Access denied

Ntsiki Mpulo, Spotlight

Activists blame government for limited access to abortion services in the public sector.

The streets of Hillbrow bustle with morning traffic. Taxis shoot in and out of the wide avenues as the Spotlight team passes through the palisade fencing and glass doors leading to the overcrowded entrance of the Hillbrow Community Health Centre. Patients sit in queues awaiting attention in the reception area and in the casualty ward. There is a din, as traffic noise competes with hundreds of conversations.

The uniformed security guard dispenses directions and acts as a traffic officer, redirecting people to different areas of the clinic in response to questions: where should I go for this ailment, what should I do with this piece of paper? She is a fount of knowledge – of necessity, as there is little signage other than the ‘Reception’ sign at casualty.

When we ask where the area for termination of pregnancy is, she informs us that the facility no longer offers this service. The sister who used to provide the service left some six months ago, and no-one else wishes to provide it.

This is the dominant narrative in many facilities across the country, according to Professor Eddie Mhlanga. Dr Mhlanga, a devout Christian and an obstetrician, is a strong proponent of choice in termination of pregnancy. He was director of the National Health Department’s Maternal, Child and Women’s Health unit from 1995 to 1999. During that time, he spearheaded the development of legislation to legalise abortion.

In his view: though the legislation is in place, in practice, women are being denied the choice to terminate unwanted pregnancies, because the prerogative of choice over women’s bodies is given to health workers. This is an untenable situation.

“Black women have little or no rights over their bodies in this country,” says Dr Mhlanga. “Their autonomy is restricted by patriarchy, in the guise of cultural practices.”

This is a view shared by outspoken sexual and reproductive health activist Dr Tlaleng Mofokeng, who does not pull any punches.

“Patriarchy and misogyny are systematic,” she says. “Power relations are stacked against women; so when they go into facilities, they feel like the healthcare professional is doing them a favour.”

According to a policy brief by Critical Studies in Sexualities and Reproduction, a research programme based at Rhodes University, just over six out of every 10 (63 per cent) young women in Buffalo City Municipality in the Eastern Cape are not aware of their right to obtain a free abortion in the public sector.

“You can’t fight for a right you don’t know you have,” says Dr Mofokeng. “It suits the department not to do a health education drive on abortion.” It seems the department is not interested in upholding the Termination of Pregnancy Act.

“It was reported some five years ago that only 40 per cent of facilities designated for providing this service were operational,” explains Dr Mofokeng. “This means there is a higher risk of women going to clinics in the second trimester, looking for surgical options – where they won’t be helped.”

Every healthcare facility should be able to offer a medical abortion up to 12 weeks, on a woman’s request. But this is not the case; a large number of facilities have insufficient or no trained personnel, and there is no protocol for referring the woman to another facility. In addition, there are often medicine stock-outs, or the drugs required are not listed on the essential drugs list.

According to Dr Mofokeng, the lack of access to abortion services is the result of a lack of care for women on all levels – from the government itself, represented by the Department of Health, to the Ministry, which does not have accurate statistics. They don’t know and can’t quantify the magnitude of the problem; they are disinterested, and disengaged from all the illegal posters advertising medical procedures.

“This is a primary healthcare issue, and it is the Department’s problem to solve,” says Dr Mofokeng.

Approach abortion with compassion

Spotlight attended a termination-of-pregnancy training workshop delivered by venerated sexual and reproductive health rights activist and medical practitioner Professor Eddie Mhlanga. During the workshop, Dr Mhlanga outlined the circumstances under which a woman of any age may obtain a legal abortion in the public sector. He emphasised that a woman does not require consent from anyone to undergo the procedure, but that those under the age of 18 should be counselled to inform their parents or legal guardian.

Circumstances and conditions under which pregnancy may be terminated

Gestation PeriodCircumstances and Conditions By WhomRequirements
Up to 12 weeks On the request of a pregnant woman of any ageRegistered Nurse
Registered Mid-wife with appropriate training
Informed consent of the pregnant woman
13 to 20 weeks Continued pregnancy poses a risk of injury to a woman’s physical or mental health
Would affect social or economic circumstances
Severe physical/mental abnormalities in the foetus
Pregnancy is a result of rape or incest
Doctor Informed consent of the pregnant woman
After 20 weeksIf the pregnancy would:
Endanger the woman’s life
Result in severe malformation of the foetus
Pose a risk of injury to the foetus
Doctor Informed consent of the pregnant woman;
consult 2 doctors, or a doctor and a midwife

Here are some of the questions we posed to Professor Eddie Mhlanga.

Who are the women seeking abortion?

“The majority of women who seek to terminate pregnancies, according to the health professionals Spotlight interviewed, are teenage girls. They report that sometimes girls as young as 14 years of age come to their facilities seeking abortions because this is their second child, and their families had forgiven them for the first ‘mistake’, but would not tolerate another; while others report having relationships with teachers or married men, and are not able to look after a child.

Sometimes it is a married woman who has ‘stepped out’ on her husband, who is perhaps out of the province. “I had a case where a woman came to me pregnant with her eighth child,” says Dr Mhlanga. “She had asked the doctor who delivered her seventh child to tie her tubes, but he failed to do so. She was a poor woman who survived on the grants provided by the state, and she simply could not afford another child. In this instance, the compassionate thing to do was to provide her an abortion.”

How many healthcare facilities offer termination of pregnancy services?

“In Mpumalanga, there are 23 facilities in the public sector that offer termination of pregnancy services. This is up from only five facilities three years ago. It is because we conduct training sessions for health professionals throughout the province, and even offer this training to other provinces. We trained doctors and nurses from Gauteng not too long ago.

In Gauteng there are 25 facilities, the majority of which offer the service only for women in their first trimester. Second-trimester terminations are only available at:

  • Chris Hani Baragwanath Academic Hospital
  • Sebokeng Hospital
  • Odi District Hospital
  • Tembisa Hospital

Services have been terminated at Dr George Mukhari Academic Hospital and Hillbrow CHC.”

