Important new MDR-TB treatment findings

Last week a number of important study findings with implications for the treatment of multi-drug resistant tuberculosis (MDR-TB) were reported at the Union World Lung Conference in Guadalajara, Mexico.

Delamanid phase III findings

Early findings from the phase III trial of delamanid for the treatment of MDR-TB were announced  last week – making delamanid the first of the new TB drugs to have phase III data. The trial compared a background regimen plus delamanid to the same background regimen plus a placebo.

Culture conversion at six months in the delamanid arm was 87.6% vs 86.1% in the control arm. Maybe most importantly, 24-month outcomes and all-cause mortality in the two arms were very similar. There were no serious safety issues with delamanid and one promising benefit associated with delamanid was a reduced risk of developing further drug resistance.

Given the high hopes many people had, and some still have, for delamanid, these findings are very disappointing. They suggest that delamanid is not the breakthrough blockbuster we had hoped it would be, or at least that the standard of care is better than most thought, especially now that many people are receiving powerful drugs repurposed for TB, like linezolid.

That said, the endTB consortium also last week reported some promising findings on the use of delamanid and bedaquiline in people with XDR-TB. 46 patients received delamanid and bedaquiline in combination, nearly half (48%) of whom started the two drugs within seven days of each other. Patients tolerated the combination well and there did not appear to be any additional increase in the side effect of concern (QT prolongation, a potentially dangerous disturbance of the heart’s electrical activity, which each drug causes independently).

Making sense of all the new evidence on delamanid will take time and will become easier once findings are reported in more detail in medical journals.

Standard of care on trial

In another critical study called STREAM stage I, the old 20/24-month World health Organisation (WHO) recommended standard of care for the treatment of MDR-TB was pitted against the still relatively new nine-month WHO recommended standard of care. While both arms in the study fared relatively well compared to abysmal treatment success rates of about 50% seen in routine care, the study findings reported so far failed to show that the nine-month regimen is non-inferior to the 24-month regimen. 78.1% of patients in the nine-month arm achieved a favourable outcome compared to 80.6% of patients in the 20/24-month arm. Surprisingly, the shorter regimen also did not appear to have an advantage in terms of side effects over the longer regimen.

These results (as well as the delamanid findings described above) are somewhat complicated by the fact that the 20/24-month regimen did much better in these studies than observed historically and in many healthcare programmes. There is some speculation that this effect is due to broader access to linezolid and clofazimine (which essentially means that the background regimen has been improved). It could also be due to earlier diagnosis of MDR-TB given much increased access to faster TB testing in the form of  Xpert MTB/RIF, or the exclusion of patients with more complicated drug-resistant TB from these trials.

Despite the failure so far to show non-inferiority, the cure rates in the 9-month arm may well be good enough to justify its continued use – especially given the cost-savings and likely improved treatment adherence associated with this shorter regimen in real-world settings. That said, it is hard to come to any firm conclusions based on early and incomplete data. It will, for example, be critical for the South African context to see how the 9-month regimen did in people living with HIV. Earlier this year South Africa’s Minister of Health Dr Aaron Motsoaledi announced that South Africa will be switching to the nine-month regimen.

Prior to these early results from STREAM stage I, the case for the nine-month regimen was built on mostly observational data. In recommending the nine-month regimen last year, the WHO recognised that the evidence-base for the recommendation was weak. The STREAM stage I findings once again shows that observational data can sometimes overstate comparative efficacy and that questions of which regimen is better is best answered by large randomised controlled trials.

The findings of STREAM stage I also vindicates earlier decisions taken about the design of STREAM stage II (the trial serving as the bedaquiline phase III trial). In STREAM stage II, two bedaquiline-containing regimens are pitted against both the nine-month regimen and the old 20/24-month regimen. Earlier thinking was that STREAM stage II would only contain the nine-month regimen as a control – it having been assumed that the nine-month regimen would be non-inferior to the 20/24-month regimen. Since this non-inferiority has not been shown, the insurance option of maintaining the 20/24-month arm as a control has been vindicated.

 

Buthelezi: SANAC to lead the prevention revolution

By Dr Sandile Buthelezi

Dr Sandile Buthelezi

In June 2017, at the end of the South African National AIDS conference, Deputy President Cyril Ramaphosa, who is also the Chairperson of SANAC, called for a Prevention Revolution to prioritize prevention, the same way we do with treatment. As I reflect on this as the newly appointed SANAC CEO, I see my appointment as an opportune moment for SANAC to take up this challenge.

In South Africa, we know that approximately 270 000 people are newly infected with HIV every year. What we also know is that almost 48 million South Africans are HIV negative. Our major task is therefore to keep these people negative.

We know what to do and how to do it: over the past few years, we have gained knowledge and appreciated the efficacy of new tools to prevent HIV, from pre-exposure prophylaxis (PrEP) to the knowledge that an undetectable viral load dramatically reduces the risk of transmission. SANAC’s urgent and immediate task will be to rally everyone behind a new prevention revolution that harnesses combination prevention approach, especially in communities hardest hit by HIV.

In a UNAIDS Discussion Paper on combination prevention, combination programming is defined as “rights-based, evidence-informed, and community-owned programmes that use a mix of biomedical, behavioural, and structural interventions, prioritized to meet the current HIV prevention needs of particular individuals and communities, so as to have the greatest sustained impact on reducing new infections.”

While we appreciate that the pace of decline in new infections is not fast enough, the reality is that we have not put prevention back at the top of our priority list. SANAC will have to take major strides to address this, which is why the new National Strategic Plan for HIV, TB and STIs (2017-2022) has placed prevention as the first goal with the bold target of reducing new HIV infections by more than 60 percent and cutting TB incidence by at least 30 percent.

South Africa has made significant progress: more than 10 million people now test for HIV each year; new HIV infections declined from 367 946 in 2011 to 266 618 in 2016, a 27.5% reduction against a target of 50%. We have also recorded major successes in the reduction of mother-to-child transmission of HIV from 3.6% to 1.5% (measured at 6 weeks postpartum), the lowest rate in Southern Africa. In addition, the number of infants born HIV positive has been reduced from 70 000 in 2003 to less than 6 000 in 2015, putting us on the road to eliminate mother-to-child transmission of HIV. But these gains could be reversed if we do not take urgent and immediate action to step up our prevention efforts.

What does a Prevention Revolution look like?

Everyone speaks of ‘combination prevention’, but we have not committed to specific programmatic priorities and actions. The referral pathway for HIV negative individuals, for instance, is poorly defined and implemented therefore an area that must be strengthened. Although targets for a multi-sectoral prevention response exist, they are not as memorable as the treatment targets. Every AIDS council must have a robust prevention plan and be capacitated and financed to monitor, track and review implementation progress.

Service providers also need guidance around the range of new combination prevention options that are now available. They are grappling with the rapidly changing landscape, and are faced with the challenge of conveying increasingly complex sexual health information in a way that resonates with key populations such as men who have sex with men, young girls and women. Furthermore, we need to create coherent and consistent prevention messages so that we don’t overemphasize one at the expense of others. We can’t afford to leave anyone behind.

To maximize impact and use resources optimally, HIV prevention interventions of proven high impact need to be delivered to key locations and priority populations. Protecting human rights, safeguarding gender equality and ensuring access to services for key and vulnerable populations remain pivotal in the HIV response. Social and structural drivers which place people at risk of infection must also be addressed earnestly by investing now for long term sustainable solutions.

We know that people at risk of HIV infection have a cascade of HIV prevention needs. They need to be aware of risk, to learn how to protect themselves (including knowing their HIV status) and to have the means to protect themselves. They also need the power to make informed decisions about HIV prevention options and to receive support for their choices.

Just as innovation has changed the landscape of HIV prevention in the past, innovation will remain critical. We can’t continue doing the same things hoping for different outcomes.

Combination prevention will only work if it is based on a genuine understanding of the nature of the epidemic in each community. Communities and local organizations are well placed to contribute their knowledge and expertise to highlight who and where to focus and what works. They should be at the forefront of the local prevention response.

Communities will need to use their power to push this new HIV prevention revolution and hold governments, donors and themselves accountable. Without community ownership, the target of reducing new HIV infections by 50% by 2022, and virtually eliminating them by 2030, will not be achieved.

I am also committed to making sure SANAC provides the leadership needed to achieve these goals. For SANAC to reach its full purpose and potential, it too must change. It is time for us to recognize our shortcomings and reform the way we work.

Let our actions count!

Spotlight on health MECs: Phophi Ramathuba

Building health infrastructure – and Brand Phophi

By Ufrieda Ho

It’s a health budget day in Limpopo, and MEC Dr Phophi Ramathuba is set to address a packed council sitting in Lebowakgomo on how R18 billion will be divided up for health needs in the province.

