A publication of the Southern African HIV Clinicians Society

The Health4Men Initiative: HIV & STIs New vaccine effective against Ebola Migration, HIV & access to public health in Southern Africa SAfAIDS Young Women Leadership Programme

September 2015 Volume 6 No. 3 Southern African HIV Clinicians Society 3rd Biennial Conference 13 - 16 April 2016 Sandton Convention Centre Johannesburg

“To rub shoulders with the best minds in the field, in the region, the SA HIV Clinicians Society Conference is the place to be.”

Professor Yunus Moosa (2016 Conference Chair)

“This conference really is the place to be for any self-confessed HIV clinician – the field moves so fast, and so differently in different parts of the world…this is the most efficient and entertaining way to find out what and who is important in our region.”

Professor Francois Venter (2014 Conference Chair)

OUR ISSUES, OUR DRUGS, OUR PATIENTS

Leading International & Local Speakers Current & Thought-provoking Presentations Skills Building Sessions Lively Debates Challenging Case Studies

Conference programme focus areas include: Antiretroviral Therapy Women’s Health Paediatric and Adolescents Basic Science Monitoring and Evaluation Operations Research Primary Health Care and Nursing TB Opportunistic Infections HIV Resistance Prevention Clinical Skills Building

Whether you are an infectious diseases physician, NIMART-trained (or interested) nurse, general practitioner, HIV specialist, academic or other health care professional there will be something for you at this conference.

Visit www.sahivsoc2016.co.za for further information and to register to attend

Conference Secretariat • Telephone: +27 (0)11 463 5085 • Email: [email protected] Southern African HIV Clinicians Society 3rd Biennial Conference 13 - 16 April 2016 Sandton Convention Centre Johannesburg

“To rub shoulders with the best minds in the field, in the region, the SA HIV Clinicians Society Conference is the place to be.”

Professor Yunus Moosa (2016 Conference Chair)

“This conference really is the place to be for any self-confessed HIV clinician – the field moves so fast, and so differently in different parts of the world…this is the most efficient and entertaining way to find out what and who is important in our region.” Professor Francois Venter (2014 Conference Chair) HIV Nursing Matters focus on HIV and key inside populations OUR ISSUES, OUR DRUGS, OUR PATIENTS

Leading International & Local Speakers Current & Thought-provoking Presentations 4 Guest editorial 16 Understanding immigration 38 Continuous QI Skills Building Sessions Lively Debates Challenging Case Studies Glenn de Swardt detention and deportation in It’s my legacy South Africa Conference programme focus areas include: 5 Message from the president 42 Competition Francesca Conradie Clinical updates Antiretroviral Therapy Women’s Health Paediatric and Adolescents 22 New vaccine is effective against 44 What to do Basic Science Monitoring and Evaluation Operations Research News Ebola in a large trial in Guinea Primary Health Care and Nursing TB Opportunistic Infections 6 Rural reflections: There is a 25 SAfAIDS Young Women 45 Where to go HIV Resistance Prevention Clinical Skills Building problem Leadership Programme 8 Nurse combines passion for mums 28 Preparing for PrEP: From theory 46 Dear clinician Whether you are an infectious diseases physician, NIMART-trained (or interested) nurse, general practitioner, with business know-how to practice in key populations HIV specialist, academic or other health care professional there will be something for you at this conference. 9 Six steps to take if you have been 30 The Health4Men Initiative – HIV raped and sexually transmitted infections On the cover Visit www.sahivsoc2016.co.za for further information and to register to attend 10 Teen’s suicide highlights risk for • Health4Men Initiave: HIV & STIs LGBTI youth Profile articles • New vaccine is effective against Ebola in a large trial in Guinea Conference Secretariat • Telephone: +27 (0)11 463 5085 • Email: [email protected] 34 Interview with a sex worker: “... first Current issues and foremost, I am also a human • Migration, HIV & access to public 12 Migration, HIV and access to being” health in Southern Africa public health in Southern 36 Sr Anna Cilliers: Working as a field • SAfAIDS Young Women Africa worker in Ebola-infested areas Leadership Programme

HIV Nursing Matters | September 2015 | page 3 Guest editorial

direct effect on the burden of HIV-related people (p. 16). The final article high­lights disease – both within the sometimes how SAfAIDS challenges tradit­ional hidden­ epidemics affecting each key patriarchal values when working with population and within the broader, young women. Although not regarded general HIV epidemic affecting all of as a key population, in that they do South Africa (SA). In this regard, sex not experience high levels of prejudice workers have clients who engage sexually and discrimination, young women are a with others; people who use drugs have group that remain highly vulnerable to sex with non-users; and most MSM also HIV. have sex with women, in addition to having sex with men. References 1. World Health Organization (2015). Importantly, health workers in SA are Consolidated guidelines on HIV ethically obliged to render equally com­ prevention, diagnosis, treatment and care petent­ services to all members of society for key populations. Geneva. Available at: Glenn de Swardt without prejudice or discrimi­­nation. Such http://www.who.int/hiv/pub/guidelines/ Senior Technical Advisor, Anova Health obligations are enshrined in the National keypopulations/en/ (Accessed 15 Aug Institute, Johannesburg Health Plan for South Africa (1994), The 2015). Patients’ Rights Charter, the White Paper 2. Rebe KB, De Swardt G, Pienaar D, Within the context of the HIV pan­d­ on Transforming­ Public Service Delivery Struthers H, McIntyre J (2010) An African Clinic Providing Targeted Healthcare to emic, several groups within society have (Batho Pele White Paper, 1997) and Men-who-have-sex-with-men; International emerged as being particularly vulner­ the Policy on Quality Health Care for AIDS Society Conference. Vienna. able to HIV infection. “Key popu­lations” South Africa (2007). These documents 3. Rebe KB, De Swardt G, Struthers H, (sometimes referred to as most-at-risk are intended to en­sure equal access to McIntyre JA (2013) Towards “men who populations) have been identified as: health services for everyone, with all have sex with men-appropriate” health gay men and other men who have sex patients being treated with consistent services in South Africa. S Afr J HIV Med with men (MSM), sex workers, people levels of respect and dignity. The South 14: 52-57. who inject drugs, trans­gender persons, African National Strategic Plan on HIV, 4. Lane T, Mogale T, Struthers H, McIntyre [1] and refugees and displaced people. STIs and TB: 2012 - 2016 also specifies J, Kegeles SM (2008) “They see you as the need for health interventions targeted a different thing”: the experiences of men Members of key populations share two at key populations.[6] who have sex with men with healthcare common realities: they are disproportion­ workers in South African township ately infected by HIV compared to the In this issue of HIV Nursing Matters, we communities. Sexually Transmitted general population, and they experience are proud to present a series of writings Infections 84: 430-433. high levels of institutionalised prejudice on the novel ways in which the needs of 5. Human Sciences Research Council (2014) and discrimination from society at large specific key populations and vulnerable The South African Marang Men’s Project. – and from the public health sector, in groups are being addressed by non- Editor: HSRC. South Africa. http://www. hsrc.ac.za/en/media-briefs/hiv-aids-stis- particular. Thus, key populations are governmental organisations (NGOs) in and-tb/marang (Accessed 12 Aug 2015). often at the highest risk of HIV infection SA. Two of the articles focus on MSM: 6. SANAC (2012) National Strategic Plan and have very low levels of health care developments regarding the incorpor­ on HIV, STIs and TB: 2012 - 2016. Pretoria, access. They are generally ignored in ation of pre-exposure prophylaxis (PrEP) in South Africa. mainstream HIV-related messaging and combination prevention for MSM (p. 28); are often denied access to basic health and insights into inno­vative MSM-focused services through harmful stereotypes and services undertaken by the Health4Men negative attitudes emanating from many Initiative (p. 30). An article on human health workers.[2-5] rights challenges encountered at the Lindela Detention Centre high­­lights the Discrimination against members of key reality of the institutional­ ised­ stereotypes­­ populations by health workers has a experienced by refugees and displaced

HIV Nursing Matters | September 2015 | page 4 Message from the president The Team

Guest editorial Mr Glenn de Swardt

President Dr Francesca Conradie

Editorial Advisory Board Dr Elizabeth Mokoka Dr Natasha Davies Dr Michelle Moorhouse Dr Sindisiwe VanZyl Ms Nelouise Geyer Ms Nonhlanhla Motlokoa Ms Talitha Crowley Ms Maserame Mojapele Mr Siphiwo Qila Dr Francesca Conradie Ms Rosemary Mukuka President, Southern African HIV Clinicians Society Contributors Monument Trust Health care workers have responded effectively to HIV by, in the first instance, Advertising working hard to access treatment for people who are HIV-positive. They have Nonhlanhla Motlokoa gone on to identify people needing treatment, and to find novel ways to ensure E-mail: [email protected] Tel: +27 (0) 11 728 7365 access and care. However, often these patients were relatively easy to find. The challenge now is to find and deliver treatment and care to those who are Article/letter submission harder to reach, due to stigma and related difficulties. These key population Nonhlanhla Motlokoa groups include: truck drivers, sex workers, men who have sex with men (MSM), E-mail: [email protected] drug users who inject drugs, young women and prison inmates. Truck drivers Tel: +27 (0) 11 728 7365 are on the move by the nature of their work. Sex work is stigmatised and is not legalised. The people involved in such work may not want to come forward For more information SA HIV Clinicians Society for medical services. Men who have sex with men may fear a homophobic Suite 233 Post Net Killarney response at a health care facility. Inmates in the correctional system seem easy Private Bag X2600 to reach until you understand that the primary concern of the correctional Houghton services is security. Young women may have had negative clinic experiences 2041 and often do not perceive themselves as belonging to an at-risk group. Health www.sahivsoc.org care needs to be delivered within these confines. As health care workers, Tel: +27 (0) 11 728 7365 we need to be careful not to convey any judgement and discrimination. We Fax: +27 (0) 11 728 1251 E-mail: [email protected] have managed challenges in HIV before and we need to do so again. So please read on and enjoy the second part of our focus on working with key The opinions expressed are the populations. opinions of the writers and do not necessarily portray the opinion of the To explore these and other clinical best practice issues, please join us from Editorial Staff of HIV Nursing Matters the 13th to the 16th of April 2016 in Johannesburg for our third biennial or the Southern African HIV Clinicians conference: Our drugs, our patients, our issues. We have an exciting group of Society. The Society does not accept any responsibility for claims made in speakers and sessions lined up. The draft programme can be accessed online: advertisements. www.sahivsoc2016.co.za

All rights reserved. No part of this publication may be reproduced in any form without prior consent from the Editor. HIV Nursing Matters | September 2015 | page 5 Rural reflections: There is a problem

By Guest Author on July 27, 2015 in HIV – Antiretrovirals (ARVs), Rural Health, Rural Reflections

As public debate rages about whether or not there are antiretroviral (ARV) stockouts in the county, our rural doctor and blogger reminds us what three letters and ARV stockouts really mean

This week I met a 19-year-old boy in my the results in front of me were negative had passed away and they didn’t know outpatients cubicle … He was tall and – but so was the blatant evidence that the mother had HIV, her gogo lanky, sporting skinny jeans, Converse that he wasn’t protecting himself from explained. They also don’t have a child All Stars and a flat cap – and his English chlamydia and gonorrhoea: HIV’s support grant or an income. was better than my isiZulu. He came into partners in crime. the doctor’s room with a host of sexually When mothers are children and transmitted infections and no HIV. This week I had three children between viruses are inheritances the ages of one and three years old He was worried about his genital ulcers who were recently diagnosed with HIV Last week, a 13-year-old girl tested and his urethral discharge. and started ARVs in the ward. One of positive for HIV five days before them was too small to speak, she just delivering her baby. She lied to the I was worried about the fact that his looked at me with milky brown eyes as nursing staff and said that she was 15. worry list didn’t contain those three her gogo tried unsuccessfully to con­ She was only started on ARVs as part letters: H-I-V. He’d tested for HIV and sole her malnourished cry. Her mom of the prevention of mother-to-child

