We turn the spotlight on people living or working on the margins in South Africa. Referred to some as key populations, these folk – sex workers, trans people, MSMs, injecting drug users, LGBTQIA+ people – are at more risk of HIV and are often forgotten. Read about them here and then go to our website to read the longer stories.
By Ngqabutho Mpofu
Ronnie came out in the early 1980s, telling his friends and sister that he was
homosexual. This was not an easy thing to do, given the traditional Xhosa culture that he is from. He credits his support network for helping him come through that period in his life. Today he works in Observatory in Cape Town as a youth programme coordinator at a child and human rights programme.
He has been closely involved in issues affecting Men who have Sex with Men (MSM) for a long time, including as a (now former) board member of the Triangle Project, which focused on health issues affecting the LGBTI community.
Over the years he has witnessed the deaths of many comrades and friends as a result of HIV/AIDS related causes. “Most of the people that were in my (age) group have passed on because there was no support from government, they had no health support, there was no one who came to visit them at their homes, so they died in isolation”, says Ronnie.
He acknowledges that much has changed in the over 30 years since he came out, including the formation of initiatives run by the State and non-governmental organisations such as the Ivan Toms clinic, with programmes specifically tailored for MSM, which have yielded great results in terms of help-seeking and greater access to health care amongst MSM.
Yet, Ronnie says there is still a very long way to go. Most of these health facilities are very far from the people who need them, which is problematic given the high levels of unemployment and poverty in the country. “Government needs to bring the services closer to the people through creating satellite clinics tailored for MSM. Unfortunately, we are still struggling with stigmatization and prejudice in South Africa against the LGBTI community in public health facilities”. This critical problem, which is not only limited to health care practitioners, but includes the attitudes of front line staff such as security guards, receptionists and cleaners, continues to severely stymie the country’s fight to attain its overall goal of an AIDS free population.
Ronnie argues that the state should implement mass sensitization campaigns so that staff in health facilities can acknowledge the LGBTI community and ensure that health care spaces are not spaces that they feel they cannot enter.
Community sensitization is also important, says Ronnie, as he has been heavily involved in community dialogues, educating them about key populations. He cites the important work done by Anova Health, which rolled out workshops in shebeens, a South African colloquial term much like the American ‘speakeasy’, a place mainly frequented by men who want to drink alcohol. Anova Health has sought to increase help seeking and foster tolerance in a country where men have been notorious for their role as perpetrators of violence.
Ronnie argues that another possible way that the State could significantly broaden its reach in terms of access to healthcare is to employ MSM from within communities as community health care workers, as they have greater access to MSM specifically and the broader LGBTI community that other health care practitioners would not be afforded.
The critical right to food is also extremely important to Ronnie, having seen his comrades waste away in the past. In a country where poverty has led to about 12 million people going hungry, Ronnie harks back to the Black Consciousness strategies of community upliftment projects through the establishment of vegetable gardens in order to be able to take one’s pills with a full stomach.
Ronnie shows no signs of slowing down. He hopes to pass on his knowledge to younger activists to join the fight for access to quality, affordable and dignified health care for MSM and other key populations.
This article is part of a Spotlight special series on people who form part of so-called key populations.
 Avert, “Men who have Sex with Men (MSM), HIV and AIDS”, https://www.avert.org/professionals/hiv-social-issues/key-affected-populations/men-sex-men#footnote1_epqbh49, accessed 16 July 2018 and MSMGF (2013) ‘MSM in Sub-Saharan Africa: Health, Access & HIV’
By Ngqabutho Mpofu
Dressed in a Robert Sobukwe Dashiki and trendy shoes, Thando Jack draws
gazes from the mainly white upper middle-class folk in Cape Town who can afford to be taking a stroll in the Company Gardens during a week day. They obviously try not to but there is something about him that captivates them.
When we start engaging, it becomes clear that it Is a genuine sense of love and concern about members of a community that embraced him that makes Thando do the work he does. It is alarming figures such as those released by UNAIDS that spur him on. According to UNAIDS, Men who have sex with Men (MSM) globally are a staggering 24 times more likely to be living with HIV than the general population. A 2015 study in South Africa found that 33.9% of gay-identified men in a research sample of 378 black MSM in the historic township of Soweto were found to be HIV positive. This is compounded by the finding that between 88% and 94% of MSM in South Africa were reported to not know their HIV status, in a context where high levels of concurrent sexual partners among the Soweto cohort, for instance, was reported by 73% of respondents.