It’s Ramathuba’s second year in the role, and it’s a balancing act for a department that only came out of administration by national treasury less than two years ago.

Some in the gallery on the late summer day are clutching bottled water, and dressed like they’ve copped an invite to the glitz party of the year. Ramathuba herself has chosen a siren-red two-piece suit. It’s matched with red high heels. Shoes are her weakness, Ramathuba has been reported as saying.

Her outfit shows off her slimmed-down figure. In recent months she’s become her own poster child for the ‘Pfuka – move for your health’ campaign, which she introduced in the province. Her office manager and spokesperson joke that they’re expected to join in on the daily 30 minutes of heart-rate-raising exercise before the desk-job part of their work day begins. It’s all about putting into action a health campaign the MEC has been punting: getting people to take responsibility for their own health and well-being.

On budget day, her staff are busy shuffling her between interviews. They’re running over time; the schedule has bottlenecked. In the end, they give Spotlight literally five minutes with the MEC, despite requests for interview time and face-to-face interaction having been confirmed weeks in advance. The MEC’s spokesperson offers Spotlight the option to wait till early evening, in the hope that Ramathuba’s schedule will ease up. That, or emailing further questions.

Even as she talks, Ramathuba is distracted; she apologises while she make a phone call on one of her two phones. She has to check in with cousins who have arrived as VIPs for the budget address, she says.

Her staff say she operates at full tilt most work days. But they don’t want to get into any personal details about what makes their chief tick. They do say that when the MEC gets angry, it’s over something like a hospital or clinic that hasn’t done something it’s supposed to have ticked off. They also steer away from controversial questions, adding quickly that budget day is a ‘happy’ day. It is certainly a day bizarrely infused with pomp and ceremony.

Far from the sham glam and the clock-watching in the council chambers, though, are real concerns. Healthcare workers have been on strike, days before Ramathuba’s budget speech. For them, time has been about waiting for unpaid bonuses, and their strike has begun to affect services at Polokwane Hospital. It’s the latest in a seemingly constant stream of bad news reports about health in the province.

There are severe staff shortages, and a glaring loss of experienced senior staff at facilities – many have been seduced by better pay and working conditions in private hospitals. There are regular reports of theft of medicines; shortages of essential equipment so dire, babies are said to have to share incubators; and ambulances are reduced to mortuary vans because they take forever to arrive, if they arrive at all.

There’s also mismanagement and corruption at some facilities. Ramathuba’s own unannounced spot visits at some of the province’s hospitals during her tenure have revealed incidents such as patients going without proper meals, even when allocated provisions have been available.

She’s also had to put out fires over corruption and scandal.

In the days before the budget speech, the Democratic Alliance has flagged an outstanding financial debt owed to Cuba for the Cuban doctors programme that runs into millions. Cuban doctors are firmly entrenched in Limpopo – this, even as their inability to understand local languages and local conditions is a cause of deep frustration for local patients.

There’s also been a scandal involving a bogus hospital laundry contract for 32 hospitals in the province. It resulted in the Economic Freedom Fighters (EFF – the official opposition in the province) laying charges against Ramathuba, even though it was a scandal she inherited. In response, Ramathuba took the decision to insource hospital laundries by introducing laundry mini-hubs. The final design and planning for these are expected to be completed this financial year.

Corruption and inefficiencies in the system cost lives, especially in a province where the Department of Health says more than 80 per cent of the population is rural, and fully reliant on public healthcare. When local clinics prove to be hopelessly under-resourced, people are referred to facilities in bigger towns. For rural people this means travelling long distances, at significant expense, to access treatment. Often they travel the night before their appointment, sleeping on hospital benches to secure a place in the queue to be seen by a doctor. Even then, sometimes people are simply turned away before they receive any help.

Ramathuba should have first-hand understanding of the challenges of under-resourced rural areas. She grew up in Vhembe, to parents who were teachers. She had a lifelong dream to become a doctor. After she graduated from what was then Medunsa she worked at the coalface of healthcare, starting out as an intern at Makopane Hospital. Ramathuba eventually worked up to the position of chief executive of Voortrekker Hospital, before joining the political ranks.

She also holds a master’s degree in medical pharmacology, through the University of Pretoria, and has qualifications in advanced health management as well as other business and leadership qualifications.

She prides herself on being an activist, though. In her budget address she invoked Biko, Fanon and Marx, even as she spoke about fighting mental health, the success of a cataract-removal programme, HIV-testing targets and increased treatment budgets to R1.3 billion (including R479 million for ARV drugs), and even the impact of continued water shortages across Limpopo on making quality healthcare a reality.

Revolutionary ideals and old struggle heroes still matter to Ramathuba, she says. They keep her in touch with why she became a doctor in the first place – Marxist ideals such as working for all, and sacrificing for the common good. She took to heart a call from the Limpopo Aids Council, in October 2016, for senior government officials to ‘adopt’ child-headed families in their constituencies; Ramathuba donates to and supports four households in need in Vhembe, a press release from her office stated.

And she believes in a bit of humour. She has a good giggle when she’s reminded that when she delivered her budget speech, her cheeky joke about the mental health of some members of the legislature didn’t go unnoticed.

Ramathuba demonstrated skill in being able to make her speech engaging and interactive – not just through the odd joke, but also by introducing some of her personal guests on the day. They include young graduate doctors, part of Ramathuba’s troop of ‘super-specialists’.

She also introduced a nurse she met on Facebook. Angela Motsusi defeated the depression that took over her life when she was diagnosed HIV-positive in 2011. Motsusi is now an HIV/Aids ambassador, and was singled out by Ramathuba as an inspiration. In turn, Motsusi later posted selfies taken in the legislature building, saying how honoured she felt to be Ramathuba’s special guest and calling the MEC “a humble leader”.

Ramathuba has a modern touch in the way she stays connected. She uses social media effectively, and taps into issues in a relevant way. Her #blessersmustfall campaign speaks directly to young people whose worlds may only seem real when they’re hashtagged. She’s even approved flavoured and coloured condoms as part of state issue stock, because she says young people prefer them.

On her Facebook page, she has just under 5000 ‘friends’; and there’s a mix of curated personal posts and professional content. Interestingly, the page includes comments of all kinds, from the odd post slamming Jacob Zuma’s salary being unequal to the job he’s doing, to a photograph of someone bringing to Ramathuba’s attention the spin of British PR company Bell Pottinger in creating the phrase ‘white monopoly capital’, seemingly to divert attention from the controversial Gupta family’s relationship with Zuma.

That she’s allowed her page to be uncensored speaks volumes. That she also manages to cram in posts of PR campaigns for the department (everything from malaria prevention to combating depression, fighting nyaope use, and even ‘insecticide pastors’) is a touch of social-media genius.

In one of her Facebook picture she’s in traditional Xitsonga dress. It garners comments such as “looking gorgeous”, and “just beautiful honourable”. She’s also seen, in official pictures promoting a vaccination campaign, in a doctor’s white jacket. There are pictures of Ramathuba holding Limpopo’s Christmas and New Year babies, as well as images of her in meetings tackling a malaria outbreak; she reposts reports about crises in troubled Vuwani, which made headlines when schools there were torched and burnt to the ground in 2016.

There are also pictures of Ramathuba and her two daughters at an ANC rally. Ramathuba gave birth to her first daughter over a decade ago – at a public hospital. It earned her significant kudos, for trusting her own state-run institutions. Though what her choices for healthcare in the province are now is unclear – Spotlight’s emailed questions to her team went unanswered.

Ramathuba does maintain popular appeal. She’s been given monikers such as ‘Dr Fix-It’ and ‘DiPhoplar’, and Limpopo TAC welcomed her appointment. It’s not so much Ramathuba being able to wave a magic wand over entrenched problems in the province; it’s more to do with her approach: staying connected, being seen to be taking the concerns of civil society organisations seriously – and even sucking up criticism from detractors.

It would be easy to for her to scoff, and retreat behind her position and title as MEC; but that would be an empty tactic. Ramathuba seems to understand this, and it’s working for her .

 

New SANAC CEO responds to questions about his past

By Ufrieda Ho

Dr Sandile Buthelezi was recently appointed as the new head (CEO) of the South African National AIDS Council. His appointment follows the suspicious non-renewal of the previous CEO’s contract Dr Fareed Abdullah and unsuccessful attempts to lure Eastern Cape head of health Dr Thobile Mbengashe to the post. The success of the new National Strategic Plan implementation and the long-term survival of a robust, relevant and ethical SA National AIDS Council will depend on the new CEO. Spotlight put a range of questions to Buthelezi regarding his involvement in the Tara KLamp debacle, the persecution of doctors at Manguzi Hospital in 2008, and allegations of corruption.

