The Western Cape is perceived as a well resourced province, but for some HIV-positive patients living in Mooreesburg, accessing treatment means relying on the goodwill of strangers for a lift and running the danger of defaulting on their treatment.

Several studies have confirmed that lack of transport could be detrimental for access to chronic treatment and adherence, eventually leading to poor treatment outcomes.

Wendy Gwayi (34) a mother of three from Mooreesburg was pregnant when she was told she had to collect her HIV treatment every month from Malmesbury Hospital, 35 kilometres away. Gwayi said she did not mind at the time as she was told transport would be made available.

 As the day for the appointment loomed she booked her place on the 17-seater managed by the province’€™s emergency services division only to be told it was full. She was left to her own devices to arrange last minute transport.

Not having the R250 charged by local motorists and not having a friend to take her free of charge she was forced to hitch a lift with a truck passing through Mooreesburg.

‘€œThe man who offered me a lift asked to for me to give him R20. On the way he said he had changed his mind and no longer wanted money. He asked me to agree to have sex with him instead and keep the money for my needs,’€ said Gwayi.

When she refused the infuriated driver drove to a secluded area where he again demanded sex.

‘€œI refused and later told him that I was HIV positive. He asked how I knew. I explained that I found out when I was pregnant and that I was going to collect treatment, but he still insisted on having sex with me. When I asked him if he had a condom he said no and said it did not matter. He then became violent and tried to force himself on me,’€ she said.

Gwayi was saved by a passing truck driver who witnessed the attack. She told her story to the clinic staff at Mooreesburg clinic and they transferred her to Tygerberg Hospital.

‘€œAfter giving birth I was told I would have to go back to collecting my treatment in Malmesbury. I could not go back there and risk being raped,’€ she said.

She stopped her antiretroviral treatment and never returned to Malmesbury.

The Treatment Action Campaign (TAC) warned that stopping treatment could place patients’€™ lives at risk. For most patients stopping treatment means reduced immunity against the virus and even death.  

A doctor at Malmesbury Hospital who asked to remain anonymous said there were numerous cases of patients who had stopped treatment because they had been unable to afford the transport to collect their ARV treatment.

However, Alvin Pedro, district manager of emergency services in the West Coast district said he had received no complaints about transport problems.

He said transporting patients who needed to collect ARV treatment from facilities remained a priority for his office.

‘€œWe always treat ARV patients as a priority because once we have started people on treatment we have to make sure that we keep them. But there seems to be a lack of communication between the facilities, the patients and transport. Had we known that there were problems we could have made a plan for ARV patients,’€ he said.

 Thabisa Mzuku (41) an unemployed mother of three was admitted to Malmesbury hospital for a week. When she was discharged Mzuku had to hike home because there was no public transport.

‘€œI could hardly walk when I was discharged but I had to get home. There was no other way for me to get there but to hike,’€ she said.

Mzuku was constantly unwell and been on HIV treatment for five years. Mzuku will have to hike again to get to her next appointment because she was told that the vehicle would not be available.

Western Cape Health MEC Theuns Botha said their priority was getting patients to the facilities rather than taking them back home.

 ‘€œI know it sounds cruel but it is more important for us to get them there when they are ill. It is not so important to get them home when they are cured although we would prefer to do so,’€ said Botha.

Pedro also confirmed it was difficult for them to take responsibility for patients after they were discharged.

Several patients in Mooreesburg who spoke to Health-e said the problem would be solved if they could get treatment from their local clinic. However, the clinic doesn’€™t dispense ARVs.

A Western Cape health department source confirmed that the Mooreesburg Clinic was not ready to dispense ARV treatment.

He said lack of human resources and capacity to train staff were among the many reasons why some facilities could not provide treatment.

He said Piketberg Clinic, in another small rural town almost 30 kilometres away from Mooreesburg, had recently started providing ARVs and that this might be closer for people from Mooreesburg.

However, the health worker in Malmesbury was not convinced that Piketberg would be a viable option for Mooreesburg patients.

‘€œIt might still not work because transport to get them there will still be an issue. There might not be a bus passing through Piketberg,’€ she said.

Marije Versteeg of the Rural Health Advocacy Project said lack of transport in the rural areas made it more expensive for patients to access treatment.

‘€œThis does not make sense from an equity point of view. Providing health care to rural communities is more expensive than to urban communities due to factors such as these. To achieve health for all, the cost factor cannot overrule the equity factor.’€

‘€œWe also know that the most deprived districts in South Africa are rural, and families can spend up to 80% of their households’€™ income in accessing health care,’€ she said.

‘€œThere have been calls for transportation vouchers to ensure that poverty cannot be the reason for patients not getting the health care they need. This is an important point for the National Health Insurance discussions, as poor patients in remote rural areas will continue to experience difficulties in accessing health care, despite the proposed  unified health care system,  unless their transport problems are addressed,’€ she said.

An East African Journal of Public Health study investigated why patients missed follow up appointments. Lack of transport was listed as one of the most common reasons for missing these appointments.

A Tropical Medicine and International Health study looking at why HIV patients failed to report for follow up treatment revealed that while patients said ARV treatment improved their health, lack of and the high cost of transport remained barriers to treatment.

Another study, done by Researching Equity in Access to Health Care (REACH), investigating access challenges in TB, HIV and maternal health services found that there was inequality in access between rural and urban areas, especially when it came to transport costs. The study compared access to services between four health sub-districts across the country: Bushbuckridge (Mpumalanga), Mitchell’€™s Plain (Western Cape), Soweto Region D in the City of Johannesburg (Gauteng) and Hlabisa (KwaZulu-Natal).

‘€œAn ART service visit in Bush Buck Ridge cost an average of R47, compared to R3 for a TB service visit in Soweto, a 12 fold difference,’€ said authors.

In most cases women from Bush Buck Ridge and Mitchell’€™s Plain had to use private transport, often hired at considerable cost compared to one-third or less in Soweto and Hlabisa where ambulance services appeared to be more accessible.