenofovir          to other cadres of staff, which may help
                        While we have some pretty great            with it for years, so there is a wealth    not yet available in any FDCs in South      as ABC is very expensive.                    alafenamide fumarate (TAF), which I will     alleviate some of the human resource
                     treatments already, there is still room       of experience with it – a bit like that    Africa, can’t be used with rifampicin-         But as DTG requires only a 50mg           discuss a little more below, and FTC.        shortages faced by healthcare facilities.
                     for improvement. Current first-line ART       comfortable T-shirt we like to sleep       based TB treatment or in anyone with a      dose, if it were to be introduced into                                                       But no matter how good the drugs
                     is a big pill to swallow and it has some      in, for us as prescribers, but perhaps     high viral load when starting treatment,    the public sector programme, produced                                                     are, ART does not exist in a vacuum,
                     unpleasant side effects, resulting in         not so much for PLWH. The regimen          and in the public sector we don’t do        by a generic manufacturer with South         An alternative to TDF                        and ART alone will not achieve the three
                     poor adherence and virological failure,       has proven virological efficacy, is        viral loads at treatment initiation,        Africa’s buying power as the largest         So, moving on to TDF: the problems           90s. ART will not fix the healthcare
                     and resistance develops quite easily;         generally well tolerated, is simple to     so it too has its warts. However, it is     consumer of generic ART in the world,        with TDF are in some ways similar to         system. ART will not address stigma.
                     and it will not get any cheaper over          take as it is dosed once daily, and is     being studied in some interesting new       DTG would be an affordable option            those with EFV. The high dose means a        ART will not help us achieve that
                     time. From the more logistical aspect,        co-formulated into a single tablet         combinations, so let’s not set it aside     for first-line ART, and is currently         high active pharmaceutical ingredient        first 90: 90% of PLWH knowing their
                     the high dose of the drugs that make          fixed-dose combination (FDC).              completely just yet. Certainly, as a        an alternative option in the WHO             requirement, which drives up the pill        status. ART will not find the missing
                     up first-line ART means they use more            What are the problems with EFV?         switch option RPV is a very good choice     guidelines. With regard to DTG and TB        size and the cost. And it also has some      in action to test them – the men, the
                     ingredients, meaning they cost more;          It comes with some unpleasant              in patients who don’t tolerate EFV, and     drugs, there is an interaction, which can    toxicity associated with it. Currently,      key populations, the adolescents, girls
                     this is also the reason the pill is so big,   side effects (abnormal dreams,             there are studies which support this.       be overcome by adjusting the dosing          we do not have any alternatives              and young women – and then link
                     which in turn means the packaging is          nightmares, hallucinations even,              Dolutegravir (DTG) is another option     of the DTG; but this might not be            available in South Africa that are           them to care to achieve the second 90.
                     big, and takes up more space in the           and other neuropsychiatric-type            already available in South Africa. Again,   necessary – some studies are under way       any better; but there is one which           ART will not then retain them in care,
                     pharmacy. Clearly, we need treatments         symptoms, mainly; occasionally,            another low-dose drug, at 50mg. In          to look into this. One of the current        should be available soon, namely TAF         and measure their viral load so we can
 #16 – August 2017

                                                                                                                                                                                                                                                                                                     #16 – August 2017
                     that are easier to take, in terms of          rash); it has a very low resistance        registrational first-line studies, no-one   challenges with DTG is that at this          (tenofovir alafenamide fumarate). TAF,       see if we are reaching that third 90.
                     size, and cheaper. And if you compare         barrier; and it requires a high dose.      with virological failure developed any      stage, we don’t know a lot about DTG in      like the TDF in current first-line ART,         Massive investment in infrastructure
                     first-line ART in lower-/middle-income        Its safety in pregnancy has been           DTG resistance, which means this drug       pregnant women. Botswana made the            is a pro-drug of tenofovir. TAF is given     and development of systems, backed
                     countries (LMIC), some of the drugs           established despite a bumpy start          is incredibly robust. DTG was also the      bold move of introducing DTG into their      at a much lower dose (approximately          by political will, is critical. Civil society
                     being used are no longer recommended          in early development, and it plays         first drug to ever beat EFV in a head-      HIV treatment programme in June 2016,        tenfold lower) than TDF. TAF is              must remain engaged, and all of this
                     in better-resourced settings.                 relatively well with most other drugs,     to-head study, where pretty much all        including for pregnant women; and it         associated with much less kidney and         must be backed by a National Strategic
                                                                   including TB drugs (but not all; for       others had previously tried and failed,     is anticipated that they will present        bone toxicity than TDF. The ADVANCE          Plan (NSP) that is realistic, detailed, and