It is these figures and his own lived experience as an MSM that led 28-year-old Thando Jack to becoming an activist since his late teens. His extreme passion for ensuring that MSM access affordable, quality health care services is clear from the moment he starts engaging.
Working as a data capturer at a prominent men’s health non-governmental organisation (NGO) in Cape Town, South Africa, Thando is at the coalface of clinical consultations focusing on ensuring that data involving HIV tests results, on the treatment programme, including the rate of defaulting, and on the outcomes of TB test results are meticulously captured. The organisation runs programmes in Cape Town and Johannesburg, as a result of the high MSM populations and the corresponding high risk of infections in these two cities.
Despite many gains, including a progressive Constitution and law reform that allows the LGBTI+ community to enjoy the same rights as heterosexual people, Thando is worried about numerous factors that continue to affect MSM’s access to healthcare services in South Africa, including stigma. “Many health workers are still not informed or sensitive about MSM issues when providing healthcare despite the numerous interventions of organisations such as Anova Health and Health4Men, who conduct sensitization trainings in health facilities across South Africa”, says Thando. “Just from engaging with a clinician in history taking and explaining how you got anal warts or Gonorrhea, you can see from the reaction that you are being discriminated against. It’s sad. You would hope that someone who has the courage to get out of bed to seek medical health care is not treated that way”, he says.
Sensitisation trainings occur for health practitioners in both public and private practice. The programme has a website that directs MSM to health practitioners who are MSM friendly. These are services that do involve greater awareness, tolerance of others and less stigmatization of health seekers on the basis of their sexual orientation. For Thando, it is imperative that programmes such as these are amplified to reach areas beyond just Johannesburg and Cape Town, as MSM in other areas will be better placed to seek health care services knowing they won’t face the discrimination they often still face. “There is still a need for more public and private health care workers to undergo this MSM sensitization training throughout the country, as only a certain portion have gone through this programme”, he says.
Ivan Toms clinic in Cape Town, which Thando highlights as an essential health care facility in improving the fight against HIV amongst MSM and the site from which they work has about 13 000 patients who leave their own communities and local clinics from areas as far flung as Paarl, Atlantis, Fish Hoek, Wellington, as well as nearby areas such as Khayelitsha, Phillipi, Gugulethu and Kraaifontein in order to access critical health care services from practitioners who are MSM friendly. They acknowledge the importance of the right to food through providing food and/or energy drinks to underweight patients in their road to health.
Having been born and raised in Gugulethu, and realizing the continued stigma faced by MSMs in his community when attempting to access healthcare, a critical worry of Thando’s is that safe spaces such as the health facility he works for will have to shut down their doors as a result of potential funding cuts from prominent international donor organisations. This could quite conceivably result in many defaulting and in an increase in avoidable deaths of many people, some of whom make up his close community.
The external stigma; continued fear of help seeking among men and the potential funding crisis form a deadly cocktail that would effectively place the gains made among MSM through the ‘universal test and treat’ policy from the national Department of Health in jeopardy.
For Thando, “when it comes to the needs of the MSM population and significantly reducing the rate of infections, it is important to find innovative ways and systems to help in fighting HIV. We need to keep up with new technologies and knowledge to do so, something we aren’t really doing at the moment.”
This article is part of a Spotlight special series on people who form part of so-called key populations.
 UNAIDS (2017), “Blind Spot: Reaching out to Men and Boys – Addressing a Blind Spot in the Response to HIV”, PDF.
 Lane T, Raymond HF, Dladla S, Rasethe J, Struthers H, McFarland W, et al. “High HIV prevalence among men who have sex with men in Soweto, South Africa: Results from the Soweto Men’s Study” in AIDS Behav. 2011;15(3):626–634.
 Ibid and Burrell E, Mark D, Grant R, Wood R, Bekker LG, “Sexual risk behaviours and HIV-1 prevalence among urban men who have sex with men in Cape Town, South Africa” in Sexual Health. 2010; 7 (2):149–153.
 Ivan Toms Clinic (2018), http://search.info4africa.org.za/Organisation?Id=83901., accessed 10 July 2018.
 Department of Health, “Re: Implementation of the Universal Test and Treat Strategy for HIV Positive Patients and Differentiated Care for Stable Patients”, http://www.sahivsoc.org/Files/22%208%2016%20Circular%20UTT%20%20%20Decongestion%20CCMT%20Directorate.pdf, accessed 10 July 2018.