How many women die as a result of unsafe abortions?

“The Minister of Health has said in a radio advert that a woman dies every eight minutes as a result of unsafe abortions; however, there are no statistics to corroborate this assertion. During my tenure at the National Health Department, we worked on the protocol for confidential inquiry into maternal deaths, which is published every three years. The last report, published in September 2015, looks at 2014 data; which revealed that in all maternal deaths, 57.3% were considered potentially preventable within the health system. However, there is no data specifically on maternal deaths caused by unsafe abortions.”

What do you think about conscientious objection?

“All healthcare professionals have taken an oath to deliver health care to all who live in this country, as stipulated in section 27 of the Constitution. Therefore, they do not have the right to object to offering the service, and the government should not enable this type of intolerance.

Compassion for the pregnant woman’s circumstances should be the primary motivation for any health worker. Currently, there is no provision in the Act for conscientious objection; and so, health workers are using the lack of clarity to deny women their right to health care.

Many health workers do not have a problem completing a botched abortion, irrespective of the cause; but they refuse to perform one at the request of a pregnant woman. This is grossly unjust.”

The ACDP has presented a private member’s bill to amend the Act. What do you think of the provisions they are suggesting?

“They recommend that a woman has an ultrasound. It is not only a coercive strategy to limit women’s ability to choose to terminate a pregnancy, but also impractical. Currently, there is no curriculum for training doctors to perform an ultrasound examination; it is simply not available in the public service. So this would be an additional burden on an already overburdened system.

In addition: in law, a foetus only becomes a life when it takes a breath; and thus, the argument that terminating an unwanted pregnancy is taking a life holds no credence in law.”

Dr Mhlanga is a lifelong advocate for the sexual and reproductive health rights of women, including the decriminalisation of sex work.

Read the full Spotlight: Youth Edition

Period-shaming must fall

Ufrieda Ho, Spotlight

Statistics about menstruation and girls’ missed school days in South Africa have been guesstimates at best, and range wildly – between two and seven million girls affected.

Numbers can be a distraction, though; whatever the numbers, in the end they

Teenager girls pose at the Hector Pieterson Memorial in Orlando West, Soweto. (Image: Sam Nzima, Alamy)

still speak to the massive challenge of ending period poverty, bringing dignity to more schoolgirls who are on their cycle, and shattering the stigma of and myths about menstruation.

For Sharon Gordon, CEO of Dignity Dreams, what struck her most in working with girls and schools in need has been a small reality that has little to do with startling numbers, but has been just as revealing.

Dignity Dreams is an NGO, started in 2013 with a mission to distribute free sanitary products to schoolgirls in need. Together with their various donors they distribute reusable cloth pads to schoolgirls who cannot afford them. In five years, the organisation has been able to distribute 67 000 packs of these reusable pads, to girls in South Africa and even to the Democratic Republic of Congo.

“I knew that the school principals would probably report back about improved attendance at schools after the distribution of the pads – almost because it’s become the norm to say this.

“We welcome the positive feedback; but research shows the reality is that the problem is less about menstruating girls who can’t afford sanitary towels staying away from school, and more about girls who are forced to use unreliable homemade products not being able to concentrate in class, or take part in sports and other school activities,” says Gordon.

However, it was one comment in a report-back that really stood out for her: schools were noting savings in their plumbing bills.

“Plumbers were being called out less to schools to unblock toilets, because girls were no longer throwing disposable pads and homemade sanitary towels into them,” says Gordon.

Items that used to be flushed down toilets included everything from disposable sanitary towels to pads made of newspaper, rags, and socks filled with sand. With the reusable pads, the girls were taking soiled pads home to be washed, dried and reused.

For Gordon, it bought home sharply the impact of positive intervention.

Dignity Dreams has also teamed up with a women’s upliftment collective employed to make the cloth pads for them. The packs contain six pads that can last four years, and they are distributed to Grade 8 pupils. The packs cost R200 each, and donors can also add panties to the packs that are distributed.

“We have focused on cloth pads because they have proved to be the product most acceptable to the girls, and the most sustainable. We also only have to visit a school once a year to distribute to every new Grade 8 class, rather than making monthly deliveries,” Gordon says.

Importantly, she adds, each delivery is an opportunity for outreach and education. The sessions are used to dispel myths and superstitions about periods – nonsense such as that washing your hair when you’re menstruating is unhealthy, or that periods are a sign of contamination.

Gordon is also pushing for men and boys to be informed about menstruation, so that period-shaming can stop; and so that society can let go of its discomfort about talking about periods, and be part of the solution to period poverty.

“We still hear things on distribution days, from teachers and principals,” she says, “saying things like ‘It’s wonderful that you have these pads, girls – now, hide them away.’”

“Periods are a bodily function, like blowing your nose, or having a wee – that’s the message we must get across.”

VAT on menstruation

The one-percentage-point VAT increase announced in February has been bad news for many, especially those campaigning for zero VAT on sanitary products.

In November last year, national treasury announced that tax exemption on sanitary towels would be put on hold – despite lobbying by activists and some members of Parliament for over a year. Instead, treasury urged individual departments to reallocate budgets in order to find funds to support subsidies or free pad-distribution initiatives.

The pressure from activists – and even from some in Parliament – was a direct response to growing evidence that girls who cannot afford sanitary pads and are then forced to use makeshift pads are compromised, in their learning and school and sports activities. They are not able to concentrate as well, and some even miss school days entirely as a result.

The number of girls in South Africa affected may not be the routinely quoted seven million, but could still be as high as around 2.6 million girls, according to fact-checking organisation Africa Check. They also found that absenteeism as a result of not having sanitary products was also not as high as the figures used for attention-grabbing headlines.

In the same fact-checking exercise Africa Check published in August 2016, they highlighted former President Jacob Zuma’s promise in 2011 that government would provide sanitary pads to indigent girls and women.

In February last year, through its social enrichment programme, the KwaZulu-Natal (KZN) Department of Education became the first province to roll out a free sanitary pad programme, to around 2 950 quintile 1 to 4 schools.