                                                                   example, some contraceptives, such         and this was probably a lot to do with      data on the first pregnancies at the IAS     study will also compare TAF and TDF,         which embodies the principles of equity
                     Current first-line ART                        as implantables). EFV is an example of     the fact that DTG is more tolerable         conference in Paris in July 2017, which      as most studies of DTG used ABC as           and access. There is a massive amount of
                     So, let’s look a little more closely at       one of the first-line drugs which has      than EFV. And as the saying goes, if it     will start to fill this gap. So, we have a   the backbone, and also would not have        work to be done to conquer HIV in South
                     our current first-line ART. According to      disappeared from first-line treatment      sounds too good to be true… In fact,        very robust drug that is well tolerated      included many African participants. TAF      Africa, but optimised ART is certainly
                     our national guidelines, most people          in many wealthier countries.               there are emerging data suggesting          and can be co-formulated into a small,       has not been studied with TB drugs or        a great step in the right direction.

12                                                                                                                                                                                                                                                                                                  13

                     Spotlight on
                     TAC provinces
                                                                                                                                                           In May, it came to light that KwaZulu-Natal’s healthcare
                     Following heavy rains in May, a malaria outbreak hit Limpopo.
                                                                                                                                                           services are in a state of emergency, with shocking
                     Clinics and other primary health facilities did not have enough
                                                                                                                                                           details shared by health workers in the province.
                     testing kits or malaria treatment to deal with the outbreak.
                                                                                                                                                           Reports reflected a collapsing health      accessible will benefit the health of          Since 2016, TAC KZN has been
                     Patients were therefore being               to most of the facilities that were           meaning that the shortage was a crisis      system which is in many cases no           all people living with HIV on campus.       working on a campaign to ‘Help Teens
                     transferred to Nkhensani Hospital.          relieving the burden on the hospital.         for the HIV response in the area.           longer delivering adequate healthcare      The evidence is clear that earlier          Protect Themselves’. Through our
                     As there were too few beds, patients           In July, Mopani district in Limpopo          After hearing and validating the          to the most vulnerable. Hospitals are      treatment reduces serious adverse           engagements with the MEC of Health
                     at the hospital were being admitted         was facing a shortage of HIV-testing          complaints, TAC Limpopo escalated           experiencing shortages of life-saving      events, such as TB and various              and the MEC of Education, and in the
                     only to be left in an undignified           kits. After many calls from members           the matter to the District Health           medicines and equipment, and suffering     cancers. Adhering properly to HIV           KZN Provincial AIDS Council, TAC KZN
                     condition on the floors of the              of the public who had been unable             Department and the Office of the            through departments that are entirely      treatment is critical to staying healthy.   has been advocating for better access
                     wards. Immediately, TAC Limpopo             to take an HIV test, TAC Limpopo              Mayor. The official response from           depleted of staff. Major delays for        Additionally, this will also help prevent   to prevention methods, the roll-out
                     organised a meeting with the CEO            intervened. Following a snap survey,          government was that the supplier’s          treatment and care continue to be          many new HIV infections. Studies            of prevention and treatment literacy
                     and Communications Manager of the           TAC members found that the following          tender had come to an end, and they         felt in oncology and various other         show that people who are stable on          training, and easier access to treatment,
                     hospital to address our concerns. The       health facilities had either very few,        had failed to calculate the risks and put   departments. In June, TAC KZN met          treatment with undetectable viral           including on campuses. Both MECs
                     hospital acknowledged the challenges;       or no testing kits at all: 1) Vyeboom         measures in place to avoid a stockout.      with MEC of Health Dr Sibongiseni          loads are highly unlikely to transmit       made a clear commitment to improve
                     in the interim, they erected tents to       Clinic; 2) Basani Clinic; 3) Hlaneki          Following TAC’s intervention, limited       Dhlomo, and raised these issues. In        HIV to their sexual partners.               youth-targeted HIV interventions. Now
                     deal with the influx of patients. TAC       Clinic; 4) Ratanang Clinic; 5) Xivulani       stock was quickly delivered to Giyani       response, the MEC complained of               The dysfunction in the public            it is important for TAC KZN to monitor
                     Limpopo was not satisfied with this         Clinic; 6) Mapayeni Clinic; 7) Khujwana       Health Centre, Nkhensani Hospital,          cost cutting and budget cuts by the        healthcare system creates its own           the roll-out. Treatment accessibility