HIV Nursing Matters | September 2015 | page 6 news transmission programme a few days Finally, we phoned her mother and steps back and reach for a TB mask before delivery. the young new gogo came in to the to secure around my mouth and nose hospital, two weeks after her daughter before listening to her chest rattle. I Starting late on ARVs meant that the had given birth to this beautiful baby hoped strep pneumonia was the culprit amount of HIV in her blood was high boy. She smelled of the local brew. and not TB once more, or worse, through her pregnancy and delivery – multidrug-resistant TB. increasing the risk that her unborn baby The gogo would help take care of would contract the virus. the new baby. The only income in Earlier this year there was a shortage the house was this new mother’s own of abacavir, one of the second-line I met her when her newborn son was child support grant that the gogo was ARVs that we use to treat patients. admitted to the neonatal nursery with receiving for her 13-year-old daughter, Some unfortunate patients effectively neonatal sepsis, or an infection in the now mother of one. defaulted on one of their three daily bloodstream. The baby was started on ARVs for no fault of their own. the ARVs nevirapine and zidovudine Can you default when there are to prevent mother-to-child transmission no drugs? The clinics ran out of abacavir and then of the virus while I tested him for HIV. the province ran out of abacavir. We These ARVs work to help protect him An 82-year-old woman was brought in waited for the new financial year, the from any HIV to which he was exposed by her family. She complained of two new tender … and bent the protocols before or during birth, but also from any weeks of vomiting and diarrhoea. She and treatment guidelines until it hap­ that may be in his mother’s breastmilk. was also coughing, and becoming con­ pened – to make sure that patients are fused. Her skin was dry and floppy, at least receiving something that will I found out five days later when the lacking subcutaneous tissue. Her eyes prevent drug resistance or treatment blood results came back that the baby were sunken deep into their sockets failure. boy had contracted HIV before or and I got the feeling that she was tired during birth. This wriggling, pink, tiny of seeing her surroundings, or maybe Abacavir returned, the crisis was over. human now had a chronic medical seeing her surroundings when she was Then there was no aluvia, another ARV condition for which he’d have to receive in the hospital … again. also used as part of second-line HIV lifelong medication. treatment. There is a supply problem; I asked a few questions from her family there is no time scale in terms of a solu­ So start the baby on ARVs … and what? while feeling her weak pulse and tion, we are told. Send the teenager home to her parents inserting a drip into her dehydrated who know nothing of her HIV status veins, taking some of the dark purple “I am sorry to the pregnant with three 500 ml bottles of ARVs to blood for baseline tests. woman who I saw today who give to a baby twice a day? She would is on abacavir and aluvia, with go back to school, and then who would She’d been in and out of hospital many bring the baby to all the follow-up visits times in the last few years, I realised as a virus unsuppressed in her and blood tests to check that the ARVs I paged through her dog-eared patient- blood and a growing foetus in weren’t damaging his liver or blood? held clinic card that all our patients her womb.” carry with them containing all their She said she didn’t know that her medical records. It said, “RVD+, known I am sorry to the pregnant woman who 23-year-old boyfriend was HIV-positive. defaulter. Previous TB x3.” I saw today who is on abacavir and Then she said that he had told her that aluvia, with a virus unsuppressed in he was born with HIV, and she didn’t It was clear that she had HIV, and her blood and a growing foetus in her know if he was taking medication. Then had stopped and started her ARVs womb. she said her stepfather would chase her many times, putting her at risk of away if he knew her status. Then she ARV resistance. She had also had I don’t think it would be forgiveable if said her mother was an alcoholic. tuberculosis (TB) three times before. our lack of medication were to result in her inability to access drugs to prevent “This wriggling, pink, tiny The family said that she didn’t take her baby from being born with this human now had a chronic her medication because she didn’t like preventable, incurable condition. medical condition for which swallowing her pills ... they stuck to her throat, they made her feel nauseas – I write out another prescription, in the he’d have to receive lifelong she’d been taking them for too long. hope that this week things might change medication.” I tried discreetly to take a couple of ... and I can’t help but feel helpless.

HIV Nursing Matters | September 2015 | page 7 Nurse combines passion for mums with business know-how

By Itumeleng Tau on August 19, 2015 in OurHealth, Women’s Health

Nurse Precious Mashupi has gone from consulting at her local clinic to running her own business in a bid that she hopes will help increase access to women’s health services in Klerksdorp

Precious Mashupi started her own Mashupi’s inspiration to become her The clinic also offers services that are women’s health clinic in 2009. This own boss, and help mothers and babies very rare in a small city like Klerksdorp, year, she bought another practice and in the process, came from one influential such as exercises for pregnant women, expanded her Klerksdorp clinic – one report: the government’s 2012 report although deliveries are not done at the of only a few catering to women in the on maternal mortality. clinic. district, she says. The product of maternal health audits Mashupi tells OurHealth she hopes her After graduating from Klerksdorp’s initiated by former Health Minister Dr clinic will ease pressure on the public Excelsius Nursing College, Mashupi Manto Tshabalala, the report found that health sector. worked for three years at the city’s almost 5 000 mothers died between Orkney Clinic, before moving to an 2008 and 2010 – more deaths than in During a 2014 protest against illegal office close to the Klerksdorp Taxi Rank. any previous years. abortions, North West MEC for Health, Magome Masike, said that illegal abor­ In 2009, Mashupi opened the Preshco The deaths were attributed to causes tions were placing further strain on the Mother and Child Clinic. This year, including infec­tions, HIV and tubercu­ public sector. Mashupi bought the Matlosana losis, and hyper­tension. Women’s Clinic and with the new “The main problem faced by the addition, moved into a bigger office Mashupi’s clinic not only offers safe department is that women using back­ space. According to Mashupi, Preshco termination of pregnancies, but also street abortion services often flock is now one of the few private practices contraception, Pap smears, ultrasounds, back to the public health facilities with catering to women in the Dr Kenneth HIV counselling and testing, infertility serious complications and they die in Kaunda District. counselling and vaccinations. our hands,” he said.

HIV Nursing Matters | September 2015 | page 8 news Six steps to take if you have been raped

By Emily Whiteside and Kathleen Dey on August 27, 2015 in Sexual violence, Violence, Women’s Health

As Women’s Month winds to an end, mind. Although this can be difficult, it antibiotics to prevent possible sexually Rape Crisis gives advice for rape survi­ is very important because this person transmitted infections (STIs)). You will vors. can help with the police investigation also be given an HIV test, and if the and later support your story in court. result is negative, you will be given ‘Claire’ (identity withheld upon request) They are known as the first contact antiretroviral treatment for 28 days to joined a study group in her second year witness. prevent contracting HIV. This is called at university. One afternoon, a guy from post-exposure prophylaxis (PEP). the group offered to walk her home and 3. Preserve evidence of the rape she invited him in for a cup of coffee. The one thing you may want to do is 6. Get support to help you recover As they chatted, he moved a little too wash. If you do, you run the risk of You can get the support you need close to her but she thought it would be washing away all physical evidence further down the line by asking for rude to say anything. Then suddenly of the rape so do not bath, shower or pamphlets or booklets on rape, and he took her coffee cup out of her hand wash your clothes. Doing this would the number of a local counselling and dragged her from her kitchen into get rid of blood, semen, saliva or hair service that can give you support the lounge, where he raped her on the that could be used as evidence of the and advice on the police report, an floor. She struggled and shouted at him rape. If you are injured, go straight eventual court case, and your own to stop but he ignored her. He later told to your nearest hospital, community physical and emotional wellbeing. If her that she had invited him in, which health centre or doctor. you do fall pregnant or contract an meant she wanted sex and so what was STI, then it is important to seek follow- she complaining about? After he left, 4. Decide whether you want to up medical care and counselling. Claire felt stunned, dazed and numb. report the rape She had no idea what to do next. You do not have to decide imme­ Claire called the Rape Crisis helpline diately whether to report the rape to later the same afternoon that she was Like Claire, many rape survivors are the police, but the sooner a doctor raped and got advice about what to do. too shocked to act in the mo­ments examines you, the more likely they As a consequence, she decided to report imme­­diately following a rape. But are to find physical evidence that they the rape to the police. A friend who knew there are practical steps you can take can link to the rapist. If you decide what had happened went with her. You immediately after someone rapes you to report the rape to the police, then have the right to access all of these to keep yourself safe and minimise both you should go to your nearest police services that will protect you from the short- and long-term health risks, and to station where the officers must take health risks associated with rape and to strengthen your chances of bringing the your statement. The police will take complain if the services do not meet your rapist to justice. you to a health centre where you needs. will receive medical attention and 1. Get to a safe place undergo a forensic examination. If Rape Crisis offers free services inclu­ The first thing you should do if you you do not report the rape, you can ding face-to-face counselling, a 24- are in any immediate danger is to go directly to a health centre to get hour help­line and support through court get yourself to a safe place. these services. cases and the criminal justice system. You can visit their website or call their 2. Tell someone what happened 5. Get medicine to prevent 24-hour crisis line on 021 447 9762. Once you are out of danger, tell unwanted pregnancies, HIV the first person you see what has and STIs This story was developed in partnership happened or contact someone you After the forensic examination, the with Health-e News by Rape Crisis know and trust, and tell them the doctor will give you the morning- Cape Town Trust intern Emily Whiteside whole story while it is fresh in your after pill to prevent pregnancy and and director Kathleen Dey.

HIV Nursing Matters | September 2015 | page 9 news Teen’s suicide highlights risk for LGBTI youth

By Bontle Motsoeneng on August 14, 2015 in Children’s Health, LGBTI, News, OurHealth, Sexuality While locals are still reeling about the suicide of 14-year-old Klara Göttert, who took her life at Northgate Mall this week, another mother in the Free State’s rural town of Bethlehem is also mourning the death by suicide of her 18-year-old daughter

The Free State teen’s family believes that “The next morning when I went to look by the non-profit organisation OUT, their reaction to the girl’s sexuality may for her, I found her,” said the mother, report­ed having considered suicide. have prompted the death of the teen, who later found a heart-breaking letter who the family asked not be identified. her daughter had written to her. Local psychologists have attributed this increased risk among LGBTI youth to Trouble at home started when the mother “I was cleaning the back room and I feelings of rejection and isolation that began suspecting that the young woman found a letter between the sheets where may stem from stigma around same-sex was smoking. “My son came to me and she wrote, ‘I just wanted you to accept sexuality. said not only was my daughter smoking me for who I want to be, mom. I am a at the tuck shop, but that she was a lesbian,’” she explained. “That’s when SADAG project manager, Naazia lesbian,” said the mother who stays I knew why she took her life and it was Ismail, said it was vitally important for about 250 km east of Bloemfontein. too late for me to bring her back.” parents to keep communication open. “It is difficult for parents,” she told “I was so angry,” the woman told Her mother now lives with unshakable OurHealth. “It is essential to try and OurHealth. “I waited for her and when guilt over the loss of her only daughter. “If keep open and clear communication she got in I couldn’t hold myself back. I only we had been able to talk in a calm and to try and have at least 30 minutes slapped her so hard and took a belt to manner, but I reacted badly,” she said. “I face-to-face with children. I suggest her and beat her.” blame myself for my child’s death.” have at least one meal together daily so you can monitor changes. Often “That day I went straight to my bedroom LGBTI youth more likely to report communication only happens when and left her to cry by herself,” she contemplating suicide one is angry when in fact it should added. “I didn’t go after her when she happen when both are comfortable,” went to the outside back room.” In South Africa, about 8% of all deaths she added. may be due to suicide and suicide deaths have more than doubled in the SADAG has urged parents teens and A 2004 study conducted last 15 years, according to the South parents to reach out for help if they are among 360 LGBTI youths African Depression and Anxiety Group having thoughts of suicide. The non- (SADAG). profit operates a specialised hotline found that about 20% had for people thinking of suicide on considered suicide. Globally, Globally, research has shown that 0800 567 567. People can also phone LGBTI youth are at a higher LGBTI youth may be at a higher risk for its 24-hour help line on 0800 12 13 14 risk of suicide, homelessness. suicide. About 20 percent of the 360 or SMS 31393 to have a SADAG oper­ LGBTI youth surveyed in a 2003 study ator call you back.