Dr Sandile Buthelezi was recently appointed as the new Chief Executive Officer (CEO) of the South African National AIDS Council (SANAC). Buthelezi’s appointment comes as a surprise, given that it was expected that the position would go to Thobile Mbengashe – who Spotlight understood to have been the preferred candidate of key members of the SANAC board of trustees. However, we understand the Eastern Cape made Mbengashe a counter offer, which made it hard for him to leave for the SANAC job.

Buthelezi’s appointment also surprised activists who are concerned about his involvement in the rollout of an unsafe circumcision device (the Tara KLamp) in Kwazulu-Natal and the persecution of doctors at Manguzi Hospital in 2008. The doctors were providing dual antiretroviral therapy to pregnant women with HIV. At the time providing dual therapy was deemed to be against the government policy of AIDS denialist President Thabo Mbeki and Health Minister Manto Tshabalala-Msimang.

Highly charged atmosphere

Buthelezi is stepping into a highly charged atmosphere with recent news reports describing SANAC as being in disarray and various civil society organisations considering a withdrawal from SANAC. Some of the concerns regarding governance at SANAC relate to the process of appointing a new CEO. For reasons that have not yet been explained, an initial recruitment process was stopped halfway and the post was readvertised early this year. In February this year the trustees, then led by Dr Gwen Ramakgopa, who is now Gauteng MEC for health, announced that Dr Malega Constance Kganakga had been appointed acting CEO for three months while interviews were being completed. It would be another four months (after those initial three months) before Buthelezi took office at the beginning of September 2017.

The board controversially decided in February not to extend the CEO contract of Dr Fareed Abdullah or to allow him to continue as interim CEO. This move was met with widespread condemnation from activists and the Democratic Alliance. Abdullah is credited by some for transforming SANAC into an independent Council that for the first time had five straight years of clean audits and better checks and balances in place to ensure good governance.

Buthelezi told Spotlight he wishes to thank his predecessors “for building SANAC into the credible organization that it is”. “SANAC operates against the backdrop of people’s perception of government institutions and hence our first duty will be demonstrating good corporate governance,” says Buthelezi. “This is a critical obligation that we at SANAC need to uphold, and it will be the hallmark of my tenure.

Persecution of Manguzi doctors

In 2008 Buthelezi was head of HIV and AIDS in KwaZulu-Natal where he played a role in the persecution of doctors at Manguzi Hospital. Dr Colin Pfaff, acting medical manager at Manguzi Hospital at the time, and colleagues broke rank from official Department of Health policy to introduce dual-therapy treatment for HIV-positive pregnant women at a time when official government policy was to provide only monotherapy.

The science at the time was clear that dual therapy was superior to monotherapy in reducing mother-to-child transmission of HIV. Pfaff raised funds from donors to pay for the introduction of dual therapy at Manguzi. Pfaff was suspended for this and faced disciplinary action – that was later withdrawn.

Buthelezi admits he worked closely with doctors in the district at the time and adds: “I believe it is unfair to expect a junior official to act out of sync with national government policy.” At the time Buthelezi was quoted making a similar argument in the New York Times saying “I am wary of us undermining national just because of what other provinces are doing (referring to the rollout of dual therapy in the Western Cape)”. At the time Buthelezi was working under controversial KwaZulu-Natal MEC for Health Peggy Nkonyeni – who was a close ally of AIDS denialist Health Minister Dr Manto Tshabalala-Msimang.

No regrets regarding Tara KLamp

In 2010, Two years after the Manguzi scandal, with government-sanctioned AIDS denialism having meanwhile “ended” under the leadership of first Health Minister Barbara Hogan and then her successor Dr Aaron Motsoaledi, the Kwazulu-Natal Department of Health was involved in another high-profile controversy. The department started providing circumcisions with an unsafe plastic circumcision device called the Tara KLamp. The device caused a number of serious injuries and eventually became the subject of a Treatment Action Campaign complaint to the Public Protector. Questions about alleged kickbacks relating to the procurement of the Tara KLamp remain unresolved seven years later.

While Buthelezi wrote letters and was quoted in the media in relation to the Manguzi scandal, it appears he was less directly involved with the Tara KLamp rollout. Another Sandile, Sandile Tshablalala, was in charge of the circumcision programme in the province. As with Manguzi, the Tara KLamp had high-profile political backing  this time in the form of MEC for Health Sibongiseni Dhlomo, then Premier of Kwazulu-Natal Zweli Mkhize, and King Goodwil Zwelithini.

Yet, as head of HIV and AIDS in the province Buthelezi would have almost certainly been party to decisions made regarding the rollout of the Tara KLamp. We can find no evidence that he opposed the rollout in any way – this while he admits involvement in the circumcision programme. “I am proud of my contribution to the roll-out of medical male circumcision in KwaZulu-Natal,” says Buthelezi, wwhich included (…) Rallying all stakeholders including His Majesty, in advocating for MMC.”

“The implementation of medical male circumcision in the province remains a watershed moment in the country’s HIV response,” he says. “A province where circumcision was not routinely practised, took the lead in including medical male circumcision as part of a combined package of prevention methods. This is a significant achievement and I have no regrets.”

Corruption allegations

In late 2010 Buthelezi left the KZN Department of Health. A source suggested to Spotlight that Buthelezi’s departure was related to allegations that he awarded a catering contract to a family member.

While Buthelezi does not dispute that the allegations were made, he insists that they are baseless and untested. “The issue relates to a tender that was dealt with at a district where I was not involved in any of the bid committees,” he says. “I only received paper work to approve payment after the district committees and management had signed that they received the goods and/or services.”

Buthelezi says he left the KZN Department of Health because he received a better job offer and that he continued to have a good relationship with the department after he left. He took up a position as country director of ICAP, a University of Columbia initiative to strengthen health systems around the world. From there he left to work at HLSP- Mott MacDonald, as senior technical lead with the health sector consultancy. In 2014 he was reappointed to the ICAP role.

“He will have to build trust”

Several of Buthelezi’s previous colleagues, members of the SANAC board and people he had professional dealings with at his previous positions were contacted to comment on Buthelezi’s appointment. Some didn’t respond and some declined to comment on record. Professor Wafaa El-Sadr the director of ICAP, based in New York, did comment, saying that in the last three years that he reported to her that Buthelezi did meet specific implementation targets and successfully built important linkages and partnerships within his team. “He had a good understanding of the lay of the land. He had the experience and he did understand South African realities.

“The challenges for a strong SANAC will be about never losing sight of the core of what we do and that is to change the lives of people. He will have to build trust and be able to bring along with him even those people who are not supportive of him,” says El-Sadr.

“He was on the wrong side”

Anele Yawa, General Secretary of the Treatment Action Campaign, says that Buthelezi’s past cannot be ignored. “He was on the wrong side – he was an AIDS denialist, like Manto Tshabalala-Msimang and Thabo Mbeki, he wasn’t for the people,” he says.

“We don’t just want a warm body in the position of CEO and we still don’t know what happened with the process of appointing a new CEO,” says Yawa. “Buthelezi must be able to add value. He can start with audits of the organisations that are part of the SANAC civil society sector – he can even start with TAC, this will make it clear who should be part of SANAC and who should not.”

Yawa says SANAC has to return to the grassroots – the face of HIV/AIDS, not be fixated on “meetings and conferences held in fancy hotels”.

Even with his outspoken criticism, Yawa says that for now TAC remains committed to staying within SANAC. “We want to fix the problems because we have come a long way. But when we ring the bell Buthelezi must come. We give him three months to get his house in order,” says Yawa.

“I believe in service”

Buthelezi says his vision for SANAC will become clearer once he settles into the role. But he says he’s up to the job. “I come from rural eShowe where humility, respect and ubuntu define human relations,” he says. “We’ve fought HIV for too long – we must see results.”

“I believe in service and I am results-driven and work well with teams. I hope we shall be an organisation that listen actively, prioritises what’s important, adapts readily and empowers others.”

 

Spotlight on health MECs: Gwen Ramokgopa

By Ufrieda Ho

Government’s merry-go-round of political appointments saw Gwen Ramokgopa return to the position of MEC for Health in Gauteng in February – a post she first held in 1999.

It couldn’t have been worse timing for Ramokgopa. She inherited the post

Dr Gwen Malegwale Ramokgopa Credit: gcis.gov.za

vacated by Qedani Mahlangu in the aftermath of the shameful tragedy of the deaths of at least 94 mental health patients released from private mental healthcare facility Life Esidimeni. They were among the approximately 1398 mentally disabled patients released to 27 non-governmental organisations (NGOs).

Her first days in office would reveal that the number of deaths was in fact over 100. As of the beginning of March, 789 of the original 1398 patients discharged from Life Esidimeni were known to be at 22 NGOs, according to health department records. The whereabouts and details of those still unaccounted for remain a glaring concern, and the focus of investigations.