One year on, information and updates on the success and sustainability of this programme – launched with a R50 million budget – are still to be disclosed by the KZN Department of Education. Spotlight has tried several times to access updates on the programme, but has not received an informative response.

The Menstrual Cup

“I never thought it would happen to me,” Nonhlanhla Phume (25) told

menstrual cup

Spotlight. A few years ago, while menstruating, she noticed blood had leaked through and stained her pants while she was studying in a computer laboratory at Wits University.

“I was so embarrassed. I had to literally walk out with the chair I was sitting on, and take it to the bathroom and clean it. I was so self-conscious whenever I was menstruating after that,” she said.

But the worry around her menstrual period vanished after she started using a menstrual cup last year, given to her by the Maternal Adolescent and Child Health Research Unit as part of a DREAMS research project.

A menstrual cup is a small silicone cup-shaped device inserted into the vagina, which traps menstrual blood.

According to lead researcher Mags Beksinska the cup, which lasts five years, saves young women a significant amount of money. This is particularly relevant for poor school-going girls who have been reported to stay at home when menstruating, due to the unaffordability of sanitary products.

Beksinska said they are distributing 6 000 free cups to young women, primarily in all the institutions of higher education in three KwaZulu-Natal districts. Five hundred will be followed up for the study to find out what their sanitary challenges are, and what their experiences have been using the cup. School-going girls are not being targeted in this project because the provincial government provides sanitary assistance in schools; also, there were cultural concerns about virginity testing in relation to the use of the cup.

Phume, who is a project assistant for the menstrual cup study, said the product has not only saved her money, but also a lot of anxiety.

“Even though I had never even used a tampon before, I hardly notice the cup when it’s in. It never leaks, and I’m not stressed about that happening to me ever again.”



The cost of liberation

Ufrieda Ho, Spotlight

A moment of true liberation came for Thembi Mahlathi when she was standing at a supermarket check-out queue. In her shopping basket, for the first time, were sanitary pads that she could afford.

“I was so happy that I could finally afford sanitary pads – I think I bought four packs,” says the 28-year-old paralegal, remembering the day she was finally earning enough to pay for her own pads.

It was a moment of empowerment, says Mahlathi – the direct opposite to how she felt as a nine-year-old girl, when her cycle started. She remembers her confusion, and not knowing what was happening to her body. She didn’t tell her mother though; she couldn’t.

“I always heard my mother and her friends saying things like, ‘If a girl starts menstruating young, then she’s messing around with boys’; so I was too scared to tell my mom,” she says.

She sneaked the odd sanitary pad from her mother; but because pads were a luxury in the home, she knew her mom would notice eventually. Mahlathi resorted to cutting up a few old T-shirts, folding them into the shape of pads, and jamming them into her panties.

“I had one for the morning and one for the afternoon, and I carried a plastic bag with me so I could take the dirty one home to wash,” she says.

When Mahlathi was 13, her mother found out by chance that she was menstruating. Even then, Mahlathi never told her mom she had been menstruating for years already. Her mother gave her some pads, but there were never enough; and when her mom lost her job and they only had her father’s wages, pads became a luxury item again.

“We both had to use T-shirt pads then, or sometimes we used a stack of tissues. I don’t think my dad understood that pads were something we needed, and that sometimes I needed more than one pack a month, because I have a heavy flow.”

The T-shirt pads were a nightmare. She couldn’t concentrate in class, worrying about an accident that could soil her yellow uniform, and the humiliation and mocking that was in store for girls who did have accidents. The thought of perhaps being called up to write something on the blackboard while she was having her period was pure terror.

“I really wanted to play netball, but I couldn’t; because that pad would move around, and the players wore mini-skirts,” says Mahlathi, who went to a school in Tembisa, east of Johannesburg.

Fear of embarrassment, lack of information, having no one to turn to for answers about her changing body, and the grinding realisation that there was no money for basics in her home marked much of her growing-up years.

“Poverty – I don’t want to go back there,” she says.

Mahlathi says she’s now able to speak openly about menstruation and poverty because as a mom to two daughters, aged 11 and six, she wants better for them.

“I don’t want any girl to go through what I went through. And I want my 11-year-old to be prepared, and to know that what is happening to her body is normal,” she says.

Mahlathi believes schools need better education programmes to teach girls and boys about menstruation, and that myths and superstition must be dispelled. She says schools should also be making pads available to girls, so that girls don’t have to resort to making ineffective alternatives like her T-shirt pads, or feel embarrassed about not being are able to afford pads.

Nowadays, Mahlathi never forgets to pack a pad in her daughter’s schoolbag. She also never forgets that liberation, for a poor girl-child, can cost as little as R20 or R30 a month.

DREAMS and She Conquers

Amy Green, Health-e News

An estimated 2 000 new HIV infections occur in young women and girls every week in South Africa. Two high-profile programmes are aiming to address this crisis. In this joint Spotlight/Health-e News Service special investigation, we go beyond the bells and whistles and ask what difference these programmes are really making.

Roughly 40km outside Durban lies the small town of Molweni. This is where a young woman, Nontokozo Zakwe – now 26 – grew up.

“One of the things I noticed growing up was that gender-based violence (GBV) was the norm,” she says. “And the mentality was: if it happens to you, get over it. If it didn’t kill you, you’re going to be okay.”

The first time ‘it’ happened to Zakwe, she was just 11 years old.

“We had two options on our walk back home from school: the road, or the short cut past the river,” she says. Most days she took the road; but one day, after staying late after school, she decided to use the short cut, because it was getting dark.

“Then this man, he raped me.”

Zakwe survived the attack and made her way home, where she lived with a number of cousins and siblings. Her mother worked in another province, she didn’t know her father at that point, and her grandmother could only afford to come home one weekend a month from her job as a domestic worker on the other side of the country.

“But being from the kind of community I was from, when I got home I decided to sleep. I cried myself to sleep,” she remembers.