HIV Nursing Matters | September 2015 | page 10 NDOH/SANAC Nerve and easy access point for information on HIV and AIDS to Centre Hotlines any member of the public, in all of • Any HCT concerns from facility the 11 official languages, at any and district managers should be time of the day or night. • Telephone Counselling: Trained reported to the NDOH/SANAC lay-counsellors offer more than mere facts to the caller. They are Nerve Centre Hotline and, able to provide counselling to specific emails for each those battling to cope with all the province: emotional consequences of the pandemic. • Referral Services: Both the South • Western Cape: 012-395 9081 African Government and its NGO [email protected] sector have created a large AIDS Helpline network of service points to • Northern Cape: 012-395 9090 0800 012 322 provide a large range of services [email protected] (including Voluntary Counselling and Testing, medical and social • Eastern Cape: 012-395 9079 services) to the public. The AIDS The National AIDS Helpline Helpline will assist the caller to [email protected] (0800-012-322) provides a contact and use these facilities.The • KZN: 012-395 9089 confidential, anonymous 24-hour toll- National AIDS Helpline works free telephone counselling, closely with the Southern African [email protected] information and referral service for HIV Clinician’s Society to update • Free State: 012-395 9079 those infected and affected by HIV and maintain the Karabo Referral and AIDS. Database. www.sahivsoc.org [email protected] • Treatment Line: A specialised • Mpumalanga: 012-395 9087 The helpline was initiated in 1991 and service of the AIDS Helpline, the is a partnership of the Department of Treatment Line, is manned by [email protected] Health and LifeLine Southern Africa. Professional Nurses. They provide • Gauteng: 012-395 9078 The Helpline, manned by trained lay- quality, accurate and anonymous counsellors, receives an average of telephone information and/or [email protected] 3,000 calls per day, and is seen as a education on antiretroviral, TB and leading telephone counselling service • Limpopo: 012-395 9090 STI treatment. They also provide within the SADC region. relevant specialised medical [email protected] referrals to individuals affected Services Offered by the AIDS • North West: 012-395 9088 and infected by HIV and AIDS in Helpline: South Africa. [email protected] • Information: The Line creates a free

HIV Nursing Matters | September 2015 | page 11 Migration, HIV and access to public health care in Southern Africa

Jo Vearey, PhD Associate Professor, African Centre for Migration & Society (ACMS), University of the Witwatersrand

The SA government has a range of bilateral agreements with neighbouring countries that relate to the specific, arranged use of the SA public health care system for their citizens

KEY CONCEPTS Background migrants) that reflects global norms, accounting for 3 - 4% of the total SA • Globally, people move within Globally, people move within their coun­ population. This includes migrants from their countries of birth and tries of birth and across borders for a other countries with visitor visas, work across borders for a variety of variety of reasons, the most common and study permits, permanent residence, reasons, the most common of of which is the search for improved asylum seeker and refugee permits, which is the search for improved livelihood opportunities such as work and those who are currently without the livelihood opportunities such as and education. An important, but much documents required to be in the country work and education. smaller number of people are forced legally – undocumented migrants. • South Africa (SA) reflects global to move in order to escape political norms: cross-border migrants persecution and civil unrest. It is estimated However, popular assumptions, including account for 3 – 4% of the SA that 3 - 4% of the world’s population lives those made by the media, often grossly population. and works in a different country to that of over-estimate the number of cross-border • Evidence does not support their place of birth – i.e. are cross-border migrants in SA. In addition, those who prevailing assumptions that migrants. It is important to acknowledge move internally in SA are not considered cross-border migrants travel to that approximately three times as many migrants. This has far-reaching impli­ SA in order to access public people have moved within the countries cations for how migration is perceived health care. that they were born in, making internal and responded to in SA, including when migration the greater global development thinking about public health responses. • All pregnant and breastfeeding challenge for regional, national and local It is also import­ant to recognise that - as women, and all children under governance structures. Migration can in other countries globally - the cross- 6 years of age, have the right – and should – be good for social and border (and internal migrant) population to free services at all levels economic development, but in order for is not evenly distributed across SA; of health care regardless of these benefits to be realised, this requires higher densities of non-nationals (and nationality/documentation status ensuring that those who move are able to SA migrants) are found in major urban • Responses to migration and maintain their health and wellbeing, an centres, in border areas and in smaller, [1–3] health should be mainstreamed ideal of “healthy migration”. growing urban areas. into public health care programming and form an Drawing on data from the South African In SA, cross-border migrants are often integral part of a health-for-all (SA) government census, and from inde­ – unfairly and without evidence – approach in SA. pendent research, the country has a positioned as spreading communicable population of non-nationals (cross-border diseases and as placing a burden on the

HIV Nursing Matters | September 2015 | page 12 current issue

SA public welfare system, including the public health care (PHC) system. [3–5] It is of concern that policy and program­matic decisions relating to health and migration are often made in light of assumptions, rather than being based on evidence. The result is that some non-nationals struggle to access the PHC services to which they are legally entitled and may, from time to time, require while in SA.

All pregnant and breastfeeding women, and all children under 6 years of age, have the right to free services at all levels of health care, regardless of nationality and documentation status

The healthy migrant effect

Evidence suggests that there is, globally, a phenomenon known as the ‘healthy migrant effect’.[6] This effect shows that there is a positive selection of those who move: to migrate, you need to be healthy. The majority who move are not moving in search of health care and are likely to be healthier than the population into which they move. They may – once in a new country or place – need health care from time to time, including maternal and child health care.

However, despite available data that suggest otherwise, it is often assumed that people move to SA in order to access PHC services. This assumption can lead to a misunderstanding of the reasons why non-nationals may occasion­ally need to make use of the SA PHC system and, as a result, cross-border migrants are often unfairly blamed for placing a burden on an already struggling PHC system.

HIV Nursing Matters | September 2015 | page 13 nation services. In SA, a means-tested co-payment system exists for all when accessing higher levels of care, i.e. hospitals; users are means-tested on the basis of income and are charged accordingly, with individuals receiving social welfare grants or those who have no income being exempt from paying. This means test should be applied to SA citizens, permanent and temporary residents, refugees and asylum seekers, as well as undocumented SADC nation­ als. Non-nationals in SA who hold visit­ or permits – e.g. tourists – should be charged full fees.

Additionally, the South African National Strategic Plan (NSP) for HIV, STIs and Tuberculosis recognises that there is a need to improve responses for migrants and mobile populations, refu­gees and asylum seekers. However, despite the The SA government has a range of in draft form.[9] In 2015, the SADC advances made in upholding the rights bilateral agreements with the govern­ Secretariat produced a framework for of non-nationals to access PHC in SA, ments of neighbouring countries that its implementation, including a much- recent years have witnessed an increase relate to specific, arranged use of the SA needed costing model (unpublished). in access challenges being reported. PHC system for their citizens. These are At the time of writing, member states limited to times when countries do not are being asked to review and ratify These challenges relate to a range of have specialist facilities/services avail­ the drafted framework and financing concerns, including: able, and a formal request for medical model. The second key process relates travel to SA will be made. to the SADC Declaration on Tuberculosis • A demand for the up-front payment in the Mining Sector that was ratified in of fees by non-nationals in need of These arrangements involve granting a 2012.[10] This calls on member states to maternal health care, including at time specific visa issued for medical travel to improve responses to TB (with a focus of delivery, with reports suggesting SA. The costs incurred by the SA PHC on multi- and extremely drug-resistant that the babies of non-national mothers system in treating the patient are then TB) within the mining industry, and holds are not released to the mother until full repaid by the patient’s country of origin. [7] mining companies accountable for associ­ fees are paid. ated health care costs. The South African policy context • A demand for up-front payment of fees At a national level, SA has a progressive before emergency treatment will be At a global level, the World Health policy framework that upholds the right provided. Assembly (WHA) – of which SA is a to health care for all in SA, and different • The misclassification of non-nationals member – passed a Resolution in 2008 categories of non-nationals are afforded when calculating co-payments, inclu­ that calls for improved health systems different rights to health care. Everyone in ding documented refugees and [8] responses for migrants. In addition SA has the right to free emergency health asylum seekers being incorrectly to a global consultation in which SA care at the point of use – no fees can be categor­­ised as full-fee-paying patients. participated in 2010, two national charged before care is provided. consultations on the WHA Resolution have been held in the country (2010, All pregnant and breastfeeding women, What is needed? 2013). Within the SADC, two key pro­ and all children under age 6 years, have cesses exist that relate to addressing the right to free services, at all levels of There is a need to think about what is migration and health. The first is the 2009 health care, regardless of nationality and needed at two levels: (i) nationally within Framework on Population Mobility and docu­mentation status. This includes all SA and (ii) regionally within the SADC Communicable Diseases that remains antenatal care, childbirth and vacci­ region. In SA, despite the protective

HIV Nursing Matters | September 2015 | page 14 current issue legislative framework that exists, evi­ ing legislation within health facilities. and form an integral part of a health- dence indicates that some non-nationals for-all approach in SA. This would better • Health passports or regionally recog­ face challenges when accessing PHC allow for the ideal of ‘healthy migration’ nised ‘road-to-health’ cards for all (a services. [3] It is essential to recognise that to be realised for all who move within and form of patient-held records). denying or delaying access to treatment into SA – citizens and non-nationals alike. or the services needed for non-nationals • Referral letters for internal AND cross- (including maternal health care) has an border migrants. References impact on the wider SA public. • The establishment of local migrant 1. IOM. Migration and Health in South health forums. There are two key considerations here. Africa: A Review of the Current Situation and Recommendations for Achieving the Firstly, a progressive and efficient public Generating evidence to inform World Health Assembly Resolution on health response needs to consider the the Health of Migrants. (2010). health of the whole population and (improved) responses recognise that delayed or interrupted 2. Landau, L. & Wa Kabwe Segatti, access to treatment for communicable Various research projects are currently A. Human Development Impacts of Migration: South Africa Case Study. diseases – such as HIV or TB and to underway at the African Centre for Hum. Dev. Res. Pap. 20095 (2009). vaccinations for children – will negatively Migration and Society (ACMS) that impact all who reside in SA, including involve a range of partnerships with other 3. Vearey, J. Healthy migration: A public citizens. Secondly, delaying access to academic institutions, civil society and health and development imperative for health care can result in higher costs government actors, and – importantly south(ern) Africa. S. Afr. Med. J. 104, 663 (2014). when treatment and care are eventually – students from Wits University and provided; e.g. when someone is so beyond. It is anticipated that this research 4. Vearey, J. Learning from HIV: Exploring sick that they now require emergency will contribute to the body of evidence migration and health in South Africa. health care treatment. Based on existing needed to inform effective policy and Glob. Public Health 7, 58–70 (2012). evidence, the following needs have been programmatic responses to migration and 5. Vearey, J. In Contemporary Migration to identified.[3] health in SA and the SADC region. South Africa: A Regional Development Issue (eds. Segatti, A. & Landau, L.) • Training on migration, mobility, health This research includes (but is not limited (World Bank, 2011). and development for all levels of to): investigation into policy processes 6. Lu, Y. Test of the ‘healthy migrant staff in the Department of Health, associated with migration and health hypothesis’: A longitudinal analysis of including frontline staff, health care planning at regional, national and health selectivity of internal migration providers, facility managers, district local levels; examination of access to in Indonesia. Soc. Sci. Med. 67, 1331– and provincial health co-ordinators, maternal and child health care services 1339 (2008). and within the national department. for non-nationals, including vaccination 7. Crush, J. & Chikanda, A. South–South programmes; exploration of HIV-related medical tourism and the quest for health • Recognition of the importance of stigma among Mozambican migrants in Southern Africa. Soc. Sci. Med. 124, internal mobility within SA and other in Johannesburg; and an assessment of 313–320 (2015). countries in the SADC region, and the ways in which migration – both from 8. World Health Assembly. World Health the development of migration-aware within the country and across borders – is health systems. Assembly Resolution 61.17: Health of impacting the SA PHC system. Migrants. (2008). • The development of a co-ordinated 9. SADC Directorate for Social and Human regional response to migration, mobili­ Conclusion Development and Special Programs. ty and health. SADC Policy Framework for Population • Effective implementation of current Migration and health are both important Mobility and Communicable Diseases protective and progressive legislation social concerns that remain associated in the SADC Region: Final Draft April 2009. relating to the right to health for non- with a range of public and political nationals in SA. misunderstandings that negatively – and 10. SADC Directorate for Social and Human unfairly – associate the movement of Development and Special Programs. • Correct classification of non-nationals people with (i) poor health and the spread SADC Declaration on Tuberculosis in when being means-tested for co-pay­ of disease, and (ii) placing a burden the Mining Sector. (2012). ment for health care. upon the PHC system. It is imperative that • Implementation of national monitoring responses to migration and health are of the correct implementation of exist­ mainstreamed into PHC programming