Ramokgopa’s public pledge at the time of taking office was to “protect the most vulnerable among us”; also, to “reflect on this experience‚ as difficult as it is, and find ways to restore the confidence of our people in our health system”. She spoke of transparency as being important as she tackled the fallout of the crisis.

However, weeks after Spotlight went through several official channels, Ramokgopa remained unavailable for interview – her communications team didn’t bother to go beyond acknowledging our several and repeated requests for an interview.*

It’s not an ideal start. Not because media should be her priority; but open communication should be right up there, and so should answering questions fully, rather than through the filter of official statements and generic email responses. This speaks to a pig-headedness in her leadership that seems to have crept into how Ramokgopa has conducted herself in recent public-office positions.

While she was mayor of Tshwane, between 2006 and 2010, she was slammed as the ‘worst mayor in the country’ – a label she received because her city was failing to deliver services such as housing, electricity, tap water, sanitation, security and refuse removal to about a quarter of the capital city’s people, according to the Empowdex Service Delivery Index. In 2009, the city’s debt stood at R3.7 billion. She had to reshuffle her leadership, and admitted publicly to cash-flow problems and low revenue collection for the city coffers. At its nadir, Pretoria teetered at the point of being placed under financial administration; but Ramokgopa continued to pooh-pooh allegations of financial maladministration.

This was a dangerous failure, because of the chilling consequences. As the Tshwane report in 2009 pointed out: “Basic services are the fundamental building blocks to economic empowerment in South Africa.” It remains a truism today.

But it was her controversial decision to ram through two key name-changes in the capital that heaped criticism at her door, and even led to her brief ‘kidnapping’. She failed to follow due process in pushing for Pretoria to be renamed Tshwane. She also pushed through with renaming Ga-Rankuwa Hospital, to Dr George Mukhari Hospital.

According to the Daily Maverick, the name change arose from a promise Ramokgopa had made to the Mukhari family, when she spoke at George Mukhari’s funeral. So unpopular was her unilateral decision and favouritism, the Daily Maverick reported, that at one point during the fiasco angry protesters bundled her into a taxi without her bodyguards and entourage, intent on spelling out their contempt to her face. She was released unharmed.

When Ramokgopa vacated the mayoral post, in 2010, the ANC filled the position by appointing her nephew, Kgosientsho Ramokgopa. It was an appointment credited to party-political loyalties, as the family were allegedly faithful backers of Paul Mashatile, outgoing Gauteng Premier at the time.

Gwen Ramokgopa is a dyed-in-the-wool ANC activist, and over the years has worked her way up from student activism to becoming a top-ranking member of the Gauteng ANC. She grew up in Atteridgeville, a township west of Pretoria. She is married to Allen Lephoko, and they have three children and a grandchild. Her publicly available personal information extends to her being a Christian who enjoys reading.

Her husband made news in 2009 when Ramokgopa and Lephoko arrived at the Hatfield Community Court, where their then-18-year-old daughter Lerato was appearing on allegations of drug possession. Allen Lephoko’s scuffle with photographers outside the court led to an assault charge being laid against him.

Ramokgopa’s official government bio says she qualified from Medunsa as a medical doctor in 1989. She worked at Ga-Rankuwa Hospital as a medical officer until 1992, before joining the Independent Development Trust (IDT) as National Health Programme Manager.

Her medical career as a practising doctor ended and her political career took off instead, though it was always linked to healthcare-related portfolios. Before returning to the role of Gauteng MEC, she was deputy health minister between 2010 and 2014.

In 2015 the Tshwane University of Technology (TUT) appointed her its chancellor. They lauded her as “a woman of stature, a visionary who is passionate about success and excellence in every cause she commits to”.

The institution also outlined some of her achievements; she is no stranger to firsts, having been the inaugural CEO of the South African Medical and Dental Practitioners Association, and the first woman MEC for Health in Gauteng Province.

Her return to the role of Health MEC will not be about firsts; most immediately, it will be about putting out the raging fires linked to the Life Esidimeni tragedy, and carrying out the recommendations from the Health Ombud’s findings into the death and suffering that occurred.

Ramokgopa was quick to outline her plan of action – including her Rapid Intervention and Response Team, which has a dedicated reporting and assistance hotline (where someone does answer the phone, Spotlight can confirm) that is expected to give weekly report-backs. She also announced an immediate halt to the deinstitutionalising of mental health patients – a decision her predecessor, Mahlangu, had taken because, she said, the private-sector provider was costing too much.

Ramokgopa also outlined plans to gather better data and information from patients and the families of the patients; vowed better consultation with families, and urgent assessment of the province’s mental health patients, so that if necessary they can be transferred from the NGOs to better care facilities.

At the time, she said: “I bemoan the fact that as a medical professional and an activist for a just society‚ together with millions of other South Africans, I could not foresee and thus intervene to prevent this tragedy as it unfolded.”

Ramokgopa stopped short of criticising Mahlangu. Closing ranks, she called Mahlangu “hard-working”, and commended her for her “integrity” in the financial management of the provincial department, which finally achieved an unqualified audit only in 2016.

In the meantime, the Economic Freedom Fighters, the Democratic Alliance and even the ANC Youth League had laid criminal charges against Mahlangu. Premier David Makhura had also suspended head of department Dr Barney Selebano.

This was the raging furore into which Ramokgopa stepped. And her own appointment was met with immediate sniping from opposition parties. The DA’s Gauteng Health spokesman Jack Bloom called her “mediocre”, judging from her first go at the portfolio in 1999, and said: “She does not have the drive to fix this deeply dysfunctional department.”

Previously, Gauteng Premier David Makhura had mapped out the enormous challenges faced by the department. In his report on the financial health of the province in August last year, he spoke of needing to lift the financial “cloud hanging over Gauteng” for over 10 years that had gathered over poor financial audits for the Department of Health (till the unqualified 2015/2016 report). He also pointed out the challenge of meeting the needs of “large volumes of people who come from other provinces to seek medical help in Gauteng”.

It is up to Ramokgopa to restore everyone’s massively damaged confidence in the Gauteng Department of Health, and to take forward the turnaround strategy the department outlined in 2014. It features eight core focus areas: financial management; human resource management and development; district health services for primary health care; hospital management; medico-legal services and litigation; health information management and systems; communication and social mobilisation; and health infrastructure management and development.

These are broad categories, with vast, complex needs. Ramokgopa, returning to her MEC role 18 years later, will need to show that this time round she has the mettle, vision and mature leadership to get the job done. It will be about inclusivity, transparency and action to radically transform the health department – not just about a high-profile cadre sent in to do a public-relations mop-up job for the political leadership.

We watch with keen interest to see what Ramokgopa’s legacy will be on the Life Esidimeni tragedy. Will she be the MEC who held the perpetrators accountable or will her legacy be the MEC who failed to act.

*A request for face-to-face interaction with MEC Gwen Ramokgopa was first made on 21 February 2017. Khanyisa Nkuna from the Department of Health took the call, and forwarded a follow-up email request to department spokesperson Prince Hamca. Hamca was also sent further emails and SMS messages, and was called numerous times. The editor of Spotlight also contacted Hamca separately to request interview time with Ramokgopa. Hamca did not respond or make any effort to suggest alternative ways to communicate with the MEC for the writing of this profile. 

 

Spotlight on TAC Provinces

The Treatment Action Campaign (TAC) reports for Spotlight on some of
its recent work in the seven provinces where TAC has branches and
provincial structures.

Limpopo

Following heavy rains in May, a malaria outbreak hit Limpopo. Clinics and other primary health facilities did not have enough testing kits or malaria treatment to deal with the outbreak.

Patients were therefore being transferred to Nkhensani Hospital. As there were too few beds, patients at the hospital were being admitted only to be left in an undignified condition on the floors of the wards. Immediately, TAC Limpopo organised a meeting with the CEO and Communications Manager of the hospital to address our concerns. The hospital acknowledged the challenges; in the interim, they erected tents to deal with the influx of patients. TAC Limpopo was not satisfied with this action, and escalated the matter. We wanted to know what the provincial department’s plan would be to resolve this crisis. Soon after engagement with the office of the MEC of Health, Dr Phophi Ramathuba, testing kits and malaria treatment were delivered to most of the facilities that were relieving the burden on the hospital.