A visiting aunt woke Zakwe up that evening, pulled back the covers, noticed blood, and asked the young girl what had happened.

“When I told her, she told me everything was going to be okay. I could tell in her eyes she was sorry for me and wished it hadn’t happened, but that she felt there was nothing she could do except tell me I was going to be okay,” Zakwe says.

“We were forced not to talk about things. Talking that could help us heal. One can imagine, these experiences – experienced by many young girls, around the country – can leave you vulnerable to HIV, teen pregnancy and other problems.”

At the age of 11, not even a teenager yet, Zakwe was expected to overcome the trauma of that violent experience, stay in school, and avoid early pregnancy, without any support – psycho-social, financial or otherwise – jn becoming a successful HIV-negative adult.

2 000 infections a week

It is against this backdrop of the lived experiences of many young women in South Africa that a staggering 2 000 new HIV infections occur in young women and girls every week. Over 70 per cent of new HIV infections in people aged 12 to 24 in sub-Saharan Africa occur in young women and girls, who overwhelmingly bear the burden of the epidemic, according to research done by Professor Ayesha Kharsany from the Centre for the AIDS Programme of Research in South Africa.

In South Africa, one third of young women and girls experience abuse, 60 per cent of young people do not have a matric qualification, and about 70 000 babies annually are born to girls under the age of 18, according to the South African National Department of Health (DoH).

It is being increasingly acknowledged that the contexts in which young women and girls live, which are often patriarchal and violent in nature, need to be addressed in order to make any meaningful impact on reducing new infections, and ultimately ending AIDS as a public health threat to the world.

Treatment and prevention campaigns alone, located in the health department, cannot by themselves address all the systemic drivers that make young women and girls more vulnerable to HIV than their male counterparts: poverty and gender inequality, as well as biological factors. These affect every facet of a girl’s life: her ability to stay in school, choose when to have children, her economic opportunities and the gendered and sexual violence experienced by women that is endemic in South Africa.

It is in this context that a number of initiatives, backed by billions in international aid, have been launched in South Africa. On the face of it, they aim to address the contexts in which young women and girls live in order to help them reach their full potential, including changing long-held perceptions in communities that leave them unsafe from violence and HIV.

It was only two years ago, when Zakwe joined the DREAMS partnership as an ambassador, that she began to receive the psycho-social support she needed 15 years ago.

DREAMS is a global partnership aimed at improving the lives of young women and girls in 10 African countries – with the ultimate aim of reducing the rate of new HIV infections in this group.

Another prevention campaign for young women and girls looking to tackle the societal problems driving their vulnerability to HIV is She Conquers, led by the DoH, launched by then-Deputy President Cyril Ramaphosa, and most famous for the controversy over a number of billboards commissioned under its name in Gauteng.

A grave historical injustice

In his response to the State of the Nation (SONA) debate on Tuesday 20 February, Ramaphosa, the newly-elected president, said:

“Another grave historical injustice that we need to correct is the economic inequality between men and women.

“It is a task that requires both a deliberate bias in economic policy towards the advancement of women and a fundamental shift in almost every aspect of social life.

“One of the programmes where we have sought to integrate various approaches is the ‘She Conquers’ initiative, which aims to empower adolescent girls and young women to reduce HIV infections, tackle gender-based violence, keep girls in school and increase economic opportunities.

“It recognises how patriarchal attitudes, poverty, social pressures, unemployment and lack of adequate health and other services conspire to reduce the prospects of young women – and then involves these women in overcoming these challenges.

“This is one of the ways we are working to build a nation that is prepared to confront the many different ways in which women are subjugated, marginalised and overlooked – a nation that wages a daily struggle against patriarchy, discrimination and intolerance.”

While Ramaphosa’s words are comforting, as they acknowledge the difficult situations in which young women and girls live, as well as the patriarchal nature of our society, one is left to wonder why so little is known about this important initiative, and how it is working to tackle the multitude of obstacles mentioned.

What is DREAMS?

What are She Conquers and DREAMS exactly? What is happening on the ground to improve the lives of South African girls and young women? Are they reaching their intended audience and achieving their aims? And how can systems of power such as patriarchy, entrenched in society for centuries, be tackled by health-led programmes only in place for a few years?

DREAMS is a global partnership, announced in December 2014, between the United States President’s Emergency Plan for AIDS Relief (PEPFAR), the Bill & Melinda Gates Foundation, Girl Effect, Johnson & Johnson, Gilead Sciences and ViiV Healthcare, aimed at reducing new HIV infections in girls and adolescent women by 40 per cent by 2017. But the South African arm of the project started late, and the target has been shifted to 2019.

PEPFAR’s Caroline Schneider told Spotlight/Health-e that to achieve this, the “ultimate goal is to help girls develop into Determined, Resilient, Empowered, AIDS-free, Mentored and Safe women” – the tenets the DREAMS name stands for.

Backed by U$385 million [about R4.5 billion], the “ambitious” initiative aims to go “beyond the health sector” to address the social factors that drive young women and girls’ particular vulnerability to HIV, including GBV, poverty, school drop-out, and gender inequality in the form of “economic disadvantage” and “discriminatory cultural norms”.

It was launched in 10 sub-Saharan African countries, with South Africa being allocated U$66 million [about R770 million], when it began operating locally in 2016.

“DREAMS uses multiple evidence-based interventions, including post-violence care, parenting/caregiver programmes, and facilitating access to already available cash transfers and education subsidies,” explained Schneider.

It operates in five districts: eThekwini, uMgungundlovu and uMkhanyakude in KwaZulu-Natal, and Johannesburg and Ekurhuleni in Gauteng, and is facilitated through 20 implementing partners.

What is She Conquers?

Also launched in 2016, She Conquers is a government campaign “aimed to reach adolescent girls and young women aged 15-24 in South Africa who have high rates of HIV as well as teen pregnancies”. Like DREAMS, it aims to do this by looking at the problems in society that make this group particularly vulnerable.