By Nomatter Ndebele
There are an estimated 75000 people living in South Africa who inject drugs. According to local NGO, Jab Smart, 1653 of these users, are located within Sub-region F in Johannesburg. Sub-region F covers the Johannesburg CBD, Braamfontein, Rossetenville, Mayfair, Hillbrow and Yeoville. 42-yeard-old, Marthinus Barnard, is just one of them.
It is a bitterly cold morning in Vrededorp, Johannesburg. Marthinus walks ahead of us with a limp that came back a few days ago, after stealing a municipal bin for his friend. We move silently and steadily along, until he turns around with a cheeky smile, opens his arms and announces “welcome to my office”.
His office is one of Johannesburg’s oldest cemeteries, the Brixton Cemetery which is adjacent to Vrededorp. We weave in and out of tombstones, trying to find a spot to settle. Eventually we come to an area that has many horizontal tombstones. Here, the trees part just enough to allow the struggling sunlight to illuminate a piece of a broken tombstone that reads “Moeder” (A formal Afrikaans reference to Mother).
“My mother told me, dead people can’t do anything, it’s the living that can hurt you,” says Marthinus.
He settles on an abandoned piece of a tombstone and turns his striking blue eyes to mine, ask me anything,” he invites.
Marthinus, who goes by “Thinus” has spent more than half his life on drugs. He has come a long way since he first smoked marijuana, with a group of school friends in an attempt to beat his depression. In these twenty years, this once handsome blue eyed boy has lost all his front teeth, his skin is patchy, he is covered in grime as washing himself is no longer a priority. His wrists are decorated with thin lines acquired from self-harm, and his arms are covered in tattoo’s, some from boyhood and others from prison stints.
Thinus spends five to six hours in his “office” every day. In this space, he has had countless “hits” and a track record of 400 clients during the time he was a sex worker. Thinus no longer engages in sex work, he does odd jobs where he can to make enough money to support his habit. Fortunately or unfortunately, Thinus quips.
A bag of heroin costs anything between R18 and R40. (around $1.20 to $3)
A bag of heroin in Vrededorp typically contains about 3% heroine, and is mixed with rat poison, ant poison and antiretrovirals. The crook of Thinus’ left arm is decorated with a red rash, that’s the “Rattex” (rat poison) he says matter-of-factly. The high from this heroin lasts three to four hours, before Thinus needs his next fix. He goes through six or seven bags every day.
The term key populations draws a blank from Thinus. Despite knowing all there is to know about the history of Vrededorp. It seems this is one term he doesn’t know about.
Although he no longer engages in sex work, Thinus is still an in injecting drug user, and is at high risk of contracting HIV. He admits having been ignorant about HIV in the early days. “I always used to tell people that there was no such thing, that if you just cleaned the needles nicely, you wouldn’t catch it, what a mistake that was,” he says while letting out a belly laugh.
A month ago Thinus learnt that he had tested positive for HIV. He knows for a fact that he contracted the virus through the sharing of needles. “There is only one guy I share needles with, and he is also HIV positive, I’m sure I got it from him.”
A local NGO and mobile clinic called Jab Smart, has started operating in Mayfair which is a few blocks away from Vrederdorp. Jab smart is currently the only organization that provides harm reduction packs (HRP) to People who inject drugs (PWID). The harm reduction packs consist of new needles, alcohol swabs and condoms. These packs are made available to people who inject drugs at least once a week. People simply have to remember when the mobile clinic is coming to the neighborhood, so they can access a HRP.
At the mobile clinic people are encouraged to take HIV tests. This is part of Jab mart’s comprehensive care package. Where they encounter users who are HIV positive, they refer them to a clinic or a doctor to try and get them on treatment as soon as possible. It was through this service that Thinus discovered that he was living with HIV.
Jab Smart is currently the only service assisting injecting drug users in the area. The programme seeks to ensure that if users cannot quit the habit, they at least continue in a safe manner or that they try to lessen their intake of drugs. The same programme independently provides OST (Opiod substitution therapy) to eligible candidates. OST therapy provides people who inject drugs with monitored dosages of Methadone – which provides relief to the severe drug withdrawal symptoms which could otherwise drive people to again use drugs.
A mobile population
Despite the fact that this service is just a stone’s throw away from Vrededorp (about 7 kilometres), it is an impossible feat for the average drug user to access it. “We can’t go there every day, it’s easier for us to make up the money to get a hit than to get together the money to travel to Yeoville,” says Thinus.