In July, Mopani district in Limpopo was facing a shortage of HIV-testing kits. After many calls from members of the public who had been unable to take an HIV test, TAC Limpopo intervened. Following a snap survey, TAC members found that the following health facilities had either very few, or no testing kits at all: 1) Vyeboom Clinic; 2) Basani Clinic; 3) Hlaneki Clinic; 4) Ratanang Clinic; 5) Xivulani Clinic; 6) Mapayeni Clinic; 7) Khujwana Clinic; 8) Giyani Health Centre; 9) Nkhensani Hospital; 10) Thomo Clinic; 11) Dzumeri Health Centre; and 12) Ratanang Clinic. Knowing their HIV status is the most important thing people can do to protect their own health and avoid the spread of HIV, meaning that the shortage was a crisis for the HIV response in the area.

After hearing and validating the complaints, TAC Limpopo escalated the matter to the District Health Department and the Office of the Mayor. The official response from government was that the supplier’s tender had come to an end, and they had failed to calculate the risks and put measures in place to avoid a stockout. Following TAC’s intervention, limited stock was quickly delivered to Giyani Health Centre, Nkhensani Hospital, and Thomo Clinic. Shortly afterwards, TAC Limpopo received a call from Giyani Health Centre extending their gratitude for our intervention in the matter. The situation must be resolved urgently at the other facilities, to ensure that HIV testing can resume.

KwaZulu-Natal

In May, it came to light that KwaZulu-Natal’s healthcare services are in a state of emergency, with shocking details shared by health workers in the province.

Reports reflected a collapsing health system which is in many cases no longer delivering adequate healthcare to the most vulnerable. Hospitals are experiencing shortages of life-saving medicines and equipment, and suffering through departments that are entirely depleted of staff. Major delays for treatment and care continue to be felt in oncology and various other departments. In June, TAC KZN met with MEC of Health Dr Sibongiseni Dhlomo, and raised these issues. In response, the MEC complained of cost cutting and budget cuts by the provincial Treasury. The response of the MEC failed to alleviate the concerns of TAC KZN. A suitable turnaround plan must urgently be put in place by the MEC, or TAC will be forced to escalate our advocacy around this crisis. The Provincial Congress will discuss and resolve a way forward. TAC will work with SECTION27, the South African Medical Association (SAMA), and the South African Human Rights Commission on this matter.

In July, TAC KZN welcomed the announcement that the University of Zululand would provide HIV treatment to students and staff on campus. If implemented effectively, this should provide an easier and quicker system for young people and staff at the university to collect their ARVs, and therefore ensure better treatment adherence. Making medicines more accessible will benefit the health of all people living with HIV on campus. The evidence is clear that earlier treatment reduces serious adverse events, such as TB and various cancers. Adhering properly to HIV treatment is critical to staying healthy. Additionally, this will also help prevent many new HIV infections. Studies show that people who are stable on treatment with undetectable viral loads are highly unlikely to transmit HIV to their sexual partners.

The dysfunction in the public healthcare system creates its own challenges for people to remain adherent. The reality is that our clinics are in crisis. People must wait in long queues for hours to get their HIV treatment. Sometimes medicine stockouts or shortages mean people leave empty-handed. This forces people to default, and puts their health and lives at risk. Students must take the decision to miss classes in order to wait at the clinic; those staying in residence must travel home to collect their treatment. Our rights to health and education are in conflict. Providing medicines on campus will not only promote better adherence for students and staff at the university; it will also relieve the burden on health facilities that are already stretched to capacity. Given the increasing uptake of HIV treatment through ‘Universal Test and Treat’, this burden will only grow.

Since 2016, TAC KZN has been working on a campaign to ‘Help Teens Protect Themselves’. Through our engagements with the MEC of Health and the MEC of Education, and in the KZN Provincial AIDS Council, TAC KZN has been advocating for better access to prevention methods, the roll-out of prevention and treatment literacy training, and easier access to treatment, including on campuses. Both MECs made a clear commitment to improve youth-targeted HIV interventions. Now it is important for TAC KZN to monitor the roll-out. Treatment accessibility must be coupled with counselling and adherence support on campus. We also urge the University of Zululand to provide easy access to preventative measures such as male and female condoms, as well as pre-exposure prophylaxis (PrEP). PrEP aimed at youth and the general population may have an important role to play in reducing new infections. Further, and critically, measures must be put in place to prevent the disclosure of people’s HIV status on campus, which would cause unnecessary stigma and discrimination. For instance, people should not be forced to enter buildings reserved only for collecting HIV medicines, and their clinic files must not be colour-coded or marked to show their status. TAC KZN will monitor the roll-out and advocate for other campuses to adopt this approach.

Mpumalanga

“Police in Ermelo used to assault, insult and arrest us often,” says Boitumelo*, a sex worker from Mpumalanga. 

“They would arrive at our houses, kick stuff, call us names, beat us. They would confiscate our medications (including HIV treatment), destroy our foods, ruin our furniture, even take our condoms. And after they had arrested us, we would spend the entire weekend in the dirty, smelly, and cold cell. Sometimes we would be released on the Monday with R500 each. Then we would appear in court where eventually the charges would be dropped.”

Boitumelo and other sex workers in the Ermelo area have been victimised by the police for years. After a chance meeting in the mall with a member of NAPWA – who happened to be wearing a T-shirt saying ‘sex work is work’ – Boitumelo and other sex workers were soon introduced to TAC Mpumalanga. In late 2015, TAC facilitated a safe-space workshop where an advocate from the Women’s Legal Centre promised to represent the sex workers in case of further arrests.

“It was here that we started to feel safe and confident to talk,” Boitumelo continues. “It wasn’t long before we got arrested again, in December. We were told to be in court on 4 December. The advocate came to represent us and TAC members were there in numbers supporting us. We had done nothing wrong. We were sleeping when the police kicked down the doors. We were just sitting inside the house. The case was withdrawn on the day.”

TAC assisted in mobilising other sex workers and members of the LGBTQIA+ community to support us on 10 December in marching to the police station, to demand an end to the police harassment. “We walked through the township singing and holding placards. We were about 300 in total, wearing our mini- skirts and high heels,” remembers Boitumelo. “Police used to say we were whores because we are dressed in mini-skirts and that is why we wore it on the day. We wanted them to arrest us officially on this day; but instead, police came to escort us – after refusing to give us permission to hold the march.”

After this, the harassment and arrests did not stop.

TAC and partners escalated the matter to the MEC of Health, Gillion Mashego. They wrote to the MEC and the Brigadier of the SAPS to demand a meeting. The police had previously refused to meet, but engaged once the MEC was involved. In the meeting, after hearing the issues, the MEC demanded that the police stop harassing the sex workers and stop taking their condoms and medications. While the police tried to deny all that the sex workers said, photographs of beaten bodies, destroyed homes, and medications thrown on the floor, shocked the attendees of the meeting. The MEC instructed the police to engage with all departments and ensure that the victimisation and harassment would finally end.

“Since October 2016 we have not had problems with police. Since the police vans are no longer coming to our place, even clients come freely, and business has been better. Now I can at least send some money to my kids.”

Since last year, KwaMhlanga Hospital in Mpumalanga has been facing a severe crisis. A shortage of staff meant that doctors in the facility repeatedly went on strike. They were overworked, without the people-power to attend to all those in need of medical care. The maternity ward was overcrowded. Women would deliver their babies, after which they would be moved to a chair to sit for six hours observation, and then be sent home. Bloody and wet sheets would remain, as the next to give birth would occupy them. The nurses had no gloves or gowns; their clothes were dirty from delivering babies. The intensive care unit (ICU) was empty – no furniture, beds, or medical equipment; an abandoned, empty space. Conditions were untenable. At the district People’s Health Assembly organised by TAC in 2016, many complaints of poor service at KwaMhlanga were made, with members of the District Health Department in attendance: reports of people dying unnecessarily; people waiting months for simple procedures. The situation was so bad that even the National Portfolio Committee on Health visited the province and gave a damning report, which lead to the notorious threats made against MP Dr Makhosi Khoza.

TAC Mpumalanga met with the Hospital CEO to raise the various challenges that had been reported to us. The matter was escalated to the District Health Department, and then the Provincial Health Department. A meeting with Gillion Mashego, the MEC of Health, led to the removal of the CEO. An interim CEO was appointed in February 2017, after which the hospital received an injection of two million rand. The maternity ward was extended into a portion of the ICU to relieve the burden on the overcrowded ward, and a new position to manage this maternity ward has been advertised. The interim CEO visited hospitals in the North West to benchmark and gain guidance as to how to turn the crisis around. Some stability has finally been found. TAC will monitor the situation, and continue engaging with the new MEC.

* Not her real name – changed to protect her identity.

Western Cape

For a long time, TAC Western Cape received complaints about Michael Mapongwana Community Health Clinic in Khayelitsha.

Parents with children and babies would be seen in a container at the back of the clinic. They would wait outside for long periods, whatever the weather conditions, to be attended to by health workers. They would have to undress their children outside because of a lack of space on the inside. Children with illnesses shared the same space with those attending post-natal check-ups. Late last year, TAC Western Cape held a picket outside the clinic, and met with the Health Department to address these concerns. Finally, in February 2017, following pressure from TAC, a new structure was opened that could accommodate the children in a dignified and appropriate manner.