HIV Nursing Matters | September 2015 | page 15 Understanding immigration detention and deportation in South Africa: A summary of law, practice and human rights violations at the Lindela Detention Centre

Roni Amit African Centre for Migration & Society

With respect to healthcare specifically, the National Strategic Plan on HIV, STIs and TB, 2012 - 2016 (NSP) sets out the country’s comprehensive strategy in relation to HIV and TB

What is Lindela? has contracted daily operations at the This ACMS issue brief explores the facility to Bosasa, a private company. state of immigration detention in Lindela is a detention facility that holds South Africa. It lays out the legal individuals arrested as illegal foreigners What procedures must be framework for detention and the while they await deportation. It was followed at Lindela? procedures for detaining someone esta­blished by the Department of at the Lindela Detention Centre, Home Affairs (DHA) under Section 34 Detentions at Lindela are administrative where individuals arrested as illegal of the Immigration Act (No. 13, 2002). in nature, which means that individuals foreigners are detained pending Section 34 authorises the Department are not entitled to a trial. There are, deportation. to detain illegal foreigners “in a however, certain administrative proce­ manner and at a place determined by dures that must be followed in order for It also highlights the key detention- the Director-General” provided that a the detentions to be legal. Detainees related human rights violations range of procedural guarantees are are also protected by the Constitution. identified in previous research. followed. Lindela is the only designated We detail these procedures and legal facility for the detention of illegal protections below. foreign­ers in South Africa (SA). Just administrative action The facility is located about 40 km outside of Johannesburg, and can Both police officers and immigration hold up to 4 000 detainees. There officers are empowered to arrest indi­ are male and female sections. Minors viduals suspected of being illegal are not detained at Lindela. The DHA foreign­ers. Before an individual can

HIV Nursing Matters | September 2015 | page 16 current issue be sent to Lindela, however, an immi-­ d. may not be held for more than o shall be provided with an ade­ gration officer must confirm within 48 30 days without a warrant of the quate and balanced diet (Section hours that the individual is an illegal court extending the detention for a 2(a)). foreigner, or release them. Police maximum of 90 days. • The diet shall make special provi­ and immigration officers must take all e. shall be held in detention in sions for detainees who require a reasonable steps to help an individual accordance with the minimum special diet because of their physical confirm his/her immigration status prescribed standards protecting condition (Section 2(b)). (Section 41), including accessing individual dignity and human rights. near­by documents and departmental • Food should be served at intervals records (Regulation 34). After 48 not less than four and a half hours In short, an individual must be notified hours, any detention may only be for apart and not more than 14 hours of his/her rights of review and appeal, the purpose of deportation. If the DHA should elapse between the evening may request at any time that a court is unable to confirm that an individual meal and breakfast during a 24- review the detention, and cannot be is legally residing in the country, s/he hour period (Section 2(d)). held for more than 120 days. will be deemed an illegal foreigner. • The Department shall provide the In practice, the burden is generally Health care and other basic rights means for every detainee to keep his/ on the individual to provide adequate her person, clothing, bedding and documentation showing legal status. At a general level, the Constitution room clean and tidy (Section 3). upholds the inherent right to human Section 41 of the Immigration Act sets dignity for all individuals (Section With respect to health care specifically, out several conditions for being detained 10), as well as the right to access to the National Strategic Plan on HIV, as an illegal foreigner at a designated health care and sufficient food and STIs and TB, 2012 - 2016 (NSP) sets facility such as Lindela. These conditions water (Section 27). These protections out the country’s comprehensive include that the indi­vidual: apply to all individuals, including those strategy in relation to HIV and TB. It a. must be notified in writing of the in detention. The Constitution also identifies migrant populations as a deportation decision and of the guaran­tees rights specific to detention, “key [target] population for the HIV right to appeal this decision. including the right “to conditions and TB response” urgently in need of a of detention consistent with human “comprehensive package of services.” b. may request at any time that dignity, including at least exercise With respect to detention, the NSP the detention for purposes of and the provision, at state expense, of states that detention facilities must target deportation be confirmed by a court. adequate accommodation, nutrition, specific efforts to screen, diagnose and If a court does not issue a warrant reading material and medical provide treatment services to detainees confirming the detention within 48 treatment” (Section 35). Both the (Intervention 3.1.2). Screening and hours of the request, the individual Constitution and the National Health treatment measures­ that target TB and must be released immediately. Act (No. 61, 2003) ensure that HIV are particularly important, given c. shall be informed of the above everyone has access to emergency the close quarters of detention. rights and in a language that s/he health care, regardless of nationality. understands where practicable and The Constitution upholds the possible. The Immigration Act requires that an inherent right to human dignity for individual be detained “in compliance all individuals, as well as the right to with minimum prescribed standards access to health care and sufficient Before an individual can be sent to protecting his/her dignity and relevant food and water. The Constitution also Lindela, an immigration officer must human rights” (Section 34). Annexure guarantees rights specific to detention, confirm within 48 hours that the B of the Regulations to the Immigration including the right “to conditions of individual is an illegal foreigner, or Act sets out the Minimum Standards of detention that are consistent with release them. Detention. These include: human dignity, including exercise and • Every detainee: the provision, at state expense, of adequate accommodation, nutrition, o shall have access to basic health An individual must be notified of reading material and medical facilities (Section 1(a)). his/her rights of review and appeal, treatment”. Both the Constitution and may request at any time that a court o shall be provided with a bed, the National Health Act ensure that review the detention, and cannot be mattress, and at least one blan­ everyone has access to emergency held for more than 120 days. ket (Section 1(b)). health care, regardless of nationality.

HIV Nursing Matters | September 2015 | page 17 Who can be detained at longer in need of protection and their Asylum seekers may not be Lindela? refugee status has been withdrawn. detained at Lindela if a final decision has not been made on The DHA is authorised to detain Who has oversight over their asylum claim. An individual individuals at Lindela for the purposes Lindela? may apply for asylum from of deportation only. This means that detention, and if they have done only individuals who have been con­ Lindela is under the authority of the so, the individual is no longer firmed to be illegal foreigners can be DHA. The DHA has contracted daily an illegal foreigner and must be detained at Lindela. Individuals with operations of the facility to a private released from detention. valid immigration documentation may company: Bosasa Operations (Pty) Ltd. not be detained there, even if they were Bosasa is responsible for the provision Because of the international not carrying these documents at the of food, accommodation, and security non-refoulement principle, which time of arrest. Individuals whose immi­ at the facility. However, the DHA is South Africa has incorporated gration status has not been verified by ultimately res­ponsible for conditions into the Refugees Act, refugees the DHA cannot be sent to Lindela, as and procedures at Lindela. and asylum seekers may not be no verification of status takes place at deported; hence, they may not be the facility. The Department of Health (DoH) is detained at Lindela. respon­sible for ensuring that the legi­ Asylum seekers — both documented slated requirements relating to the pro­ To date, monitoring and oversight and those individuals who have stated vision of health care within detention of Lindela has been severely an intention to apply — may also not be facilities are upheld. constrained. The South African detained there if a final decision has Human Rights Commission is the not been made on their asylum claim. To date, monitoring and oversight only institution that has unfettered An individual may apply for asylum of Lindela has been severely access to Lindela. from detention. Various court rulings constrained. The South African Human have determined that if an individual Rights Commission (SAHRC) is the has applied for asylum while at Lindela, only institution­ that has unfettered regarding who is being detained or for the individual is no longer an illegal access to Lindela. The Constitution how long. foreigner and must be released from empowers the Commission: “to detention. investigate and report on the Embassy representatives consult with observance of human rights” (Sec­tion their nationals in special embassy The deportation of asylum seekers 184(2) (a)). The Commission’s statute consul­ting rooms. Lawyers have limited violates the international principle also gives it monitoring and investi- access to consult with their clients, but of non-refoulement, which prohibits gatory powers. Following a 1999 legal these visits must often be cleared two sending an individual back to a challenge around unlawful detentions, days in advance. Lawyers do not have country where s/he may face harm. the DHA agreed to provide the Com­ access to the inside of the facility and South Africa’s Refugees Act (No. 130, mission with access to Lindela and must consult in an area that does not 1998) has incorporated this principle. to produce regular detainee lists for accord privacy and where they are Accordingly, refugees may not be monitoring purposes. The Commission separated from their clients by a glass detained at Lindela unless there has has not conducted regular visits to partition. been a determination that they are no Lindela since this agreement. The Commission delegated its authority What are the issues of concern over monitoring of the detainee lists to Individuals with valid immigration at Lindela? Lawyers for Human Rights (LHR). The documentation may not be DHA stopped providing these lists to detained at Lindela, even if Despite the restraints on regular over­ LHR in April 2009. they were not carrying these sight and monitoring, a series of re­ documents at the time of arrest. ports, investigatory visits, and legal Civil society and research organisations Individuals whose immigration challenges have identified a range of have had limited access to Lindela. The status has not been verified by concerns around legal procedures and DHA has denied formal requests for the Department of Home Affairs health care at Lindela. access from both groups. As a result, cannot be sent to Lindela, as no there is no monitoring of conditions at verification of status takes place at These reports and legal cases have Lindela. Outside of individual detention the facility. tracked a pattern of violations of legal cases, there is also no information rights and standards of care. The main

HIV Nursing Matters | September 2015 | page 18 current issue areas of concern identified from these A large number of detainees at to extend detentions beyond a sources are summarised below. Lindela report not receiving the 30-day period. This renders these required notifications advising them detentions extra-legal in nature, as Violations of adminis­trative of their legal rights upon being they have no basis in law. justice detained, being classified as illegal foreigners, and being slated for • Excessive and indefinite • Failure to verify immigration deportation. Many are unaware of detentions status their rights of review and appeal/ The DHA often detains individuals Individuals are often sent to are unable to exercise these rights. beyond the maximum 120 days Lindela before their immigration allowed by law. It has defended this status has been verified. The result • Extra-legal detentions as being necessary, despite multiple is that individuals with documen­ Immigration officials have routinely legal pronouncements de­claring tation, including asylum seekers failed to obtain required warrants the practice unlawful. and refugees, are detained for purposes of deportation at Lindela. In his response to the Reports published about Lindela: SAHRC’s investigation (2014), the • South African Human Rights Commission: Lindela at the Crossroads for manager of Lindela, Job Jackson, Detention and Repatriation (2000) acknowledged that individuals • Lawyers for Human Rights: Monitoring Immigration Detention in South are sometimes admitted to Lindela Africa (2008) without their immigration status being checked (para. 7.4.8.1). This • Forced Migration Studies Programme (now ACMS): Lost in the Vortex: practice contravenes the law. Irregularities in the Detention and Deportation of Non-Nationals in South Africa (2010) • Detention of asylum seekers • Lawyers for Human Rights: Monitoring Immigration Detention in South and refugees Africa (2010) The SAHRC survey encountered • ACMS: Deportation and Public Health - Concerns around the ending of 16 asylum seekers (out of 109 the Zimbabwean Documentation Process, Issue Brief (2011) respondents) in detention. An • Lawyers for Human Rights: Monitoring Immigration Detention in South ACMS survey in 2009 encountered Africa (2012) 257 asylum seekers and refugees • ACMS: Breaking the Law, Breaking the Bank: the Cost of Home Affairs’ (out of 734 respondents) in de­ Illegal Detention Practices (2012) tention. A number of legal cases have also challenged the detention • Solidarity Peace Trust: Perils and Pitfalls: Migrants and Deportation in of individual asylum seekers and South Africa (2012) refugees. These detentions violate • Justice Edwin Cameron: Visit to Lindela Repatriation Centre, Krugersdorp the international and domestic legal (2012) principle of non-refoulement, as well • South African Human Rights Commission: Investigative Report on Access as the legal procedures around the to Health at Lindela (2014) detention of asylum seekers and refugees found in the Refugees Act. The Department has maintained that it is entitled to detain asylum seekers There have been numerous judicial decisions finding individual until a final decision has been made detentions and broader detention practices unlawful. A on their asylum claim, a practice selection of these cases is listed below: that contravenes the Refugees Act • Arse v Minister of Home Affairs and Others, SCA (12 March 2010) and has been ruled unlawful by • Abdi and Another v Minister of Home Affairs and Others, SCA (15 the courts. Moreover, there is no February 2011) mechan­ism within Lindela to prevent • Bula and Others v Minister of Home Affairs and Others, SCA (29 the deportation of these individuals November 2011) while they await a final decision. • Ersumo v Minister of Home Affairs and Others, SCA (28 March 2012) • Failure to notify individuals • South African Human Rights Commission and Others v Pandor and of their rights Others, South Gauteng High Court (28 August 2014)

