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Tackling human rights barriers to health care in South Africa

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South Africa
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Global Fund
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South Africa has made huge strides in the battle against HIV and TB, but severe challenges persist. This is especially true for people in key populations, who face the additional hurdles of stigma and a range of human-rights barriers to health services.

Around 7.5 million South Africans are living with HIV, the largest HIV epidemic in the world. Almost half of new HIV infections in the country occur in people from key and vulnerable populations such as those in the LGBTQ community, people who inject drugs or adolescent girls and young women. TB remains the leading cause of death in the country, and over 60% of cases are related to HIV.

In June 2019, the South African government adopted a new national human-rights plan to comprehensively tackle the various legal and social barriers to HIV and TB services, and gender inequality in South Africa. Here are a few voices from Durban, where the plan was launched, of those working to turn the plan into reality and of those whose lives it hopes to change.

HARM REDUCTION FOR SOME OF DURBAN’S MOST MARGINALIZED

Like many people who inject drugs in Durban, Vernon Van Wyngaard, 49, is homeless. He makes money either by begging at intersections or through gardening. Zama Nene, 27, also is homeless. She has been injecting drugs since 2011, but last year was diagnosed with HIV, a result of sharing needles. She is matter-of-fact about her life: “I didn't know about the needle sharing thing, but they say that’s why I have AIDS.”

Even with a national plan in place, the political reality for those providing and accessing health services on the ground can vary wildly between different districts and regions. Harm reduction programs are among the key interventions least accepted, further stigmatizing those who rely on them.

Both Vernon and Zama use the services of Durban’s TB/HIV Care Center. It was established by Shaun Shelly, a leading voice in South Africa for harm reduction programs for people who inject drugs. He pioneered needle exchange programs in the country through his activism, work in academia and direct program implementation. But it remains an uphill struggle. Last year, a few clients of the TB/HIV Care Center were enrolled on a methadone program – but Vernon was too late to enroll and is uncertain whether another chance will come again: “I'm worried, because I missed the methadone program last year and now the local mayor has blocked a new program.”

“I'm too old for this game - I should have a house by now, but..." - Vernon Van Wyngaard

Nationwide, only around 1,500 people receive opioid replacement therapy – a treatment to help wean injecting drug users off heroin by substituting with methadone. But methadone is not recognized in South Africa as an essential medicine and so costs around 30 times more than elsewhere.

For Zama, coming to the center provides a measure of relief from an overwhelmingly hostile environment. She is constantly exposed to the threat and reality of sexual violence made worse by the stigma that comes from drug use and homelessness. She says: “Living on the streets is difficult. The guys using ‘whoonga’ [a street drug that has become widespread in the townships of Durban over the last decade] are the worst – the scariest.”

Meanwhile, boxes of unused syringes are piling up in the lobby of the center. Their distribution has also been blocked following a local political decision to clamp down on needle exchanges, resulting in a higher risk that existing users will turn to sharing needles.

“There's so much noise out there when it comes to drug use and harm reduction. Being able to tell stories, based on real data, can be powerful. We discovered our focus should be on local politicians who set the tone for what the police do and getting them to interact with real stories about real human beings.” – Shaun Shelly

PROVIDING SUPPORT AND GIVING AGENCY TO THE LGBTQ COMMUNITY

Thulasizwe’s relationship with the Mosaic Lesbian and Gay Center, where he’s been coming since his teens, has flourished from being a user of its services into becoming a peer educator – being able to reach out to others in Durban’s LGBTQ community. He says: “Places like the Mosaic Center mean I’m not going to be gossiped about in a hospital. It’s a place that gives me information, community and condoms!”

“It's so exhausting being a human being. But when you're an LGBTQ human being – that’s really exhausting.” – Thulasizwe Buthelezi

Sbongiseni Khumalo, the center’s program manager, agrees. Affectionately known as Sbo, he serves as friend and mentor to the young people coming to the center. He says: “Stigma isn’t just about reactions on the street. Some areas can be risky, some friendly. It’s more a structural issue in society. In religious communities, many are disowned for their sexuality. Civil society is building a bridge up from local structures, to district and ultimately the national scene to help change attitudes.”

The center, established by Nonhlanhla ‘MC’ Mkhize, a leading activist voice from Durban’s LGBTQ community, provides testing, counselling and referral services. Last year, the center moved from Durban’s central business district to the residential neighborhood of Morningside. This changed the demographic of its users, which Nonhlanhla says is defined more by class than race: “There are lots of sex workers in this area, and so the girls also come to us for testing and support. Our trans community has also grown.”

“As a new democracy, we're at a point in time when 80 percent of the work we're doing now is spent fighting human rights barriers, whereas previously, we were just fighting HIV as a disease." - Nonhlanhla “MC” Mkhize. She says: “Our progressive constitution helps us in South Africa, but it’s only 25 years old and most people don’t know their rights.”

“What this center provides is not only services and support. We’ve given people the agency to go beyond these walls and change things. Lots of the talented young people that come here have become peer educators and motivational speakers. They’re doing interesting things.”

FIGHTING AGAINST ENDEMIC GENDER-BASED VIOLENCE

Gogo is a traditional healer as well as activist and outreach worker for HIV and women’s rights. She established the South African Positive Women Ambassadors center in two small wooden outbuildings next to her home in KwaGudukazi outside Durban. Well known in the rural community in which she lives and works, she is also a prominent civil society voice at conferences, as well as being an unembarrassable purveyor of condoms and sex tips during her outreach visits to some of the 28,000 people in the area and the schools she visits.

She says: “I'm focused on the problem of gender-based violence and work with the community to try and change practices. Now even men are coming to me with questions about rape.”

“Gender-based violence is the main contributing factor to the spread of HIV in this community. Men are taught to have multiple partners, and women don’t have the power to tell men to use a condom”. - “Gogo” Silungile Mtambo

Gogo says that early data she has gathered from the home visits she makes around KwaGudukazi show that over 70% of the community is living with HIV. She says: “There are lots of taverns here and people are unemployed, drinking and having sex. A holistic approach to ending HIV is the only thing that will work – testing and treating is pointless without adherence counselling.”

ON THE MARCH

People from Durban's various key populations came together with campaigners and activists for a march ahead of the launch of South Africa’s new national strategy to tackle human-rights barriers to HIV and TB services, and to fight gender inequality. Marchers converged on Gugu Dlamini Memorial Park, named for a young activist who was murdered for sharing her HIV status in 1998, a symbol of the stigma the plan seeks to address.