Eastern Cape

Since 2016, TAC Eastern Cape had received numerous complaints from the Clinic Committee and community members fearful of accessing health services at Philani Clinic. Mostly this was due to the bad attitude and lack of respect shown to patients by one of the nurses.

This nurse had repeatedly and publicly disclosed people’s HIV status and other health conditions without their consent. The situation had left community members not wanting to use the clinic at all.

While the Mayor had proposed suspending the nurse in question pending a disciplinary hearing, the Sub-District Health Manager undermined this decision. The community were understandably angry at the change. In April 2017 they shut the clinic down in protest, locking its gates until the matter was resolved. According to the community, the clinic would only be reopened given the removal of the nurse. This meant no-one could access services at all. Worryingly, TB and drug-resistant TB patients in the area could not undergo treatment reviews, as their folders were locked inside the clinic. They had no option but to use another facility, given that the nearest TB hospital is 350km away.

TAC Eastern Cape and the Queenstown Council of Churches urgently mobilised the Clinic Committee, community organisations, churches and partners in the area to meet in Queenstown and come up with a strategy to re-open the clinic, to ensure people could access health care. TAC met with MEC of Health Phumza Dyantyi and Clinic Committee members to demand a way forward. After this pressure, the clinic was re-opened in June 2017, and the nurse was removed. While one battle was won, the clinic is now understaffed, with one nurse being dismissed and one more resigning. TAC Eastern Cape will continue to demand that the vacant posts are filled urgently.

Free State

TAC Free State hears many complaints of medical negligence, and endeavours to assist people in getting the healthcare they need and deserve. One incident in Botshabelo involved Samuel Selebedi, who was bleeding profusely after falling onto a glass bottle.

After attending the clinic, he was rushed to Botshabelo Hospital. A painful surgery was conducted to stitch the bleeding arm, but doctors failed to remove the glass that had been lodged inside. No X-ray was taken. Mr Selebedi was sent home. Two months later, he faced complications. When he returned to Botshabelo Hospital, no-one attended to him. He then visited a private health practitioner, who was the first person able to explain what had gone wrong. The doctor advised him to return to the hospital, to demand surgery to remove the glass from his arm. At this point, TAC Free State were contacted for support. TAC Free State accompanied Mr Selebedi to the hospital, supporting him to advocate for his right to health. The matter was escalated to the CEO of the hospital. Finally, a thorough surgery took place, and the glass was removed. TAC Free State will continue to support Mr Selebedi as he raises a case of medical negligence against the hospital, and will hold the CEO to account in ensuring no other cases of negligence occur.

In a landmark judgment in November 2016, with important implications for the right to protest in South Africa, the Bloemfontein High Court set aside the convictions and sentences of the 94 community healthcare workers (CHWs) known as the #BopheloHouse94. This finally brought to an end the state’s callous and vindictive persecution of this courageous group of mostly elderly women.

The #BopheloHouse94 are CHWs from across the Free State. They were arrested in June 2014 at a peaceful night vigil at Bophelo House, the headquarters of the Free State Health Department. They were protesting the collapse of the Free State public healthcare system, and the April 2014 decision of then MEC of Health, Dr Benny Malakoane, to dismiss without warning or cause approximately 3 000 CHWs in the province. Malakoane has recently been removed as MEC of Health.

Since the judgment, TAC Free State has been engaging with the new MEC of Health, Butana Komphela. Not only have they been advocating for the turnaround of the broken public healthcare system, they also advocated for the reinstatement of the CHWs. A Memorandum of Understanding is in development that will ensure that TAC branches in Free State can work better with clinics to ensure a functioning health system. Furthermore, a plan to reinstate the CHWs is in motion. Phase one will be the re-hiring of those in the case, with phase two seeing a bigger expansion of the programme. TAC Free State will meet with the MEC quarterly, and continue to monitor the state of health care in the province.

Gauteng

In March, community members phoned TAC Gauteng outraged and concerned after watching a white pick-up truck dump medical waste near the taxi rank in Mamelodi. Tablets, capsules, loose powder, syringes, pregnancy tests, HIV tests and office papers were strewn across the ground.

When TAC Gauteng arrived on the scene, a child was playing in the waste. Residents informed them that some of the powder and syringes had been taken by those passing by. A steady stream of people were passing by. It was not safe to leave the waste unattended. TAC Gauteng found business cards among the waste from a company called Jade Pharmaceutical Enterprises. After calling the company they were told it had closed a year earlier – the woman on the phone tried to tell them that the waste was not harmful. When they called back a second time, they were told conflicting information – that the company had closed in 2013. Calls to the police and the local counsellor landed on deaf ears. Messages were sent to the MEC of Health to intervene urgently. The local municipality was contacted. TAC Gauteng remained on the scene from the afternoon until midnight. To protect their own safety they left, returning at 4am when residents would begin to pass by in the morning. Eventually, after pressure from TAC Gauteng, the local municipality made arrangements for someone to take over from TAC in guarding the waste – and another company was hired to remove the waste entirely.

In March, TAC Gauteng was alarmed at the collapse of an entrance to the Charlotte Maxeke Hospital in Johannesburg. A hospital should be a place of safety and shelter, not a place where people are hurt. TAC Gauteng were unequivocal that urgent steps needed to be taken by MEC of Health Gwen Ramokgopa to audit the infrastructure all Gauteng health facilities, and ensure this does not happen again.

TAC Gauteng launched a fact-finding mission into the state of hospitals across the province. Not only are they monitoring the state of the infrastructure but also the state of service delivery. Are there enough doctors, nurses, porters and security guards? Are people sent home without medicines? How long must people wait to be seen in these facilities? Are the facilities clean? Are there enough beds? Do people get the service they need?

On 16 March, TAC Gauteng met with MEC Ramokgopa for the first time. They are committed to engaging with her constructively to bring an end to the crisis in the public healthcare system. In addition to other issues, they raised concerns over the state of facilities. They urged MEC Ramokgopa to undertake an urgent audit of health facilities across the province, the results of which must be made public, together with a plan to address any failings. The department must strengthen the Infrastructure Unit (in conjunction with the Department of Public Works) to address backlog maintenance, routine maintenance and the building of new health facilities – as well as ensuring better monitoring and oversight of material procurement processes – in order to prevent any further disasters in our health facilities.

Since 2012, TAC Gauteng have been raising concerns about the dire state of health facility infrastructure in the province. A report issued by TAC and SECTION27 at the time highlighted issues including the poor condition of buildings, power failures, the lack of safety features, potholes, and the non-functioning lifts; and the impact of these failures on the provision of healthcare. As recently as last September, TAC Gauteng picketed outside Thelle Mogoerane Hospital in Vosloorus, noting – among other issues – cracks and leaks in the hospital building that have yet to be addressed. Another picket took place at Pholosong Hospital in Tsakane, which is also in disrepair.

Especially alarming were reports that doctors at Charlotte Maxeke Hospital have been complaining for years about the structural problems. Even worse is that they felt the need to remain anonymous in making these reports. In our meeting, we urged MEC Ramokgopa to ensure a new era of openness, engagement and accountability from the provincial health department. No healthcare worker should fear victimisation or lack of job security as a result of speaking out. In order to ensure better communication flows, accountability structures such as hospital boards and clinic committees should be fully functional, to ensure the concerns of health workers and community members are addressed effectively. A system should be established to take management teams out of their offices and into the community to listen to the needs of the people on a regular basis.

Proper maintenance of existing infrastructure and the development of more suitable infrastructure is essential to ensure safety, suitability, cleanliness and the proper functioning of facilities across the province. While Treasury may cut the health facility revitalisation grant, the onus is on MEC Ramokgopa to ensure enough money is put towards maintenance projects through the equitable share. National cuts must not impact negatively on the quality of our health facilities.

10 things to know about TB in South Africa

Tuberculosis (TB) is still a crisis in South Africa. Here are 10 quick facts about the state of TB in South Africa.

  1. Tuberculosis (TB) remains a crisis in South Africa. It is the top cause of death indicated on death reports. There are over 400 000 cases of TB in South Africa every year. TB cases are slowly coming down, but it is not happening nearly fast enough.
  2. One of the biggest problems with TB is that we do not diagnose people fast enough and get them on to treatment fast enough. This is bad for the health of people with TB, but also contributes to the spread of TB in our communities. Two potential solutions are active case finding (ACF) and contact tracing. ACF is when healthcare workers or community healthcare workers go out and look for people with TB. Contact tracing is when we trace the family and/or work contacts of someone with TB and then test them for TB as well. Most experts agree that government must invest more in ACF and contact tracing, but unfortunately government has not shown much ambition in this regard. This lack of ambition is probably because government does not want to employ more people.
  3. Another critical problem in our response to TB is the poor infection control measures in most public spaces. In taxis, or in waiting rooms at clinics, or at Home Affairs offices, often the windows are not opened and all the people present breathe the same air. In addition, many prisons are overcrowded and create ideal conditions for the transmission of TB. Here too, government has not shown much ambition in dealing with the problem.