                     action, and escalated the matter. We        Clinic; 8) Giyani Health Centre; 9)           and Thomo Clinic. Shortly afterwards,       provincial Treasury. The response of the   challenges for people to remain             must be coupled with counselling and
                     wanted to know what the provincial          Nkhensani Hospital; 10) Thomo Clinic;         TAC Limpopo received a call from            MEC failed to alleviate the concerns       adherent. The reality is that our           adherence support on campus. We
                     department’s plan would be to resolve       11) Dzumeri Health Centre; and 12)            Giyani Health Centre extending their        of TAC KZN. A suitable turnaround          clinics are in crisis. People must wait     also urge the University of Zululand
                     this crisis. Soon after engagement          Ratanang Clinic. Knowing their HIV            gratitude for our intervention in the       plan must urgently be put in place         in long queues for hours to get their       to provide easy access to preventative
                     with the office of the MEC of Health,       status is the most important thing            matter. The situation must be resolved      by the MEC, or TAC will be forced to       HIV treatment. Sometimes medicine           measures such as male and female
                     Dr Phophi Ramathuba, testing kits           people can do to protect their own            urgently at the other facilities, to        escalate our advocacy around this          stockouts or shortages mean people          condoms, as well as pre-exposure
                     and malaria treatment were delivered        health and avoid the spread of HIV,           ensure that HIV testing can resume.         crisis. The Provincial Congress will       leave empty-handed. This forces people      prophylaxis (PrEP). PrEP aimed at
                                                                                                                                                           discuss and resolve a way forward.         to default, and puts their health and       youth and the general population
                                                                                                                                                           TAC will work with SECTION27, the          lives at risk. Students must take the       may have an important role to play
                                                                                                                                                           South African Medical Association          decision to miss classes in order to        in reducing new infections. Further,
 #16 – August 2017

                                                                                                                                                                                                                                                                                               #16 – August 2017
                                                                                                                                                           (SAMA), and the South African Human        wait at the clinic; those staying in        and critically, measures must be put
                                                                                                                                                           Rights Commission on this matter.          residence must travel home to collect       in place to prevent the disclosure of
                                                                                                                                                              In July, TAC KZN welcomed the           their treatment. Our rights to health       people’s HIV status on campus, which
                                                                                                                                                           announcement that the University of        and education are in conflict. Providing    would cause unnecessary stigma and
                                                                                                                                                           Zululand would provide HIV treatment       medicines on campus will not only           discrimination. For instance, people
                                                                                                                                                           to students and staff on campus. If        promote better adherence for students       should not be forced to enter buildings
                                                                                                                                                           implemented effectively, this should       and staff at the university; it will also   reserved only for collecting HIV

                                                                                                                                                           provide an easier and quicker system       relieve the burden on health facilities     medicines, and their clinic files must
                                                                                                                                                           for young people and staff at the          that are already stretched to capacity.     not be colour-coded or marked to show
                                                                                                                                                           university to collect their ARVs, and      Given the increasing uptake of HIV          their status. TAC KZN will monitor
                        Nkhensani Hospital erected tents (left) to deal with the influx of patients due to a malaria outbreak. Many patients
                                                                                                                                                           therefore ensure better treatment          treatment through ‘Universal Test and       the roll-out and advocate for other
                        had to lie on makeshift beds on the flloor (right). TAC kept the pressure on provincial government until resolution.
                                                                                                                                                           adherence. Making medicines more           Treat’, this burden will only grow.         campuses to adopt this approach.