While Thinus’ problem is that he is somewhat immobile, most users face the problem of being too mobile.
Anthony Manion, project manager of Jab Smart, says that the fact that most drug users are mobile provides the programme with great challenges when it comes to monitoring and supporting users. “Because people move all over the city, sometimes with all their belongings in tow, it is difficult to trace users.” Despite this challenge, Jab smart has managed to retain many of their first time users who receive HRPs.
In the month from May to June Jab smart saw a total of 1 653 new users. In the same month, they had 5 944 people who returned to use the service. They managed to test 1 086 users for HIV, of which 504 tested positive, but only 112 of them were successfully referred to a clinic or a doctor.
Despite the fact that Thinus was referred to a clinic through this programme, he has not yet gone. “I still feel healthy, but also my life is already fucked up, what is there left to do,” he says.
Thinus has been through Rehabilitation twice and relapsed each time. Despite having had the opportunity to be in a private rehabilitation facility, Thinus was unable to stay away from the drugs. He blames this on the fact that despite getting clean, he came back to the very same environment that fostered his habit for so many years. “If there is nothing to occupy your mind or something for you to do, you’ll go back, there just isn’t enough support for us when we come out from rehab.”
He isn’t lying. The lack of resources and support for people who inject drugs in Vrededorp, is glaringly obvious. The flats are all dark, most have cracked windows and are decorated with crude graffiti. The streets are deserted and there is no life, other than on a few corners where groups of boys loiter around. The community has one soup kitchen, which also operates as a crèche, for smaller children. Other than that, you’d be hard pressed to find a library or a community resource center. Leaving is hardly an option for anyone in Vrededorp.
Apart from Jab Smart, there isn’t any other programme that offers such comprehensive care to users. Even at state hospitals, where people have been specifically trained to work with people who inject drugs, not enough is done to assist this vulnerable key population group. “Often nurses will turn away drug users asking them to return when they are clean”, says Mourbadin. “In most instances, people are turned away from facilities, either because of the way they look, or how they smell.”
The threat of being mistreated or turned away from healthcare facilities has thus become a major deterrent to people looking for care services. This has caused many people who might otherwise have accessed life-saving care, to fall by the wayside. There simply seems to be no way back for people like Thinus.
Six years ago Thinus and his friends were travelling from Krugersdorp to Johannesburg. One moment Thinus was chasing a glass of Vodka with a cocktail of crystal meth, Mandrax and marijuana, the next moment he opened his eyes and a doctor was standing over him in the Intensive Care Unit, telling him that he had flat lined for a minute and 20 seconds. Thinus was clinically dead. “ Doing drugs is never enough, the only way you can win is by dying,”says Thinus.
This article is part of a Spotlight special series on people who form part of so-called key populations.
By Marcus Low
A trend-setting programme that forms a core part of the South African government’s health services tailored to the needs of men who have sex with men (MSM) is at risk of closing much of its operations because the US government has stopped its funding. Health4Men, a programme of the Anova Health Institute and the Department of Health, was notified last week that its main funder, the United States President’s Emergency Plan for Aids Relief (PEPFAR), working through the United States Agency for International Development (USAID), would not be giving it a new grant.
The funding cuts mean that men who have been receiving MSM-tailored care from Health4Men facilities in Cape Town and Johannesburg will have to return to normal public-sector clinics to receive care should last minute fund-raising efforts be unsuccessful. Since funding under the current grant will run out in a matter of months, the process of de-escalating the programme has already started. According to Dr Kevin Rebe, Specialist Medical Consultant at Anova, they have already started notifying clients that changes are imminent.
“It is very tragic that an effective locally developed MSM health model, which is admired internationally and has been replicated in many African countries, is coming to an end in our own country. This is sad news for our patients and unfortunately I believe this might negatively affect their access to enabling health services,” says Rebe.
Health4Men operates two so-called centres of excellence clinics in Cape Town and Johannesburg – both set to be impacted by the funding cuts. They work in an additional nine Department of Health facilities, one in each of South Africa’s nine provinces. The funding cuts mean that they will have to withdraw their clinical staff from five of these nine facilities. Similarly, withdrawal from five provinces means that instead of providing ongoing training and monitoring at 400 public sector facilities, they will in future only be able to provide this support in around 175 facilities.
