Approaching a public health facility can be a daunting experience for certain population groups. For people who use drugs, sex workers and members of the LGBTQIA+ community, visiting a clinic can mean opening themselves up to mockery, hostility or even the denial of care.

The second edition of the Ritshidze “State of Healthcare for Key Populations” report, launched on Monday, highlighted the barriers facing key populations by drawing data from 9,137 surveys with gay and bisexual individuals, men who have sex with other men, people who use drugs, sex workers and transgender people.

Ritshidze is a community-led monitoring system developed by organisations representing people living with HIV, including the Treatment Action Campaign (TAC), the National Association of People Living with HIV and partners.

“These [Ritshidze] reports are assisting the National Department of Health and government to look at where the gaps are and how they can close those gaps,” said Sibongile Tshabalala, chairperson of the TAC.

“This report is very important in so many ways… that we tell our stories as communities, but also to assist the government in working with communities.”

Data was collected between July and September 2022 across 21 districts in seven provinces. The report showed that 12% of those surveyed were not receiving health services anywhere.

This marks an improvement on the survey results in the first edition of the “State of Healthcare for Key Populations” report, released in January 2022, which showed that 20% of key population respondents were not accessing health services anywhere.

“We acknowledge the improvement and we feel like we are on the right track, although we are not where we would like to be because we still have so many key populations who are not receiving adequate treatment,” said Tshabalala.

The 2023 report showed that in the category of “gay, bisexual and men who have sex with men” (GBMSM), 53% of respondents said they did not access health services anywhere, because these services were not private.

Across the categories of sex workers, transgender people and people who use drugs, the top reason for not accessing services was unfriendly staff at facilities.

“Ritshidze data show that both clinical and non-clinical staff such as security guards continue to be unfriendly and discriminate against key populations, be it at the clinic gate, in waiting areas or even during medical consultations,” stated the report.

Survey results indicated that staff at public health facilities were less friendly and professional to key populations than those at drop-in centres and mobile clinics.

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“This is consistent across all key population groups, with just 37% of respondents reporting that facility staff are always friendly and professional towards GBMSM (down from 42% last year); just 24% towards people who use drugs (down from 41% last year); 46% towards sex workers (up from 42% last year); and just 41% towards trans people (down from 46% last year),” stated the report.

Some members of key populations are refused access to care — outright. 

In the report, 19% of respondents who used drugs said they had been refused access to a public health facility in the past year. The proportion of respondents who reported having been refused access in the GBMSM, sex worker and transgender groups stood at 5%, 12% and 9%, respectively.

“People need to be sensitised… people need to understand what it means when we talk about key populations, and I don’t think that is something we can do overnight — but it’s something that we need to slowly engage people on so that they understand,” said Tshabalala.

A recommendation put forward by Tshabalala is that each district has at least one “monitor of key populations” who could travel between health facilities to provide training and guidance to staff.

Specific services for key populations

Key populations are disproportionately affected by HIV and therefore need access to certain services, including the provision of condoms, lubricants and sexually transmitted infection (STI) screenings and treatment.

However, the Ritshidze report shows that key populations often struggle to access basic HIV and STI prevention tools, either because the items aren’t available, or because members of key populations are questioned or denied when seeking them.

“Ritshidze data gathered in 396 facilities show that lubricants were only freely available in 27% of sites, external condoms in 81% of sites, and internal condoms in 65% of sites,” stated the report.

In both the GBMSM and transgender groups, 80% of respondents who sought STI treatment at a public health facility were able to access it. Only 72% of sex workers who sought STI treatment were able to access it.

James Oladipo, a researcher on key populations for Ritshidze, recommended that there should be at least two specialised public health facilities for key population services and care in each district.

“This will ensure that everybody would have accessibility to one of these facilities,” he said.

Collecting the data

Ritshidze aimed to double the number of surveys for the second edition of the key populations report, going from 5,979 to 9,137 surveys between 2022 and 2023. This ensured that the sampling behind the data was robust, according to Oladipo.

“Being fortunate enough to be one of those who does in-depth interviews… that are added to the quantitative data that was collected… I could see from key populations that they felt [they were] part of the solution,” he told Maverick Citizen. 

“They see that agreeing to those surveys, agreeing to do interviews, is one step towards finding solutions to the problems that they face at the facilities.

“We are hoping that when we do this drive again and present the third edition of the report, a lot of the recommendations have been actioned and that we have more good news.”

During the launch of the report on Monday, Deputy Minister of Health Sibongiseni Dhlomo thanked the organisations behind Ritshidze for the hard work done to collate rich data that could assist the health department.

“We have to work with that data and… our improvement as a health department must be informed and assisted by that data,” he said.

“I have seen that there are challenges in the country in terms of access to health services by our key populations, and we can only improve from this base.” DM/MC