This is according to the DoH’s Dr Yogan Pillay, who said that more than R3 billion has been invested in the programme by three major donors: PEPFAR, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and the German Development Bank (KFW).

He added that the campaign is being rolled out in three phases, with the first phase being implemented in the 22 districts with the highest HIV burden, “where the need is the greatest”. Based on what is learned in these areas, the interventions will be rolled out nationally.

The five targets to be achieved in the 22 priority districts for the three-year-long campaign are ambitious:

  1. Decrease new HIV infections in this group by at least 30 per cent, from 90 000 per year to fewer than 60 000 per year;
  2. Decrease teen pregnancies, in particular under-18 deliveries, by at least 30 per cent, from 73 000 to 50 000;
  3. Increase retention of this group in schools by 20 per cent;
  4. Decrease sexual violence and GBV in this group by 10 per cent;
  5. Increase economic opportunities for young people, particularly young women, by increasing youth employment by 10 per cent.

It is unclear whether progress against these targets will be measured and reported in a way that allows the public and independent experts to hold these programmes accountable in a meaningful way.

There is also much confusion in the public domain as to what the campaign is, whether it is a communication and awareness initiative, or if it involves practical interventions; and if it is adequately responding to the needs of girls and young women: the people it aims to benefit.

The confusion extends to how these initiatives are linked.

Health minister Dr Aaron Motsoaledi told Spotlight that “She Conquers became the South African expression of how to implement DREAMS”.

Schneider said the $66 million South African DREAMS funding allocation falls under the She Conquers umbrella, but that the money is not directly funding the local campaign.

“DREAMS is contributing to achieving the objectives of She Conquers. The US PEPFAR programs in the DREAMS focus districts are in line with the She Conquers strategy, and support She Conquers initiatives in those districts. We can’t speak to the overall She Conquers budget, as this is a Government of South Africa initiative,” she said.

Pillay said She Conquers is a “combination of awareness and practical projects”. But many activists have questioned, firstly, if the campaign is adequately raising awareness in a nuanced way that speaks to the myriad societal ills preventing girls and women from staying safe; and secondly, whether the other interventions are reaching those affected.

Billboard controversy

She Conquers has been most visible in its communication campaign – particularly in the controversy surrounding two of the billboards it commissioned.

Social media erupted in September last year when a billboard next to the N1 in Johannesburg was erected with the tagline: ‘Who says girls don’t want to be on top?’ In smaller letters underneath it reads: “Complete your matric, study hard and graduate!”

While the DoH rejected claims that the message contained sexual innuendo and therefore failed to address the context of violence and lack of support in which girls are expected to ‘study hard and graduate’, many on social media felt the message to be insulting.

Sexual and Reproductive Justice Coalition founder Marion Stevens said that instead of trying to address the circumstances in which young women remain vulnerable, this kind of messaging only perpetuates the status quo: expecting girls themselves to rise above their trying circumstances, be resilient, and somehow succeed.

“With the black girl emoji attached to it and the sexual innuendo, it reinforces the harmful tropes of black women as hyper-sexualised, and places the burden on young black women to overcome obstacles that are out of their control. How can a young woman stay in school when she has to choose to buy food for herself and others in the household instead of paying school fees? Girls drop out because of a range of factors, such as food, security and transport,” she said.

In this type of messaging, Stevens said, there is no mention of the challenges affecting their ability to stay in school or protect themselves from HIV.

Nicknaming the campaign #HeDecides, Stevens questioned who is actually responsible for constructing the She Conquers messaging, because the voices of young women themselves have been left out.

Long-standing HIV activist Yvette Raphael was involved in the initial conceptualisation of the She Conquers campaign, and said that the initial “consultations went well”.

“It looked like it was going to be an overarching campaign that would support very successful campaigns on the ground already working with women. But that is not the reality now. I don’t even know what to make of it – it’s very confusing,” she said.

Young women left out?

While the campaign was initially conceived as being youth-led, Raphael said that young women have been left out of campaign decisions on more than one occasion.

“I don’t think enough engaging of the target audience is happening and that’s why we are getting messages that are insulting to young women. Girls want to be on top – which young person would say that, outside of a relationship? Which young person can own that tagline?”

Raphael said that young women were asked to vote on a campaign name, but that name was never used; instead, ‘She Conquers’ was chosen, without an explanation as to why the name chosen by the young women was ignored.

Motsoaledi said a young woman from Limpopo was responsible for the She Conquers name, and suggested it to the DoH through social media.

Raphael said the problem is that “old people are thinking they can think like young women”. “She Conquers can only serve its purpose if it’s led by young people, and comes from them.”

She Conquers has set up a youth advisory committee located within the South African National AIDS Council (SANAC), consisting of nine young woman representatives who were elected at a She Conquers bootcamp.

But members of this committee told Spotlight that they do not have much decision-making power.

The executive secretary for the committee, 23-year-old Koketso Rathumbu, said the committee was not involved in formulating the messaging for the communications campaign, including the controversial billboards.

“The DoH is the one who facilitates and decides on the communication plan; and unfortunately, this was not shared with us, and there no clear reasons as to why – we have made a request,” she said.

While Rathumbu had positive things to say about the campaign – for example, that it is getting people talking about these issues, and is reaching some young women with beneficial interventions – she said that it is failing in other areas.

“We are advocating for the visibility of the campaign, over and above the media campaigns and billboards. We are fighting for more engagement and inclusivity at grassroots level, but it has been a challenge; many people in rural areas, for example, are not being reached.”

She also said that if every stakeholder, including various government departments, were “synchronised”, then “She Conquers would be a success”.

“The biggest challenge we’ve had is getting different departments to play a role, not just Health – for example, the Department of Basic Education to go into schools with the She Conquers plan. What we need and don’t have is a synchronised system that integrates all stakeholders.”

This could be why She Conquers is so confusing to the public, and even to the people involved in it. Conceived of and led by the DoH, so far it has failed to adequately integrate all sectors.

Who is in charge?

