Healthcare for Key populations: “Accommodate everybody”

This is Tebogo Matlaki’s fourth time going into rehab. 

The 31-year-old is from Vosloorus, a township 30 kilometres southeast of Johannesburg. He lost his policeman father to gun violence and turned to drugs when he was 16 writes Hannah Zhihan Jiang.  Matlaki started with mandrax and marijuana. Later, he used nyaope and rock (crack cocaine). 

“My father was a policeman and he got shot with nine bullets in our street. This really affected me,” Matlaki says.

Matlaki has been in and out of rehabilitation since he was 18, but he relapsed the previous three times. As a known drug addict in his community, Matlaki says his addiction brought shame to his family. Worse, it influenced his little brother to also use drugs.

“I couldn’t even stop him because I was using at the time as well. I know that it is better for me to stop and change,” he says. “But it was so hard. Even though I felt stuck and like my life is not progressing, it was hard to change. I was used to sleeping in the street, or in tunnels and doing drugs.”

More centres of excellence for Key Populations needed

Eventually, he decided to get clean and a local clinic referred him to Jabulani Dumani Community Health Centre, which he has frequented since 2022. 

“People always judge people like me who use drugs. They see you as dirty, a failure, a thief, and all these things. They don’t know how this makes us feel. But here they don’t judge us, they make us feel welcome.” 

Jabulani Dumani Community Health Centre in Vosloorus is one of the two public clinics designated as Centres of Excellence for Key Populations in Gauteng Province with their staff fully or mostly sensitised and trained to treat members of Key Populations. 

During Health-e News’s visit to Jabulani Dumani patients and employees shared how respect and understanding are always extended. However, contraceptive shortages and infrastructure deficiencies such as the lack of non-gender bathrooms remain barriers to accessing dignified healthcare for Key Populations. 

According to UNAIDS, Key Population includes gay men and other men who have sex with men, sex workers, transgender people, people who inject drugs and prisoners and other incarcerated people. KP are particularly vulnerable to HIV and frequently lack adequate access to services.

“We realised that 12% of Key Populations we interviewed don’t even access services anywhere because they’ve given up based on the type of experiences that they receive. The drop-in centres that are available: a lot of them don’t know about it,” says James Oladipo, a researcher at Ritshidze, a clinic monitoring organisation.

Staff attitudes, stigma barrier to care for Key Populations

Ritshidze spoke to over 9 000 key populations across South Africa in 2022. They found extensive poor staff attitudes, lack of safety and lack of privacy at public health facilities. Only 24% of the respondents reported the staff were friendly towards people using drugs, 37% towards gay men and other men who have sex with men and 41% towards trans* people. 

The project recommends that the Department of Health should establish two Centres of Excellence per population group per district. Olapido said the DoH has promised one Centre of Excellence per district in 2023, which falls short of Ritshidze’s recommendation.

Three more facilities in Gauteng have been identified to be established as KP Centres of Excellence by the end of June 2023, according to Motalatale Modiba, Gauteng Department of Health spokesperson. 

“I think the hope will be for this Centre of Excellence [model] to flow out into the other clinics, a focused intervention approach,” says Oladipo. “There’s still a lot to be done, based on what we’ve recommended, based on what we’ve found on the ground, to what they’ve committed to doing.”  

“An eye-opener”: KP sensitisation training

Jabulani Dumani CHC is surrounded by “hotspots” where sex workers work and where people who use drugs gather, says Sandile Matsaba, Centre Assistant Director. It also has a history of treating inmates and other incarcerated people. The clinic treats both Key Populations and general patients. 

Matsabe says the centre “scaled up” staff training in 2022 to sensitise staff with a focus on Key Populations. They have used the Key Populations Sensitisation and Competency Development Toolkit developed by the Department of Health with support from PEPFAR, a U.S. government initiative to address the global HIV/AIDS epidemic. 

The modules include defining and identifying Key Populations, sexual orientation and gender identity as well as recognising each KP group’s needs. 

Olive Nomakhosazana, operational manager at J Dumani, says she saw a difference in the staff’s attitudes towards Key Population before and after the training. 

“They used to have that thing of: Did you see? Who is she? After the training, they treat everybody normally with respect and dignity. They must not take a final decision. They must ask the person.”

At J Dumani, after registering at the reception, both Key Populations and general patients are sent to private consulting rooms. Six doctors are on-site to prescribe treatment or refer patients to other facilities. 

“We didn’t want to segregate them. Because if you [separate by] this is the key population, there’s their consulting room. People will be labelled,” says Matsaba.

Need for more resources and continued training

While condoms are provided at the entrance and bathroom, the clinic has seen an inconsistent supply of lubricants, which reduces friction and lowers the risk of HIV transmission when men have sex with men. 

GDoH did not respond to questions about the shortage by time of publication. Contraceptive stockout has been an issue since 2022 as it represents 40% of medicine stockout, according to a Ritshidze survey last April monitoring 15 750 public healthcare users.

Sister Nomakhosazana mentioned that the infrastructure condition prohibits the construction of gender-neutral bathrooms in J Dumani. “Back in our training, I understood that they must have their own bathroom and it must be labelled. The infrastructure doesn’t allow us to do some of the things.” 

Both Oladipo and Matsaba say continuous staff sensitisation training is needed. “You can’t receive a one-day or a one-week training, and then you’re all changed if someone is homophobic or transphobic.”

With the slow rollout of the Centre of Excellence, Oladipo pointed out that some members of Key Population might not be able to afford the transport cost or have access to transport arrangements. 

More leaflets or pamphlets are also needed from the Department of Health to raise awareness of the clinic as a Centre of Excellence for Key Populations in the community, says Nomakhosazana and Matsaba. 

“Everybody must be accommodated. We are a free country. The education must start somewhere,” says Nomakhosazana. 

“I have hope that when I come back from rehab, my life will change and get back on track. As a changed person, I could also help other people struggling with the same thing, like my little brother. He will see that I can change and will do the same. For as long as I use drugs, nothing in his life will change. When he sees that I have changed, he will do the same,” says Matlaki.  – Health-e News