This year’s World AIDS day theme of “Equalise and integrate to end AIDS” was a call to action to end the pandemic across the country – and we should start at the frontline of service delivery. 

Critical to the HIV response is the 95-95-95 global targets. These targets mean 95% of people living with HIV should know their status, 95% of people diagnosed with HIV receive sustained antiviral therapy, and 95% of all people receiving antiviral therapy should have viral suppression by 2025. 

The South African HIV response is off track to meet these targets, with progress towards the second target being the worst. According to the latest UNAIDS data, South Africa is on 94-78-89, which means 94% of people living with HIV know their status, only 78% of those diagnosed are on HIV treatment, and 89% of those on therapy are virally suppressed. 

Free State PLHIV face many challenges.

Even though the Free State province is doing better than other provinces in progress towards the 95-95-95 goals, a lot still needs to be done to address ART continuity. The Ritshidze report into the State of Health in the province revealed numerous challenges experienced by PLHIV in accessing HIV care, which often leads to complete disengagement from care, including negative staff attitudes. 

“I have not been taking my ARVs for about a year,” one patient, Tumi*, told us. “I missed an appointment at the clinic. When I returned, the nurses disrespected and humiliated me and disclosed my status to everyone. I never went back to the clinic.” 

Like Tumi, many people living with HIV (PLHIV) continue to experience ill-treatment from healthcare workers at the facilities in the province, affecting their willingness and ability to access care over time. 

Retention is a  critical component in the HIV response. People need to be started and continuously engaged in care. Retention is what keeps PLHIV healthy. It’s also a prevention move as we all know that undetectable is untransmittable: If you take treatment. It suppresses the virus successfully in your body; then, you cannot transmit the virus.

Long waiting times, staff shortages and medicine stockouts

Healthcare services in the province are characterised by long waiting times, a shortage of staff, medicine stockouts and a poorly managed HIV response. Structural issues are causing debilitating HIV services, such as understaffing and inadequate facilities. Still, negative staff attitudes are a significant barrier to accessing HIV prevention and treatment services. 

Out of 1346 patients interviewed by the Ritshidze project between July and August 2022 at 29 clinics in the province, only 41% of patients said the staff were friendly and professional. HIV patients face the most abuse and humiliation at the clinics, discouraging them from accessing HIV services. For example, when patients miss appointments to collect ARVs, nurses often fail to empathise but treat patients with rudeness and send them to the back of the queue.

Out of 382 PLHIV interviewed, 40 reported that staff reprimanded them for missing an appointment; Another  114 were told to go to the back of the queue, which meant longer waiting hours before they were attended.

In addition to these punitive methods, healthcare workers can refuse to provide HIV services by demanding unnecessary transfer letters when an HIV patient moves from one clinic to the next. Demanding a transfer letter is not in line with the updated national adherence guidelines standard operating procedures (SOP) and the re-engagement SOP, which states that facilities should not require transfer documents as it may delay continuation in care or restarting care. Healthcare facilities in the province continue to deny HIV patients services due to transfer letters; 181 HIV patients from 23 clinics in the province were refused access to HIV services because they did not have a transfer letter.

Critical issues need addressing.

For the Free State Department of Health to get the HIV response back on track, these critical issues must be addressed. As the Ritshidze project recommended, staff attitudes should be improved, and patients re-engaged in a welcoming and friendly manner to improve adherence. 

Staff who were reported to be mistreating patients should be investigated and taken through disciplinary processes to rid the system of unwelcoming cultures. 

Understaffed clinics have contributed to poor service, with about 79% of the clinics reporting that they had staff shortages – mostly nurses. The Free State Department of Health should address the staffing issue as it contributes to poor HIV services. Patients often don’t get the relevant services because nurses are always rushing. For example, about 125 HIV patients reported that the staff took their blood tests but did not explain the viral load test results to them.

Voluntarily decanting stable HIV patients to external pick-up points can also help ease the burden on nurses at the facilities and save patients time. Only 16% of patients from the 29 clinics use an external pick-up point. Out of 727 patients interviewed by Ritshidze, more than 60% indicated that they would like to collect medication closer to home.

External pick-up points make it easier and more convenient for patients to collect their medication without going to the clinic. It also saves them from the clinic’s long waiting hours, which can sometimes be up to 4 to 5 hours. Most patients –  72%  – using external pick-up points reported that they were very satisfied with the method. 

Clearly, clinics are not the only roleplayers. Patients and communities also have a critical role in improving HIV services at our clinics. Incidents perpetuating HIV stigma, discrimination and any abuse should be reported, and they should be followed up with relevant duty bearers, starting with clinic management. 

Until we address these critical issues, our efforts to equalise and integrate to end AIDS will be fruitless, and the 95-95-95 goals will remain a mirage. 

Makhosazana Mkhatshwa is the Treatment Action campaign’s Research Officer; she writes in her organisational capacity.