The Medical Research Council’s Dr Fareed Abdullah (a former SANAC CEO) said that SANAC – as a body designed to facilitate multi-sectoral collaboration between various government departments, civil society and other stakeholders – should be responsible for the running of the She Conquers campaign. It should also be the seat responsible for the coordination of various partners working on HIV prevention in young women under the She Conquers banner, including the DREAMS partnership and others.

Pillay admitted that She Conquers is “supposed to be a programme that links various initiatives under one banner”, but that “coordination is not an easy thing to do”. While Ramaphosa was deputy president, he asked that SANAC take on this role – indirectly acknowledging that the DoH cannot fulfil the mandate on its own.

But the confusion around the programme continues. While Pillay said that handing over the running of She Conquers to SANAC had been done as early as last year, SANAC spokesperson Kanya Ndaki told Spotlight a different story.

“SANAC is not responsible for the overall running of the She Conquers campaign, but this is something we are working towards. We are hosting a summit on young women and girls in March, and will be bringing all the partners involved to reflect on what has worked, so that we can coordinate the response better,” she said.

Ndaki said that the She Conquers campaign has been led by the DoH, but “we want to change that. We want it to be a multi-sectoral response, and SANAC is best placed to provide that multi-sectoral coordination.”

She added that while locating the running of She Conquers has been discussed on various platforms, it has not been finalised; but it is expected to be at the March summit.

Moreover, according to Schneider, DREAMS and its funding “was intended to spark investment globally in adolescent girls and young women programming, with biomedical, structural, and behavioural interventions, using multi-sectoral approaches”.

But when asked if there has been any domestic investment in She Conquers on top of the international aid, Pillay said no – “just the money we have. We have already made it clear from the beginning, from government, the funding will be a reprioritisation of existing funding,” he said.

But Abdullah made the point that the programme – should any impact it makes be sustained – “cannot only be funded by donors, and the South African Government also needs to make significant investments in this programme”.

Will young women have access to PrEP?

Abdullah also said that “one of the key weaknesses of the programme is the very limited offering of pre-exposure prophylaxis (PrEP)”. PrEP consists of a daily dose of antiretroviral medication to prevent HIV infection, and has been shown to be highly effective if taken as indicated.

The World Health Organisation recommends PrEP for young women in areas where the rate of new HIV infections is high; but according to Abdullah, even though this is “one of the most effective interventions” in existence for HIV prevention, “South Africa has limited PrEP to a few pilot sites”.

This is despite the fact that the latest National Strategic Plan (NSP) for HIV, tuberculosis and sexually transmitted infections makes provision for the implementation of PrEP for populations at a high risk of acquiring HIV.

Abdullah has been critical of the NSP, saying it limits PrEP access. The Plan’s targets are that between 2018 and 2022, there should be just over 104 000 new PrEP users. PrEP will be offered to young women, female sex workers, men who have sex with men, and people who inject drugs.

According to Pillay, through She Conquers, PrEP is slowly being rolled out: it was made available to young women at nine university campuses in October 2017. Only 26 people were initiated on PrEP during the first month; after that, the programme was stalled, because universities were closing for the end-of-year holidays. Those who had started PrEP were given a supply for the holidays.

Since February, two more university campus clinics have begun offering PrEP, bringing the total to 11; but the DoH does not have data on new uptake at these sites for 2018.

Pillay said: “During the next six months, PrEP will be made available at some 20 primary healthcare clinics in the 22 She Conquers priority sub-districts.”

The aim is to offer PrEP to between 5 000 and 8 000 young women over the next year.

There are multiple programmes running under the She Conquers banner that are doing important and effective work. But the success of any HIV-prevention campaign that seeks to solve systemic issues in society such as violence and gender inequality will rely on the successful integration of every actor on every level.

To truly help young women and girls in South Africa, programmes will need to put them and their views, voices and suggestions at the epicentre of decision-making. ‘She’ can only ‘conquer’ when ‘she’ is actively engaged and listened to.

In this context, it is important to remember Ramaphosa’s final words on the epidemic of GBV in South Africa during his SONA response:

“It is a social issue that must engage, involve and mobilise the whole of society.We must be prepared, as government, to acknowledge where we have failed our people. Where we have made mistakes, we will correct them.”

Cutting-edge youth services

by Thuthukile Mbatha, Spotlight

The Desmond Tutu HIV Foundation (DTHF) is implementing a number of innovative youth-focused health services around Cape Town. Others could learn from their approach and successes.

The DTHF Youth Centre was established in 2011; situated in Masiphumelele

Professor Linda-Gail Bekker, Director at the Desmond Tutu HIV Foundation. (Image: Thom Pierce)

township, it is at the forefront of trying to find answers to the tough questions regarding young people and access to healthcare services. The foundation is specifically interested in innovative HIV research, and even more so where it intersects with young people’s issues. Simply, they want to find innovative health-delivery mechanisms that keep young people healthy, HIV-free, and without the burden of teenage pregnancy and similar challenges.

The adolescent girls and young women division focuses on sexual and reproductive health rights, mental health, HIV, life skills, and sero-neutral service delivery. ‘Sero-neutral services’ means that everyone is treated the same, irrespective of their HIV status.

The DTHF’s director, Professor Linda-Gail Bekker, has been at the helm for over 10 years, and has led a team trying to figure out how young adolescents can be ethically involved in HIV prevention research. This is because the laws against HIV research on adolescents are very tough, prompted by the assumption that because adolescents are below the age of consent, they are therefore vulnerable. However, the DTHF has made great strides in fighting for adolescents to be included in HIV research trials.

The DTHF has been involved in adolescent PrEP studies, including PlusPills, the 3P project, and the ADAPT study. The Foundation has also conducted HIV vaccine studies (SASHA) and HIV self-testing studies. “Our current range of research (treatment, prevention, socio-behavioural, structural) is vast, but we are always looking to explore and expand the evidence base around what works for adolescents. Permission to conduct research is sought through our ethics committee, and is – rightly – a strict process. We take great measures to adhere to ethical guidelines around adolescent research, and work with our ethics committee and youth advisory board to make sure we go about this in the best way. To best serve adolescents and meet their needs, we need to know what works; so this research is important to do,” says Bekker.