MDR TB

  1. There are over 20 000 cases of drug-resistant TB (DR TB) in South Africa per
    It appears that the rates of DR TB are going up – something which surely constitutes a public health emergency.

    year at the moment. It appears that the rates of DR TB are going up – something which surely constitutes a public health emergency. DR TB is much more difficult and more expensive to treat than normal TB. There is also evidence suggesting that most people with DR TB did not develop the drug resistance while being treated for normal TB, but were infected with TB that was already drug-resistant.

  2. Until recently, treatment for multiple drug-resistant TB (MDR TB) took two years, and often resulted in severe side effects such as deafness. However, the World Health Organisation recently recommended a new nine-month regimen with fewer side effects for the treatment of MDR TB. South Africa is in the process of introducing this new, shorter regimen.
  3. While the new nine-month MDR TB regimen is an improvement on previous regimens, it still entails a large number of pills and injections, and has is associated with substantial side effects. The good news, however, is that a number of trials are under way to test even shorter regimens that will contain no injections, and hopefully will have even fewer side effects. We should start seeing results from these trials in 2019.

XDR TB

  1. Extensively drug resistant TB (XDR TB) is the most difficult form of TB to treat, and over 70% of people with XDR TB in South Africa die within five years. There is good news, however: an ongoing trial in South Africa called Nix-TB is showing much higher cure rates for XDR TB than we’ve ever seen before. In the Nix-TB trial, people are treated with three drugs: bedaquiline, pretomanid and linezolid.
  2. While bedaquiline and linezolid are already registered and available in South Africa, pretomanid is not yet registered. Pretomanid is not being developed by a pharmaceutical company, but by a non-profit called the TB Alliance. Donors should work with the TB Alliance to make pretomanid available under compassionate-use concessions, so that people in South Africa with XDR TB can access the drug.

Latent TB

  1. People living with HIV are at higher risk of contracting TB. For this reason, people are given isoniazid preventative therapy (IPT) to prevent the development of TB. For years IPT treatment rates in South Africa were very low, but recent figures suggest that many more people are now receiving IPT and being protected against TB.
  2. IPT works well and can be taken for six months or a year, or even longer. It consists of a pill you must take every day. However, there is a new form of TB-preventative therapy called 3HP, which consists of isoniazid and another drug called rifapentine. The 3HP regimen involves taking pills only once a week, for a period of 12 weeks. If ongoing trials of 3HP in South Africa are successful, 3HP will replace IPT at some point in the next five years.

Renewed hope for crypto, a deadly AIDS-defining fungal opportunistic infection

By A/Professor Nelesh Govender, National Institute for Communicable Diseases, Johannesburg

Cryptococcosis (“crypto”) is a common AIDS-defining fungal opportunistic infection worldwide. It has been neglected for many years. This is about to change; two exciting new developments in the fight against crypto will directly contribute to the UNAIDS goal of substantially reducing global AIDS deaths:

  1. A simple screening programme to detect and treat crypto earlier (“crypto screen-and-treat”) was implemented across South Africa in October 2016. Recommendations to screen-and-treat for crypto have now been included in the national HIV guidelines of at least 24 countries.
  2. Shorter, simpler and less toxic antifungal treatment regimens for crypto meningitis (the most severe and deadly form of the disease), which are suitable for resource-limited settings, were proven to be equivalent to the gold standard in the ACTA (Advancing Cryptococcal meningitis Care in Africa) trial, recently reported on at the 2017 International AIDS Society conference in Paris.

Nevertheless, the following barriers need to be overcome before we see a reduction in deaths:

  1. We need to focus on differentiated care for patients with advanced HIV disease who have been “left behind” in HIV programmes and are at high risk for opportunistic infections such as crypto
  2. We need the crypto screen-and-treat policy to be actively implemented in resource-limited countries with a high crypto burden
  3. We need improved access to affordable antifungal medicines, including quality-assured flucytosine. Flucytosine is an off-patent medicine which isn’t registered or available in any sub-Saharan African country

What is the scope of the problem?

Over a million people died from AIDS-related illnesses in 2015. Globally, crypto affects hundreds of thousands of the sickest patients with HIV each year and accounts for 15% to 20% of all AIDS deaths, second only to tuberculosis. Crypto is the commonest cause of meningitis in sub-Saharan Africa and South East Asia and disproportionately affects people in low and middle income countries. Without treatment, crypto meningitis is universally fatal. Even with treatment, between 20% and 60% of patients will die. Patients may be disabled by severe headaches which occur weeks before diagnosis or complications such as blindness and deafness which may occur after the severe brain infection. Crypto is a substantial economic burden on patients and their families.

The current gold standard treatment (amphotericin B and flucytosine for 2 weeks followed by fluconazole for many months) is intensive, costly and requires hospital admission for intravenous amphotericin B and laboratory monitoring for toxicities related to this medicine. In addition, flucytosine is neither registered nor available in any sub-Saharan African country.

Diagnostic/ screening tests for crypto, in particular the accurate, quick, simple and cheap antigen detection tests, are unfortunately not available in all countries with a high crypto burden.

We need differentiated care for patients with advanced HIV disease

The World Health Organization (WHO) has recently issued a guideline that strongly recommends that all patients with advanced HIV disease (CD4 <200 or WHO clinical stage 3/4) be offered a package of interventions including opportunistic infection screening, treatment or prophylaxis. It is essential that CD4 testing be offered before or at the time of ART initiation so that patients with advanced disease can be identified. For crypto, the focus is on screening and treatment of patients with CD4 <100 for early crypto. Governments and donor agencies should implement this recommendation.

We need the crypto screen-and-treat policy to be actively implemented by countries

Following South Africa’s lead in rolling out a national crypto screen-and-treat programme (approximately 250 000 people will be screened per year), other resource-limited countries with a high crypto burden should make similar efforts. This may depend on donor-funded access to crypto antigen tests and antifungal medicines. A challenge in many countries is that laboratory screening for early crypto may not be possible with limited laboratory infrastructure.

We need access to quality-assured and affordable antifungal medicines for crypto including flucytosine

The ACTA trial aimed to define antifungal regimens for crypto meningitis that could be more feasibly implemented than the accepted gold standard of 2 weeks of amphotericin B and flucytosine. The trial compared an oral combination of fluconazole and flucytosine for 2 weeks OR short-course (1 week) amphotericin B with either fluconazole or flucytosine to the gold standard. Both oral and 1-week regimens were equivalent to the gold standard based on deaths at 2 weeks. The best performing arm was 1 week of amphotericin B with flucytosine in terms of deaths at 10 weeks. Notably, all the best-performing arms in the trial contained flucytosine which was associated with better clearance of the fungus from patients’ cerebrospinal fluid.

Urgent efforts are required to ensure that affordable and quality-assured antifungal medicines, including flucytosine are made widely available for the treatment of crypto meningitis. Once flucytosine is available, the 1-week amphotericin B regimen with flucytosine should be used preferentially

Future research

The CAST-NET implementation science study will evaluate the effectiveness of South Africa’s national crypto screen-and-treat programme to reduce crypto deaths over the next 4 years. The planned AMBITION trial will explore the efficacy of single high-dose liposomal amphotericin B with oral flucytosine versus the gold standard for the initial treatment of crypto meningitis. Study results are expected in a few years’ time. Liposomal amphotericin B may allow shorter hospital admissions and fewer toxic side effects compared to conventional amphotericin B. Several other planned trials, including REFINE, have been designed to simplify the “treat” arm of the crypto screen-and-treat intervention by defining more efficacious and potentially shorter antifungal regimens for patients with early crypto.

 

 

TAC congress elects new leaders, sets priorities

The Treatment Action Campaign’s (TAC) 6th National Congress held in

Deputy President Cyril Ramaphosa accepts the iconic HIV positive t-shirt from TAC Deputy General Secretary Vuyokazi Gonyela, while General Secretary Anele Yawa looks on. Photo: Joyrene Kramer

Sterkfontein, Gauteng  concluded today with the re-election of Anele Yawa as General Secretary and the election of Sibongile Tshabalala as Chairperson. Vuyokazi Gonyela was elected as Deputy General Secretary and Patrick Mdletshe was re-elected as Deputy Chairperson.