HIV Nursing Matters | September 2015 | page 19 current issue

Violations of conditions of o There are not sufficient that shapes global discourse on human detention measures to ensure continuity mobility, development and social of treatment for detainees on transformation. The ACMS is one of • Excessive periods between chronic medication, particularly the continent’s leading institutions for meals treatment for TB and HIV. research, teaching and outreach on Lindela serves a morning and an o Detainees do not receive any migration. after­noon meal; there is no evening buffer stock of medication upon meal. This violates the minimum re­ deportation. Contact details: quired standards of detention, laid School of Social Sciences out in the regulations, that there be What rights violations have University of the Witwatersrand no more than 14 hours between the been identified? P.O. Box 76 evening meal and breakfast. Wits 2050 Both the courts and the Human Rights Johannesburg, South Africa • Personal hygiene Commission have identified a range Tel: +27 (0)11 717 4033 Individuals are provided with some of violations of South Africa’s Bill of Fax: +27 (0)86 553 3328 basic items for personal hygiene, Rights based on the above practices. [email protected] but they must purchase some items, The constitutional rights that are being www.migration.org.za or purchase additional supplies of violated at Lindela include the following: items that run out. Many arrive at Lindela with only the clothes they • the right to human dignity (Section References were wearing at the time of arrest 10) • Human Rights Commission, Baseline and are not provided with a change • the right to freedom and security of Investigatory Report [on Lindela], Ref. of clothes. the person (Section 12) No. GP/2012/0134, 18 September • the right to health care (Section 27) 2014, available at http://www.sahrc. • Health care org.za/home/21/files/Gauteng%20 This is problematic at Lindela, and • the right to access to information -%20Investigative%20Report%20 it is unclear who is currently in (Section 32) -%20Lindela%20-%201%20 September%202014.pdf charge of health care at the facility • the right to just administrative access — Bosasa, DHA, or the DoH. The (Section 33) SAHRC report identified a range of • Republic of South Africa, problems: • the rights of arrested, detained, and National Strategic Plan on accused persons (Section 35). HIV, STIs, and TB 2012-2016 o Detainees have no access to (2011), available at http://www. psychological services. thepresidency.gov.za/MediaLib/ o Lindela does not provide African Centre for Migration & Downloads/Home/Publications/ SANACCallforNominations/ extensive counselling and testing Society (ACMS) services for HIV. A5summary12-12.pdf

o The clinic isolation unit lacks The ACMS is an independent, • South African Human Rights ventilation and natural light. interdisci-plinary and internationally Commission Act, Act No. 40 o There is no tetanus vaccine in the engaged Africa-based centre of of 2013. clinic fridge. excellence for research and teaching

HIV Nursing Matters | September 2015 | page 20 What is the Stop STOCKOUTS Stock Outs Project?

The Stop Stock Outs Project (SSP) is an organisation that monitors availability of essential medicines in government clinics and hospitals across South Africa. The SSP aims to assist healthcare workers in resolving stock outs and shortages of essential medicines at their facilities, enabling them to provide patients with the treatment they need.

How do you report a stock out to the SSP?

Our hotline number is You can also email us at 084 855 7867 [email protected]

• Send us a Please Call Me • Send us an SMS • Phone us or missed call us

We will then phone you back to get some more information.

What information do you need to report to the SSP?

The name of the medicine The name of the clinic or that is out of stock hospital where you work

Reporting is an anonymous process and your name, if provided, will not be disclosed to anyone outside of the SSP. New vaccine is effective against Ebola in a large trial in Guinea

Article from Doctors Without Borders (Médecins Sans Frontières) Southern Africa

Despite the ongoing prevalence of Ebola in West Africa, July brought fresh hope of ending the epidemic: a preliminary review in Guinea, one of the three West African countries stricken by Ebola, has found an Ebola trial vaccine to be 100% effective. We spoke to Doctors Without Borders (MSF) Southern Africa about the organisation’s involvement in the vaccination trials.

Although MSF began responding to In May 2015, Liberia was declared of cases in Guinea, Sierra Leone and the largest Ebola outbreak in history in Ebola-free after 42 days with no new Liberia stagnated at around 30 new March 2014 and progress has been recorded cases of the disease. But in infections per week, a number that made in the fight against the virus, July, new cases emerged in the country. would be considered a disaster in Ebola stubbornly lives on in Guinea, With cases of Ebola also recorded normal circumstances. Sierra Leone and Liberia with more than in neighbouring Guinea and Sierra 27 678 people infected and 11 276 Leone, MSF teams are still fighting In Sierra Leone, the number of Ebola lives lost. the disease. In July 2015, the number cases continues to fluctuate as hotspots

HIV Nursing Matters | September 2015 | page 22 clinical update persist in Western Area (Freetown), Port Loko and Kambia districts. In Guinea, active chains of transmission persist in Conakry, Boké and Forecariah.

In Liberia, MSF is not directly involved in the patient care or investigation of the new cases, but remains ready to support the Ministry of Health should they require it. For now, MSF is running a 69-bed paediatric hospital in Monrovia to help restore the second­ ary health system, which like those in Guinea and Sierra Leone has been paralysed following the deaths of hundreds of health workers. In the grounds of the hospital, MSF also runs a clinic specifically for Ebola survivors who suffer from a number of health complications following their recovery from the virus.

Results of tests of the new VSV-ZEBOV vaccine to protect against Ebola indicate a high level of efficacy in a trial involving more than 4 000 people in close contact with the deadly virus. British medical journal The Lancet published the results of the trials on 31 July.

In March 2015 the clinical trial started in Guinea to test the safety, efficacy and capacity of the substance to provoke an immune response of the vaccine. The trials were run by the World Health Organization (WHO) in collaboration frontline workers in Guinea including tein of the Zaire strain of the Ebola with MSF and a broad consortium of doctors, nurses, paramedics, laboratory virus, which ravaged West Africa, organisations and countries, including staff, cleaning staff, and burial teams. and VSV, another unrelated virus. The Norway, Canada, Guinea, MSF, The volunteers who received the vaccine combination of these components the Universities of Florida, Maryland came from areas in Guinea that had results in a weakened vaccine virus and Bern, and the London School of Ebola outbreaks. These volunteers were that cannot cause disease, but that Hygiene and Tropical Medicine. directly in contact with those who had does stimulate the body to generate contracted the virus or were contacts- an immune response. In this way, the The trial focused on vaccinating ‘rings’ of-contacts, such as neighbours, class­ vaccine triggers the production of of people around infected patients mates or extended family. In some antibodies to fight off the disease, with­ – who are most at risk – as well as cases, the clusters were whole villages. out having the disease present. frontline workers at risk of contracting In others, the clusters were smaller the disease. In the ring vaccination, the sections of towns and cities. The trial Using the ring approach, vaccinators direct contacts in a ‘ring’ around an monitored immune response and side- and the trial team were able to move Ebola patient are vaccinated to stop effects. with trials when the Ebola epidemic the virus from spreading further. MSF in Guinea had dispersed into smaller was heavily involved in the trial and According to WHO, the vaccine local outbreaks. This allowed the administered the vaccine to 1 200 combines a gene encoding a key pro­ trial to continue and at the same time

HIV Nursing Matters | September 2015 | page 23 seamlessly contribute to the control of across the affected region. It would President Dr Joanne Liu declared in the Ebola outbreak. be more effective to focus energy and July, “going from hundreds of cases to resources on vaccinating people most 30 per week took considerable time MSF Medical Director Dr Bertrand at risk of contracting the disease. All and massive resources, yet getting from Draguez, who has been spearheading the components of the fight against the 30 to 0 requires the most meticulous, the MSF platform on experimental disease need to be continued. “This difficult work of all.” Liu also stated tools for Ebola, said the results are includes Ebola case management, that no one was prepared for the scale encouraging. “More data are needed isolation, community outreach, safe of this epidemic, the largest in human to tell us how efficacious this preventive burials, health promotion, psycho- history, nor that it would last so long. tool actually is, but this is a unique social support and contact tracing.” “But we cannot lose focus now and breakthrough. The mere possibility of said Draguez. “Now that we know that must push on until the entire region is finally possessing a tool to put an end the vaccine works, people who need it declared Ebola free,” said Liu. to this epidemic is very exciting,” said most should imperatively get it as soon Draguez. as possible to break the existing chains Liu emphasised the need to remain of transmission,” he said. vigilant in the fight against Ebola. “We MSF is now calling for the vaccine to be have seen so many reports calling for expanded for use in Liberia and Sierra “Adding a preventive tool in the mix will change, with everyone focused on Leone. MSF urges the manufacturer accelerate the break-up of transmission how to improve future responses to (Merck) and financing mechanisms to chains by targeting people who have outbreaks and meanwhile, with new ensure the availability of enough doses been in contact with infected patients as Ebola cases each week in the region, as soon as possible. well as frontline workers,” said Draguez. we still don’t have the current epidemic under control. On Ebola, we went from While the epidemic persists, a vaccine MSF is urging governments in affected global indifference, to global fear, to could help end it. At the moment, countries to start using this vaccine as global response and now to global according to MSF, the epidemic soon as they can within the framework fatigue. We must finish the job.” is quite localised in a few hotspots of the existing trial. MSF International

HIV Nursing Matters | September 2015 | page 24 clinical update Sexual and reproductive health for adolescent girls: SAfAIDS Young Women Leadership (YWL) Programme

Looking to the future: Unleashing the power of young women leaders to amplify the voices of young people on sexual and reproductive health and gender equality at continental level

Virginia Maserame Mojapele, BNSC (Hons), MCur SAfAIDS

Unleashing the power of young women leaders is important in amplifying the voices of young people to champion issues of sexual and reproductive health and gender equality at continental level. It is hoped that this will give them personal skills to make choices and decisions that positively impact at an individual and community level.