Responding to a question regarding the emphasis on young women, Bekker says: “Young people, particularly young women and girls, are disproportionately affected by the HIV epidemic, and are at high risk for infection. Young people are also undergoing a unique phase of life, characterised by biological and physiological changes, increased risk-taking behaviour, etc.; and so it is important to have services and strategies that are specifically tailored to them.

“The foundation employs a harm-reduction approach, as opposed to a ‘prevent sex from happening’ strategy,” Bekker explains from her office on UCT’s medical campus. In 2005, the foundation conducted a survey at Masiphumelele township in Cape Town’s southern suburbs, and found that many young women they spoke to were already infected with HIV. One of the outcomes of their survey was information that a contributing factor to the high HIV incidence rates was that young women had no-one to talk to about sex.

The DTHF is now running a number of youth programmes at youth centres, such as the Philippi Village and Hannan Crusaid Youth Clinics (in Philippi and Gugulethu respectively); the Masiphumelele Youth Centre; and the Tutu Teen Truck (mobile service). These include the Health Zone (where young people learn about sexual and reproductive health rights, for example), an Edu Zone (where learners are assisted with school homework), a Fun Zone (where young people participate in sports), the Women of Worth study (see article on page 29), and 18-month internships – offered to youth who have graduated from the Zimele programme, and no longer fit the targeted age category of 10-24 years; these interns run the Zones.

The DTHF delivers youth-friendly sexual and reproductive health services through various platforms, including the Tutu Teen Truck (a mobile clinic delivering health services to young people) and youth-friendly clinics (mobile health facilities providing services that are targeted at and designed for young people). About 4 000 young women use the youth centres, and 300 of those are on Pre-Exposure Prophylaxis (PrEP). This form of PrEP is an antiretroviral drug called TRUVADA, taken daily by HIV-negative people to prevent HIV acquisition.

Innovative reward system

The programme uses some innovative systems to keep track of the young people. Every young person who is part of the youth programme has a unique identifier, logging in using a fingerprint on the biometric machine at the entrance, at which point their medical file is uploaded on the healthcare provider’s computer.

To encourage young people to stay healthy and HIV-free, the foundation has a reward system for all its young members through which they earn points for doing all the vital tests. Undergoing an HIV test gets you double points. This initiative is also aimed at normalising HIV among young people. The ‘currency’ used for the points system is the ‘Tutu’ – three Tutus are equivalent to R1. These can be exchanged for food vouchers. An HIV test is rewarded with 100 Tutus. According to Bekker, “You’ll find a 19-year-old boy asking his friends if they have done an HIV test yet, because he is short of Tutus.” The youth use Tutus to buy a number of items from a local mall or an onsite café.

If someone has a negative test result, they are reminded about the importance of staying HIV-negative, and encouraged to use available HIV-prevention tools. A person who tests positive will receive the same number of Tutu rewards. “We do not penalise mistakes, because that doesn’t work well,” says Bekker. This means that young people get rewards regardless of their HIV status; however, they receive different packages of care. For instance, a person who tests positive would be offered counselling, encouraged to go onto treatment, and advised to encourage their partners to be tested as well.

The Tutu reward system is also aimed at preparing the youth for the grown-up world, and teaching the importance of saving. This is part of positive youth development. The foundation offers 18-month internships to youth who have graduated from the programme, from age 24. The internships involve running the three Zones for younger people, and teaching life skills. There are two interns for each Zone. Most young people relate better to their peers. “What I’m really passionate about doing for this country is to develop a cadre of community healthcare workers who are adolescents,” says Bekker.

The Tutu Teen Truck

According to Bekker, the Youth Centre has been criticised for its perceived inability to be scaled up, as it would not be possible for the government to replicate the same programmes for the entire country. But there are some important elements of the programme that the government could apply, and which are cost effective. The Tutu Teen Truck is one of them. It takes the elements of the sexual and reproductive health services and puts them in a funky-looking truck, which is an “adult-free and adolescent-aware environment”. It is brightly painted, and designed to be attractive to young people. The staff are properly sensitised and trained to be adolescent-friendly.

A range of services is offered to 12- to 24-year-olds. Bekker is trying to get the government to approve the provision of antiretroviral therapy (ART) through the Truck, so that young people – whatever their test results – can get appropriate care and support as part of a combination prevention strategy, without delay.

The Truck travels around Mitchells Plain, Klipfontein and Mfuleni townships, and stops in areas with high HIV prevalence. It draws the attention of young people by playing loud music. It operates every Monday to Friday from 12pm to 6pm, as well as some Saturdays. It offers a range of contraceptives and sexually-transmitted illness (STI) screening interventions, through the use of a GeneXpert machine installed in the truck – a machine mainly used to detect TB, via sputum samples, but which can also be used to test for various other diseases.

A person’s sample is inserted into the GeneXpert, which then conducts an antigen test. “A large number of young people are walking around with untreated gonorrhoea and chlamydia that we are missing, so this offers same-time STI detection and treatment,” says Bekker. The truck also offers tuberculosis (TB) screening to young people suspected of having the infection. Those who require abortion services are referred to health facilities in their neighbourhood that offer such services. “A lot of the young people who use these services just need to talk to someone who will not judge them in any way,” Bekker adds.

To explore the cost-effectiveness of providing effective youth-friendly services to young people, the same elements of the youth centre and the Tutu Teen Truck are being piloted in some public health facilities. The Global Fund to Fight AIDS, Tuberculosis and Malaria has funded a three-year programme aimed at 22 000 young women and adolescent girls between the ages of 10 and 24 years, in the Klipfontein and Mitchells Plain areas. Alongside the DTHF youth centres, the foundation has identified 24 public health facilities in the Mitchells Plain and Klipfontein health sub-district where they could render the same youth-friendly services to young women and girls. In all of these facilities, they are guided by the National Adolescent and Youth Policy 2017.