14                                                                                                                                                                                                                                                                                            15
Mpumalanga                                                                                                                                  Western Cape
                     “Police in Ermelo used to assault, insult                                                                                                   For a long time, TAC Western Cape received complaints about
                     and arrest us often,” says Boitumelo*,                                                                                                      Michael Mapongwana Community Health Clinic in Khayelitsha.
                     a sex worker from Mpumalanga.
                                                                                                                                                                 Parents with children and babies would       their children outside because of a lack    met with the Health Department to
                                                                                                                                                                 be seen in a container at the back of        of space on the inside. Children with       address these concerns. Finally, in
                     “They would arrive at our houses, kick              TAC and partners escalated the                                                          the clinic. They would wait outside for      illnesses shared the same space with        February 2017, following pressure from
                     stuff, call us names, beat us. They would        matter to the MEC of Health, Gillion                                                       long periods, whatever the weather           those attending post-natal check-           TAC, a new structure was opened that
                     confiscate our medications (including HIV        Mashego. They wrote to the MEC and                                                         conditions, to be attended to by health      ups. Late last year, TAC Western Cape       could accommodate the children in a
                     treatment), destroy our foods, ruin our          the Brigadier of the SAPS to demand                                                        workers. They would have to undress          held a picket outside the clinic, and       dignified and appropriate manner.
                     furniture, even take our condoms. And            a meeting. The police had previously
                     after they had arrested us, we would spend       refused to meet, but engaged once the
                     the entire weekend in the dirty, smelly,         MEC was involved. In the meeting, after
                     and cold cell. Sometimes we would be             hearing the issues, the MEC demanded
                     released on the Monday with R500 each.           that the police stop harassing the sex
                     Then we would appear in court where              workers and stop taking their condoms                                                      Eastern Cape
                     eventually the charges would be dropped.”        and medications. While the police tried
                        Boitumelo and other sex workers in the        to deny all that the sex workers said,
                     Ermelo area have been victimised by the          photographs of beaten bodies, destroyed                                                    Since 2016, TAC Eastern Cape had received numerous complaints from
                     police for years. After a chance meeting         homes, and medications thrown on
                     in the mall with a member of NAPWA –             the floor, shocked the attendees of
                                                                                                                                                                 the Clinic Committee and community members fearful of accessing
                     who happened to be wearing a T-shirt             the meeting. The MEC instructed the                                                        health services at Philani Clinic. Mostly this was due to the bad
                     saying ‘sex work is work’ – Boitumelo and        police to engage with all departments
                     other sex workers were soon introduced           and ensure that the victimisation
                                                                                                                                                                 attitude and lack of respect shown to patients by one of the nurses.
                     to TAC Mpumalanga. In late 2015, TAC             and harassment would finally end.
                     facilitated a safe-space workshop where             “Since October 2016 we have not                                                         This nurse had repeatedly and                matter was resolved. According to the       organisations, churches and partners in
                     an advocate from the Women’s Legal               had problems with police. Since the           TAC has helped some sex                      publicly disclosed people’s HIV              community, the clinic would only be         the area to meet in Queenstown and
                     Centre promised to represent the sex             police vans are no longer coming to           workers victimised by police in              status and other health conditions           reopened given the removal of the           come up with a strategy to re-open the
                     workers in case of further arrests.              our place, even clients come freely, and      Ermelo to find their voice.                  without their consent. The situation         nurse. This meant no-one could access       clinic, to ensure people could access
                        “It was here that we started to feel          business has been better. Now I can at                                                     had left community members not               services at all. Worryingly, TB and         health care. TAC met with MEC of Health
                     safe and confident to talk,” Boitumelo           least send some money to my kids.”                                                         wanting to use the clinic at all.            drug-resistant TB patients in the area      Phumza Dyantyi and Clinic Committee
                     continues. “It wasn’t long before we got            Since last year, KwaMhlanga Hospital      National Portfolio Committee on Health           While the Mayor had proposed              could not undergo treatment reviews,        members to demand a way forward. After
                     arrested again, in December. We were             in Mpumalanga has been facing a severe       visited the province and gave a damning       suspending the nurse in question             as their folders were locked inside         this pressure, the clinic was re-opened in
                     told to be in court on 4 December. The           crisis. A shortage of staff meant that       report, which lead to the notorious threats   pending a disciplinary hearing, the Sub-     the clinic. They had no option but to       June 2017, and the nurse was removed.
                     advocate came to represent us and                doctors in the facility repeatedly went on   made against MP Dr Makhosi Khoza.             District Health Manager undermined           use another facility, given that the        While one battle was won, the clinic is
                     TAC members were there in numbers                strike. They were overworked, without the       TAC Mpumalanga met with the Hospital       this decision. The community were            nearest TB hospital is 350km away.          now understaffed, with one nurse being
                     supporting us. We had done nothing               people-power to attend to all those in       CEO to raise the various challenges that      understandably angry at the change.             TAC Eastern Cape and the Queenstown      dismissed and one more resigning. TAC
                     wrong. We were sleeping when the                 need of medical care. The maternity ward     had been reported to us. The matter           In April 2017 they shut the clinic down      Council of Churches urgently mobilised      Eastern Cape will continue to demand that
                     police kicked down the doors. We                 was overcrowded. Women would deliver         was escalated to the District Health          in protest, locking its gates until the      the Clinic Committee, community             the vacant posts are filled urgently.
                     were just sitting inside the house. The          their babies, after which they would         Department, and then the Provincial
                     case was withdrawn on the day.”                  be moved to a chair to sit for six hours     Health Department. A meeting with
                        TAC assisted in mobilising other sex          observation, and then be sent home.          Gillion Mashego, the MEC of Health, led
                     workers and members of the LGBTQIA+              Bloody and wet sheets would remain,          to the removal of the CEO. An interim
                     community to support us on 10 December           as the next to give birth would occupy       CEO was appointed in February 2017, after
                     in marching to the police station, to            them. The nurses had no gloves or gowns;     which the hospital received an injection
                     demand an end to the police harassment.          their clothes were dirty from delivering     of two million rand. The maternity ward
 #16 – August 2017