“The second phase of TAC’s struggle is for quality healthcare delivered through a well-functioning healthcare system where the dignity of all is respected and nobody is excluded,” read a TAC statement. It also said that “In 2017, the HIV and TB epidemics are far from over in South Africa and in many other countries. To bring an end to these epidemics we will require more healthcare workers and properly functioning healthcare systems. We will require a movement that politicises access to healthcare and that refuses to accept that some people can get quality treatment while others cannot”.

The congress, attended by representatives from close to 200 TAC branches from seven of South Africa’s nine provinces, made a long list of resolutions that will guide the organisation’s work over the next three years. Amongst others, the congress resolved to recommit to the empowerment of TAC branches and the reinvigoration of the organisation’s treatment literacy programme. It was also resolved that each of TAC’s branches must adopt a clinic and a school which they should monitor and engage with.

Earlier the congress was addressed by Deputy President of South Africa and chair of the South African National AIDS Council (SANAC) Cyril Ramaphosa. Ramaphosa said that “we must acknowledge that our health system is under great strain and that it is struggling to meet the needs of our people”. He also urged TAC to not to disengage from the SA National AIDS Council. The congress eventually resolved that TAC will remain in SANAC, but that the organisation will leave SANAC should its concerns regarding SANAC governance not be addressed with sufficient urgency and transparency. (Ramaphosa’s speech can be read in full here.)

The congress also earlier heard from Minister of Health Dr Aaron Motsoaledi who presented government’s plans on National Health Insurance. TAC resolved to continue its support of NHI while also raising concerns regarding certain aspects of NHI, such as the exclusion of foreign nationals and the exclusion of civil society from six of the seven recently announced NHI committees. TAC also undertook to assist patients who could not access appropriate treatment and care in the public sector to seek such treatment in the private sector. It was stressed that this would be done in a dignified and non-disruptive way.

The full list of TAC national leaders elected at the congress are as follows:

  • Chairperson – Sibongile Tshabalala
  • Deputy Chairperson – Patrick Mdletshe
  • General Secretary – Anele Yawa
  • Deputy General Secretary – Vuyokazi Gonyela
  • PLHIV Sector Representative – Andrew Mosane
  • Women’s Sector Representative – Thandi Maloka
  • LGBTQIA+ Sector Representative – Philemon Twala
  • Youth Sector Representative – Amelia Mfiki
  • Men’s Sector Representative – Pule Goqo

A full list of congress resolutions is available on the TAC website here.

Note: Spotlight is a joint publication of the Treatment Action Campaign and SECTION27. We have been granted substantial journalistic independence – which we guard jealously.

 

Nkhensani Mavasa’s speech at the opening of TAC’s sixth National Congress

Treatment Action Campaign (TAC) Chairperson Nkhensani Mavasa delivered the below speech at the opening of the TAC’s sixth National Congress on 23 August 2017. The speech has been lightly edited for publication.

Comrades,

It is my privilege to welcome you to TAC’s 6th National Congress.

Let us make overcoming this crisis central to all our work. – Nkhensani Mavasa, Chairperson of the Treatment Action Campaign (TAC)
Photo: AP

We are gathered here in a critical time in our history – both as members of TAC and as people who live in South Africa.

We have come a very long way since TAC was founded on the steps of St George’s Cathedral in Cape Town in 1998.

We have had many victories.

In 2002, we used the Constitution of this country to force our government to provide PMTCT to pregnant women who are living with HIV.

In the years that followed we kept up the pressure for a treatment programme for all people with HIV who need treatment.

Under the leadership of Health Minister Dr Aaron Motsoaledi, South Africa’s ARV programme has become the largest ARV programme in the world.

Comrades, together we won the battle for AIDS treatment. We helped save many thousands and thousands of lives.

We are still winning important victories in the courts – from our intervention in the case of Dudley Lee who contracted TB while in prison, to our intervention in the large silicosis and TB class action case last year, and most recently, the case of the Bophelo House 94 who stayed determined until their unjust convictions were overturned, and who in the process affirmed the right of all people in this country to protest.

Comrades, there are many heroes in TAC, but few more courageous than the brave and determined Bophelo House 94. Let us pause for a moment to applaud them.

Comrades, we also had many victories outside of the court room. Through our sustained and committed activism we have in recent years unseated under-performing MECs for Health like Benny Malakoane, Sicelo Gqobana and Qedani Mahlangu. This is hard work, but holding those in power to account is now needed more than ever given the crisis in our healthcare system. We must continue this work.

But maybe most important, are not the court victories or the holding accountable of MECs for health, but the clinic-level victories that are won on a day to day basis by our branches. These victories do not make the front pages, but they directly change the lives of our members and the people in our communities.

To all our branches, leadership, and staff across the country, we recognise you. You are the beating heart of TAC.

We also recognise our partners and allies in the struggle for social justice, many who are in the room here with us.

But even while we have had important victories, there is still a long and difficult road ahead.

I will speak about three crises we have to overcome on this road: gender discrimination, poverty, and our broken healthcare system.

Firstly, let me say this clearly, comrades, we have a serious gender discrimination crisis.

This is a crisis throughout our society and our various cultures. It is a crisis of men who hit or rape women, but also of everyday discrimination – a crisis of men who listen when other men speak, but who do not listen when women speak.

Comrades, this is not just a crisis out there, but also in here, inside TAC.

And even worse than the discrimination against women, is the discrimination against our LGBTQIA comrades.

Let us be clear, TAC has, and will always stand for the full equality of all people irrespective of gender or sexuality. There will be no room for discrimination at this Congress, and there should be no room for discrimination in any TAC branch or in any of our communities.

Let us make overcoming this crisis central to all our work.

Secondly, we continue to have a crisis of poverty in this country. Many of us are poor. Our friends and families are poor. And when you are poor, you can’t always buy food, you can’t afford transport, you can’t afford private healthcare.

Comrades, the crisis of poverty and inequality is at the root of so many of the problems in our country – be it healthcare, education, housing, or sanitation.

As TAC, we must strive for a more equal and a more fair world. This is why it is obvious that we should support National Health Insurance. It will take many years, but ultimately NHI will make us more equal and will bring quality healthcare to more people in this country.

Poverty is also the reason why we must insist on good governance. We cannot afford for the state’s money to be wasted while the people are suffering. We should never turn a blind eye to corruption – whether it be in the public sector or in the private sector, at district, provincial or national level. It is always the poorest of the poor who pay the highest price for corruption and mismanagement.

Thirdly comrades, our clinics are in crisis – and with it much of the public healthcare system.

Posts are being frozen, provinces are running out of money, the National Health Laboratory Service only has enough money until December.

I do not have to tell you about the poor TB infection control, the understaffing, or the medicine stockouts at our clinics or hospitals. We, we the TAC branches, we see these things every day. Our branches are on the frontlines – and it is our branches who can help turn things around. Every branch must hold its local clinic, hospital and school accountable. We must be on the clinic committees, on the hospital boards and on the local and district AIDS Councils.

We must monitor our clinics, as we did with our recent TB infection control survey.

We must tell the stories of our people who are struggling to access decent healthcare.

We must know our rights and we must know the science and treatment of HIV and TB.

Armed with this knowledge, we must hold those in power to account.

Comrades, we won the battle for ARVs, but at the moment we are losing the battle for quality healthcare for all.

At this Congress, we are tasked with making the decisions and electing the leaders who will help us overcome the three crises I have described – of gender discrimination, of poverty, and of our broken healthcare system.

Comrades, we are all part of one TAC. And because we are part of TAC we share certain common values.

  • We all want to see an end to all forms of discrimination – be it based on gender, on disability, on how much money you earn, or on your race.
  • We all want to see a healthcare system that provides quality healthcare to all who live and work in this country.
  • We all want to see a public service that is free of corruption and mismanagement.
  • We all know the power and the value of the Constitution and the importance of using it strategically.

There will be disagreements this week. I urge you, let us disagree constructively.

Let us respect all our comrades, and let us listen to the arguments of those who disagree with us.

Let us not be lazy in our thinking, but let us respectfully interrogate both each other and ourselves.

Let us be serious about our task – for lives will depend on the decisions we make this week.

And let us respect TAC’s democratic processes and give the new leadership we will elect this week our full support.

Above all, let us be drawn together by our common purpose.

  • Comrades, we know poverty.
  • We know the stigma of HIV.
  • We know what it feels like to lose a loved one to illness.
  • We know what it is like to wait for hours at the clinic, just to be told there are no medicines.
  • We know what it feels to have our dignity trampled on.

Let this common knowledge draw us together.

But comrades, in TAC we also know our rights – and our rights continue to be violated every day.

Let this be the congress where we come together and say “NO MORE!”

No more.

I thank you.

You can follow @SpotlightNSP and @TAC on twitter for updates from the TAC National Congress.