WATCH | How the health department plans to stop alleged discrimination in clinics

When researchers from Ritshidze, a group of organisations that represent people with HIV, asked transgender people, men who have sex with men, sex workers and injecting drug users about how they’re treated at government health centres, less than half — and in some cases not even a quarter — of the more than 9,000 respondents reported being greeted by a friendly face.

In some of these groups, about one in five people said they’ve been blocked from getting health services. 

This is bad news for South Africa’s plan to curb HIV infections, which recognises these groups as key populations who need health services that can help prevent the spread of HIV, such as getting condoms, HIV prevention pills and testing and counselling. 

People from these groups have a high chance of getting HIV — and knowing they will be discriminated against, they stop going to clinics, James Oladipo, one of the Ritshidze report’s authors, told Mia Malan in May.  

It’s one more way in which discrimination fuels the spread of disease. 

“Public health should be where we can run to,” says Viyonce Mabena, a trans woman who works at The Aurum Institute. But instead they get turned away. 

Luyanda Mzimela, a trans woman who works as a counsellor at one of The Aurum Institute POP INN clinics, where people from key populations can get free sexual health services, recounts her experience of going to a government clinic. 

“I felt like I was not human. You’ve heard of human zoos [in European countries] back then? I felt like people looked at me like I’m an animal.” 

So what is the government doing to fix this? Mia Malan spoke to Thato Chidarikire, acting head of HIV programmes at the national health department, to find out in the latest episode of Bhekisisa’s monthly TV programme Health Beat. 

Mia Malan (MM): Who gives the training to health workers, the health department or do you contract it out? 

Thato Chidarikire (TC): It's both. Most of the training happens through partners, but we also do some. 

MM: What is it you teach health workers that helps change their attitudes? 

TC: We have a training curriculum. It has a participants' manual and a facilitators' manual. The first few chapters have an introduction to basic HIV information, [for example, symptoms and prevention tools]. Then it introduces how to deal with clients, especially key populations, [for example] the LGBTQ community, sex workers, men who have sex with men. [This is part of the training so health workers will] know how to respond and how to manage a situation [they are unfamiliar with]. We also train lay counsellors because they often do HIV testing. 

MM: In a specific example, say, a doctor who sees a transgender patient and argues the person is just confused about their identity, how [does the training help ] change the doctor’s attitude so that they don't discriminate in that way? 

TC: This training has video clips [where real people share their] experiences. [For example], there’s a chapter on transgender people with a trans person talking about their experience at a [health] facility. Because of a lack of information, people [struggle to] understand [key populations]. [The curriculum] starts from the basics, from [people’s] reality. What we’re trying to [achieve is] to say, “Be sensitive, be competent”. 

MM: Has the department sent a circular to all clinics to explain that people from key populations should never be refused healthcare, as the Ritshidze report recommended? 

TC: I can confirm the circular was signed and sent.  

MM: The report also recommended that the department work with people from populations with high HIV infection rates, for example sex workers or drug users, to develop posters that can sensitise health workers to those populations. Has that happened? 

TC: We're working with partners who specifically serve key populations to develop education and communication material, posters and pamphlets for healthcare workers and communities. 

MM: Who would be the audience for materials? 

TC: Anyone who uses public health facilities. [The idea is that] you will [see] posters on the walls that talk about different services provided by the facility. In the waiting rooms, you’ll find pamphlets that can be taken home. We also distribute the material to communities [during outreach activities].

MM: Have you investigated cases of discrimination mentioned in the report? 

TC: My office hasn't gone out to investigate. Because our community monitoring organisation works with provincial health departments, implementation happens at the district level and that's where the investigations are supposed to happen. [The national department] follows up to look at what the problems [are], especially logistics, because that's where we have power. For example, if a report says there hasn't been training, [we will try to resolve it]. 

MM: What would happen if a worker is found to have discriminated against someone from a key population? 

TC: There would be an investigation to get to the root cause. When we started [the] sensitisation programme with Pepfar [the US President’s Emergency Plan for Aids Relief], we went to facilities and spoke to health workers about training. [When we hear of discrimination we explain that as a health worker] you don't judge, because it's not your job. You give the services [needed] without judgment. 

MM: The Ritshidze report also pointed out many transgender people said they wanted access to hormone therapy. But this seems to only be available at large institutions in cities. At clinics in rural areas, people struggled to get it. How can you change that?  

TC: This is a specialised therapy [that is] scheduled and [people on it] also need psychosocial support. That’s why it's in specialised facilities such as tertiary hospitals [where there are specialist doctors]. [With] our [new] HIV plan, which is more community centred, we want to ensure everyone gets the services they need. However, when we think about moving a service out of a clinic or hospital and into a community, we need to talk about the infrastructure, training and how it’s going to be done safely. It’s a work in progress. 

This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.