                                                                                                                                                                                                                                                                                                        #16 – August 2017
                     “We walked through the township singing          babies. The intensive care unit (ICU) was    was extended into a portion of the ICU
                     and holding placards. We were about 300          empty – no furniture, beds, or medical       to relieve the burden on the overcrowded
                     in total, wearing our mini- skirts and high      equipment; an abandoned, empty space.        ward, and a new position to manage
                     heels,” remembers Boitumelo. “Police used        Conditions were untenable. At the district   this maternity ward has been advertised.
                     to say we were whores because we are             People’s Health Assembly organised by        The interim CEO visited hospitals in the
                     dressed in mini-skirts and that is why we        TAC in 2016, many complaints of poor         North West to benchmark and gain
                     wore it on the day. We wanted them to            service at KwaMhlanga were made,             guidance as to how to turn the crisis

                     arrest us officially on this day; but instead,   with members of the District Health          around. Some stability has finally been
                     police came to escort us – after refusing        Department in attendance: reports            found. TAC will monitor the situation, and
                     to give us permission to hold the march.”        of people dying unnecessarily; people        continue engaging with the new MEC.
                                                                                                                                                                     The community shut down Philani Clinic after a nurse there had disclosed patients’ health
                        After this, the harassment                    waiting months for simple procedures.        * Not her real name – changed
                                                                                                                                                                     information without their consent. TAC assisted in resolving the issue.
                     and arrests did not stop.                        The situation was so bad that even the       to protect her identity.

16                                                                                                                                                                                                                                                                                                     17
You can also read