“The Health4Men Initiative is a broad one consisting of community engagement activities, training of health providers, an ongoing clinical mentoring program as well as the direct service clinics,” says James McIntyre, CEO of Anova Health. “The programme is currently funded by USAID in five provinces and by the Global Fund in the other four. Loss of the USAID funding will impact all aspects of the Initiative in the USAID supported provinces (Western Cape, Gauteng, Limpopo, Mpumalanga and North West.). Work in the Global Fund supported provinces will continue until the end of this grant cycle (March 2019).”
Direct services to 15 000
Rebe says that the Health4Men programme has directly provided clinical services to around 15 000 men in the ten years since its launch in 2008.
Currently around 650 men who are not living with HIV are receiving pre-exposure prophylaxis (PrEP) through Health4Men’s programmes in order to prevent HIV infection. Rebe explains that since PrEP is not currently being provided at normal public-sector clinics, there is nowhere where they can refer these men to continue receiving PrEP and as it stands these men are at risk of losing access.
While there are other programmes working with MSM, Rebe says that in some areas Health4Men is the only programme providing clinical services, including PrEP, that caters specifically for the needs of MSM.
The specific needs of MSM include promotion of knowledge about reducing their risk of HIV and STIs, providing access to commodities such as condoms, lubricants PrEP and antiretroviral therapy, and access to trained staff who are sensitive to diversity and have the clinical skills to detect and treat conditions that improve health outcomes specifically in this population. “All of this needs to be provided in an enabling, non-judgmental environment and also needs to be founded on engagement with MSM communities who will use the service,” says Rebe.
A decade at the forefront of MSM services
Since being founded in 2008, Health4Men has been at the forefront of service provision to MSM in South Africa. In 2015 they conducted the first demonstration programme in South Africa to test the provision of PrEP to prevent MSM from contracting HIV. Four of their sites are currently listed as Department of Health PrEP scale-up sites.
“We believe that the centre is a critical resource in MSM care for both South Africa and the region: in addition to all the South African training, both Government staff and NGO’s from ten African countries have been trained by Anova over the past few years either on site at the clinic, or by Health4Men trainers in their countries, and we believe that this is worth maintaining, in addition to the expert service provision for our community,” says McIntyre.
Earlier this year Anova Health applied to USAID – one of the entities through which PEPFAR provides funding – for a new grant to continue the work. Their application was unsuccessful. Rebe stresses that they are not interested in blaming USAID for not getting a new grant and that their concern is simply with ensuring their patients continue to receive quality and appropriate treatment and care. So far Health4Men has received no indication that any other organisation will be taking over the clinical services that they have been providing.
Anova Health is currently pursuing alternative funding to keep at least The Ivan Toms Clinic (one of the centres of excellence) in Cape Town open in the short term, while looking at other solutions longer term, says McIntyre. “As we presume a new USAID partner will provide alternative community outreach services in the USAID target cities, the most impact on the community in Cape Town and Johannesburg is likely to be the loss of the dedicated clinical services platform. Anova is pursuing other avenues to maintain the Centres of Excellence, but if we were unable to negotiate a way forward with alternative funding and the relevant Provincial Departments of Health, the direct service provision at these sites would close.”
USAID to appoint new service provider
According to Cynthia Harvey, U.S. Embassy Spokesperson, USAID “remains committed to supporting excellent and expanded health services to men who have sex with men (MSM) in South Africa” and is committed to ensuring a smooth transition between its implementers. “USAID and the successful applicant will work closely with government officials and civil society stakeholders to ensure this smooth transition,” says Harvey.
“USAID is conducting a “competitive process to select an implementer for the next phase of activities related to the MSM population in SA,” says Harvey. According to her the successful applicant will “provide a comprehensive package of services for MSM in the City of Johannesburg, City of Cape Town Metro, Buffalo City Metro and Nelson Mandela Bay Metro, which will include empowerment-based, peer-led outreach, provision of condoms and lubricant, referrals or services for treatment of STIs, HIV testing services (including linkage to ART for those testing positive), ART for HIV-positive individuals (including adherence support) and PrEP services.”
Harvey also said that targets for the upcoming U.S. government fiscal year (starting in October 1st) have increased significantly from the current year, demonstrating USAID’s commitment to providing expanded coverage.
Questions Spotlight sent to the Department of Health had not been responded to at the time of publication. According to Rebe, Anova Health will be meeting with the Department of Health in the next few days to discuss the way forward.