Background Adolescence is a decisive age for girls estimated that girls under the age of 15 around the world. What transpires are at greater risk of dying in childbirth Sexual and reproductive health and during a girl’s teenage years shapes than women in their 20s.[3] rights (SRHR) are usually understood the direction of her life and that of her as the rights of all people, regardless family. For many girls in developing Educated young women offer a power­ of their nationality, age, sex, gender, countries, the mere onset of puberty ful boost to their families’ well-being, health or HIV status, to make informed that occurs during adolescence marks contributing to increased household and free choices with regard to their a time of heightened vulnerability – to income and savings, better family own sexuality and reproductive well- leaving school, child marriage, early health and improved opportunities for being, on condition that these decisions pregnancy, HIV, sexual exploitation, future generations. Taken together, their do not infringe on the rights of others. coercion and violence. Adolescent actions can help lift communities and This includes the right to access edu­ girls are less likely than older women to countries out of poverty. The delaying cation and information, services and access sexual and reproductive health of marriage until later in life increases health care on SRHR. care, including modern contraception the space between generations, lower­ and skilled assistance during pregnancy ing the desired family size as more Through the ratification of various pro­ and childbirth.[2] Many girls who be­ educationally accomplished girls are lific international, regional and national come pregnant drop out of school, less reliant on multiple children for instru­ments, sexual reproductive health drastically limiting health and the health security, and decreases the power is understood to be of vital import­ of their children. Thus, adolescent differential between partners, thus ance to the overall well-being of all pregnancy fuels the intergenerational positively affecting a woman’s ability to individuals.­ [1] cycle of poverty and poor health. It is meet her fertility goals.[4]

HIV Nursing Matters | September 2015 | page 25 Young people have the right to decide whether or not, and when, to have children

SAfAIDS experience

As a way of addressing these gaps, SAfAIDS designed a young women leadership-training programme with a three-tier approach to enhancing the leadership capacity of young women. Launched in 2011, the SAfAIDS Young Women Leadership (YWL) Programme focused on building the leadership skills and capacity of young women aged 18 - 24 years from Botswana, Namibia YWL graduates (Photo courtesy of SAfAIDS). and Zimbabwe, to become leaders and champions in SRHR, HIV and gender- based violence (GBV) prevention, gender explore and assess their individual Lessons learned equality and sexual rights in Africa. personalities in order to identify their strengths and areas for improvement Unleashing the power of young women The programme seeks to mobilise through comprehensive guidance. In leaders is important in amplifying the young women; empower them to module 3, the candidates underwent voices of young people to champion serve as advocates; provide them with a 10-month rotational placement:­ they issues of sexual and reproductive health information and skills to develop their were placed at a recognisable SRHR, and gender equality at continental leadership capacity and to implement gender and women’s organi­sation to level. It is hoped that this will give them gender equality programmes; and put their gained know­ledge and skills personal skills to make choices and provides a platform to raise awareness (from the training in modules 1 and 2) decisions that positively impact at an of SRHR and HIV issues and speak on into practice. individual and community level. It is behalf of young women and girls at also important to give young women an country, regional and continental level. The programme has a strong mentoring opportunity to design and implement approach: each day the young women personal projects that relate to SRHR The aim is to: were attached to elder and prominent in their communities, so that they create women who inspired them and linked change at a community level. – inspire change in the lives of young them to educational and economic women and girls opportunities. Recommendation for clinical – empower them to take charge of service providers their sexual and reproductive health The YWL candidates were able to – reduce the risk and vulnerability unpack their innate capacities and Young people are diverse; programme related to HIV and GBV. build their vision, gaining technical approaches are multifaceted and should skills such as negotiation, interrogating therefore be tailored for young people’s The selected candidates underwent policy, advocacy and organisational individual characteristics and contextual training­ based on three modules: (i) management. To date, the nine young factors (age, sex, sexual activity, sexual theoretical skills, (ii) competencies in women are employed by different orientation, gender identity, marital SRHR and (iii) leadership development. organisations at African Union and status, school enrolment, residence, Modules 1 and 2 focused on local level. SAfAIDS expanded this employ­ment status, and family bonds). enhancing the theoretical skills and programme to other southern Africa competencies of the candidates; countries to reach out to more young Young people face unique challenges providing them with a platform to women. and have distinct needs compared with

HIV Nursing Matters | September 2015 | page 26 clinical update adults; these should be recognised and programme approaches should be prioritised to accommodate age-related needs, challenges and access barriers.

Young people have the right to decide whether or not, and when, to have children. Information and education materials can assist young people in understanding their readiness to have children. As example, the diagram below (derived from the SAfAIDS toolkit on Integrating SRHR into HIV Programming) probes information on the use and type of contraception, and whether the partner was involved in decision-making. Such resources should be implemented more widely and young people should be encouraged to access and make full use of them.

“Your right to decide whether or not, and when to have children”

References 1. Department of Social Development (2015) National Adolescent Sexual and Reproductive Health and Rights Framework Strategy. 2. UNFPA (2012) From Childhood to Womanhood - Meeting the sexual and reproductive health needs of adolescent girls, Fact sheet - page 1. 3. UN General Assembly (2011) “The Girl Child – Report of the Secretary General”. 4. UNFPA (2012) “Marrying Too Young: End Child Marriage”.

HIV Nursing Matters | September 2015 | page 27 Preparing for PrEP: From theory to practice in key populations

Kevin Rebe,1,2 Oscar Radebe,1 Helen Struthers,1,2 James McIntyre1,3 1 Anova Health Institute, Johannesburg and Cape Town, South Africa 2 Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, South Africa 3 School of Public Health & Family Medicine, University of Cape Town, South Africa

The WHO estimates that the use of pre-exposure prophylaxis (PrEP) could prevent 1 million new HIV infections in MSM over the next 10 years

With 7 400 new HIV infections daily, the largest MSM surveillance study were considered, the protection rate South Africa (SA) is in need of sound to have been conducted in SA, MSM was approximately 90%.[8] Additionally, strategies for HIV prevention. This is were found to have sub-optimal HIV in the PROUD study in the UK, PrEP was particularly true among vulnerable knowledge and to engage in ongoing so effective at preventing HIV in MSM and key populations, which are those risky behaviours such as alcohol abuse that the study was stopped early; the groups of people in SA who are the and low condom use. They also report intevention provided an 86% reduction most likely to be exposed to, or transmit experiencing stigma from some health in the risk of acquiring HIV.[9] PrEP was HIV. [1-3] These key populations include care providers.[7] well tolerated, with nausea and other men who have sex with men (MSM), gastrointestinal symptoms being the people who inject drugs, commercial PrEP for MSM – what does the most common minor adverse effects sex workers and transgender persons, research say? that occurred in a minority of subjects, as well as vulnerable populations and these were self-limiting.[9] When such as prisoners, migrants and young The WHO estimates that the use of adherence was measured by looking at women aged between 15 and 24 years pre-exposure prophylaxis (PrEP) could the levels of ARVs in the blood of study old, among others.[4] prevent 1 million new infections in MSM participants, it was shown that when over the next ten years.[4] Currently, PrEP adherence was high, HIV protection was A look at MSM in particular consists of a combination regimen of consistent and high. [9] Another French antiretroviral (ARV) medication (teno­ study, known as the Ipergay study, Local research conducted by the fovir and emtricitabine) taken as an examined the use of sex-based dosing Anova Health Institute in Johannesburg oral pill. When used daily on a long- of PrEP in MSM, as opposed to daily and Cape Town has confirmed that term basis, such as in the iPrEX study, dosing. This is known as intermittent, MSM are at a very high risk of HIV it decreased the HIV transmission rates coitally based PrEP. The study yielded transmission and acquisition. [3,5] In fact, by 44% in MSM.[8] Although this does similar results to the PROUD study and during their research, more than one not look like a good protective result, it showed an 86% reduction in the risk of in three MSM tested HIV-positive.[3] represents an average protection level contracting HIV. [10] In virtually every country that reports for men in the study, independant of reliable surveillance data, it is shown that whether they took medication or not. If An interesting point is that in the studies, MSM have a disproportionately higher only men who actually adhered to the unprotected sex and STIs were less HIV prevalence.[6] In the Marang study, study guidelines and took PrEP correctly common over time – suggesting that

HIV Nursing Matters | September 2015 | page 28 clinical update ongoing risk-reduction counselling along while that sexual relationship endures, Results from the Soweto Men’s Study. with PrEP was decreasing the amount but may choose to stop PrEP if the Aids Behavior 15: 626-634. of risky behaviour in which the MSM relationship ends and he is no longer 4. World Health Organization. (2015) were engaging.[8-10] This is important as being exposed to the virus. Consolidated guidelines on HIV it answers a concern that many people prevention, diagnosis, treatment and care for key populations. Geneva. have about MSM increasing their Implementing PrEP in SA Available at http://www.who.int/hiv/ sexual risk-taking because they feel they pub/guidelines/keypopulations/en/ are protected by PrEP. There are logistical challenges in imple­ (Accessed 15 Aug 2015). menting PrEP in the public sector, such 5. Rebe KB, Struthers H, De Swardt G, The conclusion drawn from these and as cost, creating demand (MSM must McIntyre JA (2011) HIV Prevention and numerous other trials is that PrEP can be know about the option to take PrEP and Treatment for South African Men Who delivered safely as part of an effective be willing to do so), how to minimise the Have Sex With Men. S Afr Med J 101: HIV-reduction package. PrEP trial sub- number of health care visits needed and 708-710. group analy­ses have also shown that adherence support. Additionally, health 6. Beyrer C, Wirtz AL, Walker D, Johns B, PrEP is effective for those at greatest risk care workers need to be trained on Sifakis F, et al. (2011) The Global HIV of contracting HIV.[8,11] administering PrEP, and how to monitor Epidemics among Men Who Have Sex with Men. Washington DC: The for possible side-effects and poor adher­ International Bank for Reconstruction Prescribing PrEP ence. and Development / The World Bank. 7. Human Sciences Research Council Guidelines for the safe use of PrEP in Ultimately, PrEP has a significant (2014) The South African Marang Men’s MSM have been published by the role to play as one of the range of Project. Editor: HSRC. South Africa. Southern African HIV Clinicians Society HIV-prevention options MSM and Available at http://www.hsrc.ac.za/en/ and should be used when prescrib­ other high-risk groups can use to media-briefs/hiv-aids-stis-and-tb/marang (Accessed 12 Aug 2015) ing PrEP in SA.[12] Candidates for PrEP prevent becoming infected with are those at high risk of contracting HIV. This has been reinforced by a 8. Grant R, Lama JR, Anderson PL, McMahan HIV. The candidate should be HIV- recent announcement by WHO that V, Liu AY, et al. (2010) Pre-exposure Chemoprophylaxis for HIV Prevention in negative, have adequate renal function PrEP will be included in their revised Men Who Have Sex With Men. N Engl and should be tested for hepatitis B recommended HIV guide­lines due for J Med 363: 2587-2599. virus (HBV), although recent data publication in December 2015. It is 9. UK Medical Research Council (2014) have shown that PrEP use could be now important that PrEP demonstration PROUD: Examining the Impact on Gay safe for people infected with HBV.[13] projects in key populations such as Men of Using Pre-Exposure Prophylaxis. PrEP is prescribed for daily use, with MSM are conducted in SA as this Editor: Medical Research Council. http:// regular HIV tests conducted every three will pave the way for scaling up this www.proud.mrc.ac.uk/news/study_ results.aspx (Accessed 12 Aug 2015) months. Risk-reduction counselling is intervention for MSM, but also for all essential as is creating and supporting South Africans who may benefit from it. 10. Molina J, Capitant C, Spire B, Pialoux G, an adherence plan. PrEP is not meant Chidiac C, et al. On Demand PrEP With Oral TDF-FTC in MSM: Results of the to be lifelong and should only be ANRS Ipergay Trial; 2015; International taken during periods of highest risk, References AIDS Society Conference, Seattle. i.e. periods when the likelihood of HIV 11. Baeten JM, Donnell D, Ndase P, 1. Baral SD, Burrell E, Scheibe A, Brown exposure is highest. For example, if an Mugo NR, Campbell JD, et al. (2012) B, Beyrer C, et al. (2011) HIV Risk and HIV-negative MSM has a longstanding Antiretroviral Prophylaxis for HIV Associations of HIV Infection among Prevention in Heterosexual Men and sexual relationship with an HIV-positive men who have sex with men in Peri-urban Women. NEJM 367: 400-410. person, he may choose to take PrEP Cape Town, South Africa. BMC Public Health 11: 766. 12. Bekker LG, Rebe KB (2012) Southern African Guidelines for the Safe Use of 2. Lane T, Osmand T, Marr A, Shade SB, Currently, PrEP consists Pre-Exposure Prophylaxis in Men who Dunkle K, et al. (2014) The Mpumalanga have Sex with Men who are at Risk for Men’s Study (MPMS): Results of a of a combination HIV Infection. Southern African Journal Baseline Biological and Behavioral of HIV Medicine 13(2):40-55. regimen of antiretroviral HIV Surveillance Survey in two MSM Communities in South Africa. Plos One 13. Solomon M, Schechter M, Liu AY, Grant medication (tenofovir 9: e111063. R (2015) The saftey of pre-exposure prophylaxis in the presense of hepatitis and emtricitabine) taken 3. Lane T, Raymond F, Dladla S, Rasethe B infection. International AIDS Society J, Struthers H, et al. (2009) High HIV Conferece on HIV Pathogenesis, as an oral pill Prevalence Among Men Who have Treatment and Pevention. Vancouver. Sex with Men in Soweto, South Africa:

HIV Nursing Matters | September 2015 | page 29 The Health4Men Initiative: HIV and sexually transmitted infections

Kevin Rebe,1,2 Clarissa Arendse,1 Sue Ferreira,1 Glenn de Swardt,1 Helen Struthers,1,2 James McIntyre1,3 1 Anova Health Institute, Johannesburg and Cape Town, South Africa 2 Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, South Africa 3 School of Public Health & Family Medicine, University of Cape Town, South Africa

Many of the MSM who attend Health4Men clinics also have sex with women and do not identify as gay

Background HIV rates if they provide targeted key 1. Direct HIV and STI service provision population services. [8] This holds true at two Centers of Excellence and re­ Men who have sex with men (MSM) for South Africa (SA) where we have a lated support sites. are at increased risk of HIV infection generalised heterosexual HIV epidemic 2. Training and mentoring of state sec­ compared with their heterosexual and concentrated epidemics in key tor health care workers in MSM peers. [1-4] (See textbox for an expla­ popu­lations including MSM and sex sensitivity and skills competency. nation of the term ‘MSM’.) MSM are workers. MSM-targeted services are often reluctant to seek health care likely to provide positive overall country 3. Community engagement, outreach because of real or perceived stigma benefits in the response against HIV; and peer education activities to from health providers because of their a reason for this being that MSM may stim­ulate community aware­ness of sexual behaviours. [5] form a bridging population. Up to 50% of surveyed Soweto MSM reported they MSM frequently report that the state also had female partners. [4] Men who have sex with men health system is not responsive to their (MSM) refers to sexual behaviour medical needs. The combination of The Health4Men Initiative was devel­ and not sexual identity. The term higher HIV prevalence and incidence oped and implemented in 2008 by the ‘MSM’ simply describes the fact in the MSM population, together with Anova Health Institute to address these that such men have same-sex homoprejudice and discrimi­ ­nation in concerns.[6,9] Funding and support was sexual partners. The term does the state health care system means initially received from PEPFAR/USAID to not refer to identity, culture or that without a focus on providing implement a broad-ranging package of belonging to any specific group. MSM-specific HIV treatment, care and services aimed at improving the health For example, some MSM identify prevention, these individuals’ right to of MSM in SA. The initiative has been as homosexual (gay) and some adequate and competent health care successful and, in partnership with the MSM identify as heterosexual will not be met.[6,7] National Department of Health (DoH), (straight)despite having same sex MSM-competent services have expanded partners. Using the term ‘MSM’ Furthermore, researchers have demon­ from Cape Town and Johannesburg is more inclusive, especially in strated that countries that have both to over 200 trained and mentored Africa where many MSM do not generalised heterosexual epidemics public clinics across the country. Key consider themselves as ‘gay’ and and key population epidemics, will see components of the Health4Men Initia­ have no notion of a ‘gay identity’. benefits in their general heterosexual tive include:

HIV Nursing Matters | September 2015 | page 30 clinical update

relevant sexual health issues and the initiative. DoH district hospitals Community • Word of mouth • Events 4. A dynamic national sexual health Health4Men • Outreach workers campaign targeting MSM, initially DoH ARV clinics • Advertising In-house services • Social media focusing on Gauteng Province. • STIs • HIV & ART 5. The provision of support to MSM- • Mental health TB clinics focused, community-­based organi­ • Psychosocial & education sations to render direct services • Community education Hospital special units • ID & HIV units to MSM, with an emphasis on DoH and NGO HIV- • Research • Harm reduction • Liver unit conducting HIV counselling and test­ testing sites • Neurology unit ing (HCT). • Psychiatry • Urology 6. Deployment of diverse media plat- Health4Men outreach • Ano-rectal surgery HIV-testing sites • Dermatology ­forms to link MSM into care, including a dedicated cellular Figure 1. Referral pathways for Health4Men clinics. phone site for MSM (H4M.mobi) that directs them to their nearest, spaces only for ‘gay’ men. Many of the Scope of services competent public clinic. MSM who attend Health4Men clinics 7. Research relevant to informing SA’s also have sex with women and do not 1. HIV. The clinic offers a range of HIV response to HIV among MSM. identify as gay. services from testing, to monitoring and antiretroviral therapy (ART) where indi­ The clinics receive referrals from a cated. Testing is performed according Prior to approximately 2010, very little variety of sources and are networked to the DoH’s ACTS model, but with was known about the epidemics of HIV with other primary, secondary and appropriate counselling which is not and other sexually transmitted infections tertiary health services (see Figure 1 heteronormative and is accepting of (STIs) among MSM in SA. Since then, a above). MSM sexual behaviours.[12] Counselling large volume of research has confirmed that this key population has HIV rates of 10 - 39%, significantly higher than the general male population, and that STIs Table 1. HIV testing at the Ivan Toms Clinic in Cape Town. are also common.[10,11] HIV screening (includes only in-clinic screening and excludes off-site activities) Since the launch of the Ivan Toms (February 2009 – July 2015) Clinic, sexual health and wellness Total clients who received HCT 3 062 services have been provided to almost 8 000 MSM. This clinic is regarded as Tested HIV-positive 410 (13.3%) a flagship of the Health4Men Initiative Tested HIV-negative 2 652 (86.7%) and has become a site where best prac­ tice guidelines for the care of MSM Table 2. Current HIV treatment in Cape Town. have been developed, implemented and monitored. A second flagship clinic MSM receiving HIV treatment (antiretrovirals) via Health4Men* is now operating in Yeoville, Gauteng. (February 2009 – July 2015) Lessons learned from these clinics Total HIV-positive ever in care 1 887 serve as a template for medical service delivery and training of health providers Total HIV-positive remaining in care 957 in MSM health skills across SA. Total HIV-positive pre-ART (HIV wellness) 391 The Ivan Toms and Yeoville clinics Receiving DoH-sponsored ART 920 are positioned as primary-health-care First-line DoH regimen (2 NRTIs + 1NNRTI) 87% level, sexual health clinics, rather than HIV clinics. They are also positioned Second-line DoH regimen (2NRTIs + 1 PI) 13% as enabling health spaces for MSM * Excludes MSM who receive care at the clinic but obtained ART privately or to attend, irrespective of their identity, from an alternate source. cultures and traditions, rather than as

HIV Nursing Matters | September 2015 | page 31 also includes sexual risk-redu­ction ad­ visits revolve around STIs other than discharge, which is managed as per vice including discussions about anal HIV. Patients attending our clinic are DoH guidelines with ceftriaxone and sex. ARV initiation and selection are as not identifiable as HIV-positive because azithromycin. MSM are, however, for any adult in SA.[13] When prescribing they are attending an ‘AIDS clinic’. STIs more likely to be asymptomatic in the ART, consideration needs to be given thus serve as a hook to attract MSM face of an STI and the rates of gono­ to side-effects, which if experienced, into HIV care.[9] ccocal resistance to cephalosprins is could decrease adherence. Examples increasing. [17,18] Neisseria gonorrhea include avoiding nucleoside reverse A wide range of STIs is seen at the is becoming increasingly resistant to transcriptase­ inhibitors (NRTIs) which clinics. The most common conditions cephalosporins and this could lead to cause lipodystrophy in body-conscious are non-specific urethritis and syphilis. treatment failure in MSM. To date, four MSM and being aware of protease Genital warts are also extremely pre­ cases of resistant infections have been inhibitor (PI)-induced diarrhoea in MSM valent. More than half of clinic visits are detected among SA MSM and this is who practice receptive anal sex. Also, for STI symptoms rather than for HIV likely to increase.[18] Treatment failure additional care needs to be given to care. STI numbers from the Ivan Toms should be referred for assessment and adherence support, as MSM may not Clinic in Cape Town are shown in Table retreatment with alternative antibiotics. have the support they require from their 3 below. families or their communities. Conditions Human papilloma virus: This causes such as depression and alcohol and STIs are managed according to the sexual warts that are often difficult to substance abuse need to be addressed DoH’s syndromic guidelines document treat at primary health care level. Acids to support adherence.[14] See Tables 1 and are similar to management in such as podophyllin are difficult to use and 2 for indicators of HIV care. heterosexual men.[15] Although it is safely for anal warts, and cryotherapy not possible to discuss all STIs as they is often unavailable. The Health4Men ARVs can also be used for HIV pertain to MSM in this article, there are clinics have arranged for cryotherapy prevention in the form of post- (PEP) some important factors to consider and services to be available and are able or pre-exposure prophylaxis (PrEP). some specific examples are discussed to refer MSM with extensive or non- PrEP does not currently form part of below. responsive warts for surgical excision. the DoH’s HIV response plan despite Gardasil® vaccination should be ad­ mention in the National and various Syphilis: Syphilis rates are high among vised to all young MSM (9 - 26 years Provincial Strategic Health Plans. The MSM globally and have risen in many of age), but cost is currently prohibitive Ivan Toms and Yeoville clinics will be countries despite good risk-reduction and this vaccine is not available to men offering PrEP as part of a demonstration health messaging. MSM need to be in the state health sector. Vaccination project funded by the Elton John Aids screened frequently (6 - 12-monthly) would prevent warts and future penile Foundation during 2015 (Cape Town) if there is risk of exposure.[16] Clinical­ or anal cancers.[19] and 2016 (Johannesburg). PrEP can presentation may be atypical in that also be obtained in the private sector. syphilitic chancres can occur intra- Viral hepatitis: Hepatitis A, B and C anally and may not be visible to the can all be spread sexually by MSM. 2. STIs. Providing HIV and other STI patient or health provider. Treatment is MSM who are at risk (e.g. multiple services together at a single site has with intramuscular penicillin. sexual exposures, substance abuse or served the Health4Men clinics well. It abnormal liver function tests) should be assists in creating an enabling clinical Gonorrhea and chlamydia: The usual screened for viral hepatitis and referred space as approximately half of clinic symptoms include non-specific urethral for management if positive.[16]

Asymptomatic STIs: Many STIs pro­ Table 3. STIs at the Ivan Toms Clinic in Cape Town. duce no or minor symptoms that are STIs 2010 - 2015 unrecognised by MSM. Examples include viral infections such as viral Number of STI consultation visits 15 103 hepatitis and even HIV. Bacterial Number of patients with an STI 7 780 examples include gonorrhea and chlamydial infection, among others. Asymptomatic STI diagnosis 3 808 A recent study at the Ivan Toms Clinic found that one in four MSM screened New ano-genital fungal infection* 300 was positive for asymptomatic gonor­ *Approximately 10% of clients with STIs present with anal symptoms rhea or chlamydial infection despite a lack of symptoms.[20] The World Health