Part of the Global Fund grant is used to pay peer navigators at government clinics. A peer navigator is a young person who welcomes young people at the clinic as they arrive at the door, and directs them to the relevant staff. Each clinic also has an adolescent-youth-friendly service champion who has been identified at the clinic. This could be anyone at the clinic: a nurse, a security guard or an administrator, for example. The role of the champion is to ensure that youth-friendly services are rendered to young people without prejudice.

The Foundation is currently developing what is called an ‘adolescent pack’, which outlines how nurses should treat adolescents in clinics. This was prompted by the fact that traditionally, nurses only operate using ‘adult’ and ‘child’ packs; they do not know how to address adolescent health issues, which are largely sexual- and reproductive-health-related. Every clinic staff member – including the security guards, nurses and cleaners – is trained in how to render youth-friendly services.

On top of these programmes, the Foundation has approached all the high schools in the sub-districts to find out from the headmasters what kind of services they would allow to be provided in their schools. Some choose contraception only; others want the comprehensive sexual- and reproductive-health package. Again through the Global Fund grant, the foundation has hired four nurses who visit all the schools that require these services. Some schools only allow counselling to be offered to learners, and nothing else.

Keeping girls in school

The DTHF has another initiative, called the Keeping Girls in School programme, which targets 15- to 19-year-old girls, with the aim of keeping them in school. Young women and girls are taught about their reproductive organs, and the importance of HIV and pregnancy prevention. This initiative is run by peer educators in schools; through the initiative, the foundation supplies sanitary pads and tampons to female learners.

The DTHF is also conducting a study called Women of Worth, targeting 19- to 24-year-old girls out of school. The study aims to enrol 10 000 young women in order to equip them with self-empowerment skills, in 12 sessions. These sessions cover a variety of issues, such as gender-based violence, sexual and reproductive health, and how to prepare for the job market; a type of life-skills training.

Of the 10 000 young women, 5 000 will receive a cash incentive as part of the study. This research aims to establish whether a cash incentive could help improve health outcomes. The sessions offered include topics such as self-empowerment, sex talks dealing with HIV, STIs and family planning, gender-based violence, personal finance management, and so on.

The study will assess how well these programmes work. Half of the participants will be randomly selected to receive a cash incentive and the empowerment course, whereas the other half will only receive the empowerment course. The study will establish whether these young women’s health outcomes are significantly improved by them attending empowerment sessions and receiving a cash incentive. The cash incentive is an example of behavioural economics, based on the assumption that a lot of young women get into difficult relationships because they want cash. The cash transfer is dependent on their involvement in the study. After completing the 12 sessions, the young women will graduate, and some will be enrolled in the learnership programme in the DTHF – provided they finish and excel during the two-year period of the programme. The majority of the young women in the study already have a child, and come from very poor backgrounds.

“Unless we try to address the socio-economic challenges that young women face on a daily basis, through equipping them with income-generation skills, we can offer as many contraceptives and HIV-prevention tools as we want; but we will not see any progress,” says Bekker. The young women who have completed the programme are encouraged to recruit their peers to enrol as well.

There is a parallel programme targeting young men, in which participants discuss men’s issues and how to treat women. The sessions are a ‘woman no-go zone’. Both the Women of Worth programme and the men’s health component include a session on LGBTI needs and issues. Every young person has a tailor-made programme meant to address issues specifically related to them.

“If all these programmes do not work in three years, I will know that we had a fair try,” says Bekker.


Rape emergency in Rustenburg- MSF

By Nomatter Ndebele

One in four women surveyed in the Rustenburg  area reports having been raped, according to a report released yesterday at the 1st South African National conference on Violence being held at the Birchwood Hotel in Boksburg.

The Doctors without borders (MSF) report titled Untreated Violence: The need for patient-centred care for survivors of sexual violence in the platinum mining belt, detailed the results of a survey of over 800 women between the ages of 18 and 49.

Of those women in the survey who had reported being raped, 40.5% of women stated they had been raped by a non-partner only, 28.2% by a partner only and 31.2% said they had experienced rape by both a non-partner and partner over the course of their lifetime.

The MSF report said that the over 800 women in the study were representative of women in the area. Based on the survey findings, they estimate that  around 11 000 women and girls are raped each year in the Rustenburg Municipality. 95% of the women in the survey who said they had been raped also said they did not report it at a healthcare facility. Only 4% of women told a counsellor and only 3% told a social worker that they had been raped.

According to crime stats SA, there were 166 cases of sexual violence reported in 2015 in the Rustenburg Municipality – which amounts to 9.3% of cases in the Northwest.

Kernel Sabata Mokgwuabone of the Rustenburg SAPS said that the department had always maintained that “One case is one case too many. As the police, we are doing our best to work with structures like community forums or anyone else that wants to assist in curbing the incidents of sexual violence”

Lack of services

Rustenburg is located in the Bojanala Health district and according to the North West Province Department of health, of the 783 health facilities in the district, only 11 facilities provide post-exposure prophylaxis (PEP) to prevent HIV infection, and support forensic examination for rape survivors.

MSF Epidemiologist Sarah-Jane Steele, explained that one of the issues aligned with these high incidents of rape was that opportunities to reduce serious health impacts of rape were being missed. “The majority of women we interviewed don’t even know that such treatment (PEP) exists, services close to where they live are sorely lacking and lack of financial independence may make access difficult even when services are present,” she said.

In light of this MSF has called on the South African Government to roll out a comprehensive and widely accessible medical and psychosocial response that addresses and removes the barriers to accessing a basic package of health care services for victims of Sexual violence, not just in Rustenburg, but across the country.

According to MSF medical Co-ordinator Amir Shroufi  a patient centred approach to rape and sexual violence that prioritises the medical and psychosocial needs of survivors is what is needed to curb the problem. “All rape survivors should receive access to comprehensive medical and psychosocial services to reduce the risk of contracting HIV and other infectious diseases, preventing unwanted pregnancy, addressing psychological distress and linking the patient to appropriate social support,” he said.