HIV Nursing Matters | September 2015 | page 32 clinical update

Organization recommends empirical 5. Lane T, Mogale T, Struthers H, McIntyre J, 15. South African Department of Health STI treatment for MSM who are at Kegeles SM (2008) “They see you as a (2015) Sexually Transmitted Infections. high risk of asymptomatic gonorrhea or different thing”: the experiences of men who Management Guidelines. Department of Health, South Africa. Available at: http:// [21] have sex with men with healthcare workers chlamydial infection. in South African township communities. www.sahivsoc.org/upload/documents/ Sexually Transmitted Infections 84: 430- STIguidelines-1-28-15(LC).pdf (Accessed 15 In summary, HIV and STI treatment for 433. Aug 2015). MSM at Health4Men clinics is similar 6. Rebe KB, Struthers H, De Swardt G, McIntyre 16. World Health Organization. (2015) to that for heterosexual men, with the JA (2011) HIV Prevention and Treatment for Consolidated guidelines on HIV prevention, addition of the factors discussed above. South African Men Who Have Sex With diagnosis, treatment and care for key All services are offered in an enabling Men. South African Medical Journal 101: populations. Geneva. Available at: http:// 708-710. www.who.int/hiv/pub/guidelines/ environment by staff who have received keypopulations/en/ (Accessed 15 Aug 7. Rispel LC, Metcalf CA (2009) Breaking extensive training to meet the needs of 2015). MSM patients in a sensitive and non- the silence: South African HIV policies and the needs of men who have sex with men. 17. Lewis DA (2010) The Gonococcus fights judgemental fashion. Reproductive Health Matters 17: 133-142. back: is this time a knock out? Sexually Transmitted Infections 86: 415-421. Lessons learned from the Health4Men 8. Beyrer C, Wirtz AL, Walker D, Johns B, Sifakis F, et al. (2011) The Global HIV 18. Lewis DA, Sriruttan C, Muller E, Goldparian clinics show that state-sector MSM- Epidemics among Men Who Have Sex with D, Gumede L, et al. (2013) Phenotypic and targeted health services are feasible Men. Washington DC: The International genetic characterization of the first two and implementable in South Africa. Bank for Reconstruction and Development / cases of extended-spectrum-cephalosporin- Such services are well received by gay The World Bank. resistant Neisseria gonorrhoeae infection in South Africa and association with cefixime 9. Rebe KB, De Swardt G, Struthers H, McIntyre and other MSM who have attended in treatment failure. Journal of Antimicrobial JA (2013) Towards “men who have se with numbers for a large variety of prevent­ Chemotherapy 68(6): 1267-1270. ion and treatment interventions. Word- men-appropriate” health services in South Africa. S Afr J HIV Med 14: 52-57. 19. Poynten IM, Tabrizi SN, Jin F, Hurley A, of-mouth promotion of MSM-friendly Hillman RJ, et al. (2014) Potential impact 10. Burrell E, Mark D, Grant R, Wood R, Bekker clinics, together with community- of human papillomavirus (HPV) vaccination LG (2010) Sexual risk behaviours and HIV- based work by peer educators and among HIV-positive and HIV-negative 1 prevalence among urban men who have homosexual men: vaccine-preventable anal ambassadors allied with nuanced sex with men in Cape Town, South Africa. HPV types in the SPANC study. Internaitonal health promotion material distributed Journal of Sexual Health 7: 149-153. Aids Society Melbourne, Australia. in places where MSM congregate, has 11. Rispel LC, Metcalf CA, Cloete A, Reddy V, 20. Rebe K, Lewis DA, Struthers H, De Swardt resulted in increased service utilisation Lombaard J (2011) HIV prevalence and risk G, McIntyre J. Asymptomatic Sexually practices among men who have sex with by MSM who perceive the programme Transmitted Infections among Men who men in two South African cities. Journal of as valuable to themselves individually have sex with men (MSM) in Cape Town; Acquired Immune Deficiency Syndrome and and to the MSM community. South African AIDS Conference. Durban, Human Retrovirology 57: 69-76. South Africa. 12. De Swardt G, Rebe K (2010) From top 21. World Health Organization (2011) to bottom: a sex-positive approach for References Prevention and treatment of HIV and other men who have sex with men - a manual sexually transmitted infections among men 1. Baral SD, Burrell E, Scheibe A, Brown for healthcare providers. Johannesburg: who have sex with men and transgender B, Beyrer C, et al. (2011) HIV Risk and ANOVA Health Institute. Available at: people. Recommendations for a public Associations of HIV Infection among men http://www.health4men.co.za. who have sex with men in Peri-urban Cape health approach 2011. World Health Town, South Africa. BMC Public Health 11: 13. South African Department of Health Organisation, Departments of HIV/AIDS. 766. (2015) National Conslidated Guidelines Geneva. Available at: http://www.who.int/ for the Prevention of Mother to Child hiv/pub/guidelines/msm_guidelines2011/ 2. Beyrer C, P. s, Sanchez J, Baral SD, Collins Transmission of HI and the Management en/ (Accessed 15 Aug 2015). C, et al. (2013) The increase in global HIV of HIV in Children, Adolescents and Adults. epidemics in MSM. AIDS 27: 2665-2678. South African Department of Health. 3. Human Sciences Research Council (2014) Johannesburg:. Available at: http://www. The South African Marang Men’s Project. sahivsoc.org/upload/documents/ART%20 Available at: http://www.hsrc.ac.za/en/ Guidelines%2015052015.pdf (Accessed media-briefs/hiv-aids-stis-and-tb/marang 15 Aug 2015). (Accessed 15 Aug 2015). 14. Stoloff K, Joske JA, Feast D, De Swardt 4. Lane T, Raymond F, Dladla S, Rasethe G, Hugo J, et al. (2013) A description of J, Struthers H, et al. (2009) High HIV common mental disorders in men who have Prevalence Among Men Who have Sex with sex with men (MSM) referred for assessment Men in Soweto, South Africa: Results from and intervention at an MSM clinic in Cape the Soweto Men’s Study. Aids Behavior 15: Town, South Africa. AIDS Behavior 17: 626-634. S77-S81.

HIV Nursing Matters | September 2015 | page 33 Yes, I am a sex worker; but first and foremost, I am also a human being

Michelle Robinson, BSc (Hons) Southern African HIV Clinicians Society

“Sex workers are mothers. They are health care. Sex workers are incredibly defaulting on treatment and running fathers. They are sisters and brothers vulnerable to abuse and stigma, which the risk of becoming ill or developing and sons and daughters. They work threatens their health in numerous ways. drug resistance. Maria emphasises, hard to put food on the table and to HIV prevalence rates among female “And then, once they are released, the care and provide for their families.” sex workers is estimated at 59.6%, go on to infect their clients, who infect ‘Maria’ (not her real name) is a compared to 13.3% in the general their wives and partners.” SWEAT and member of Sisonke, a human rights population, and the associated risk of Sisonke have embarked on a sustained movement which is run by sex workers contracting TB and sexually transmitted campaign for the decriminalisation for sex workers. Established by the Sex infections (STIs) is much higher among of sex work. This would make it more Workers Education and Advocacy sex workers. difficult to exploit and abuse sex workers Taskforce (SWEAT) in 2003, Sisonke and would bring about legislation to aims to unite and organise sex workers Police harassment is a big issue give sex workers occupational health across South Africa (SA) in order to for sex workers, with very negative and safety protection. Maria is firm on advocate for better living and working consequences for those who are HIV- this: “Sex work is work. It is a profession conditions. In SA, there are an estimated positive. Sex work is criminalised under like any other.” 130 000 - 180 000 sex workers, 90% the Sexual Offences Act, and if women of whom are female and 10% male or are found with more than four condoms Another important issue facing sex transgender. on them at once, police are able to arrest workers with HIV, STIs and other them as potential sex workers. Once health issues is that of marginalisation One of the issues Sisonke is focused they are locked up, there is no access to when attempting access health care. on, explains Maria, is that of access to their ARV medication, resulting in them Maria describes how sex workers

HIV Nursing Matters | September 2015 | page 34 profile article

and in addition, increases their risk of sex workers, as well as being better transmitting infections to their clients. equipped to understand their health Maria also points out that reproductive needs. Ultimately, though, Maria, health services are also denied to sex SWEAT and Sisonke all wish to bring workers. Some are forced to give birth awareness to the fact that sex workers at home as the result of being turned deserve to be treated with dignity and away from hospitals, others choose to respect when being treated by a health have illegal terminations after failing care professional. Maria says, with to obtain one in time from clinics who determination, “We won’t stop fighting, refuse to see them. Maria is quick to until sex work is decriminalised. We add that “It is not all doctors, not all won’t stop until we have the same rights health care workers who treat sex as everybody else.” workers this way. However, there are problems with people who disapprove Sisonke is a national sex worker of what we do and thus, judge us or movement formed in 2003. treat us with less respect than other It works alongside SWEAT to advocate for equal rights patients.” She adds, “It is very hurtful to for sex workers, to inform sex experience this. We are human beings workers about their rights through who have chosen to make a living this peer education, provide legal way. Perhaps we cannot make enough assistance to sex workers and money for our children’s education give them support in the form of another way. Perhaps our own lack of activities such as Creative Space are insulted or shouted at when at education limits our options in terms of workshops and work skills training the clinic to collect ARV drugs or test work. Some of us are educated, but courses. For more information for STIs. Some sex workers are too just cannot find another job.” Maria call +27 (0) 21 448-7875 or afraid to seek health care, as they suggests that sensitisation training be email [email protected]. The Sex Worker Hotline number is 0800 conducted to assist health care workers are afraid of how they will be treated. 60 60 60. This results in them becoming very ill, to feel more comfortable working with Experiences of a professional nurse working in Ebola- infested areas in Africa

Q&A with Anna Cilliers (professional nurse)

was actually relieved that at the time I care. In my training as a nurse, I had couldn’t even consider joining one of also learnt to counsel patients – which the Ebola teams. I expressed this notion became an essential tool in working to the MSF recruitment department. I in an Ebola project. One skill I had to suffer from claustrophobia and wearing learn, however, was getting dressed in the yellow Hazmat suit seemed like the protective suit. I also had four days something I wouldn’t be able to bear. of training on working with Ebola – on Secondly, these are malaria areas what to expect, how the CTCs work, where it is essential to use anti-malarial infection control, psychosocial support medication. I have always suffered and health staff. from severe side-effects from using anti-malarials, so that alone put me off What were your initial going to an Ebola project. impressions of the situation when you arrived? What made you change your When I arrived in Sierra Leone, I was mind? struck by the fact that most other health When faced with an unprecedented In September 2014, I was home for services in the country had either been outbreak, MSF rallied against the a month and started to reconsider my discontinued, or had been severely disease with a swift reaction and decision. MSF urgently needed more hampered by Ebola-related restrictions. creative strategies. MSF Southern staff for their Ebola projects in order Transmission so often happened at rural Africa sent more than 34 highly to try and bring the epidemic under and under-developed health centres, experienced people (professionals) to control, and I decided to take up the where infection control measures with join the massive Ebola response. challenge. elaborate protective gear were not always implemented. For that reason, Intensive care nurse Anna Cilliers Of all the countries where MSF many health centres were forced to was one such fieldworker who chose is treating Ebola, why did you close down in the country as they to travel to Sierra Leone to work at go to Sierra Leone? were unable to take the necessary Bandajuma in Bo, one of MSF’s Ebola I had a choice between going to Liberia precautions to prevent other patients Treatment Centres (CTCs) for five weeks and Sierra Leone. I chose to go to from contracting Ebola. Where they in 2014. Anna currently works as a Sierra Leone. I had previously worked stayed open, only non-invasive services Medical Focal Point for MSF Pakistan. in Liberia and was afraid I would not be were provided. Many pregnant women She also worked with MSF in South able to cope with the emotional trauma who would previously have been Sudan in 2013. of possibly seeing former colleagues helped by these centres were turned suffering from Ebola. away because health care staff did not Why did you decide to offer want to be exposed to the body fluids your services as a fieldworker Did you require any special related to the delivery process. in the Ebola response? training to work as a nurse in I was initially hesitant to work in an an Ebola context? What was your role as a Ebola project. When the outbreak As a nurse, one needs to be vigilant fieldworker in the Ebola happened I was on an emergency with infection control in any health Treatment Centre? assignment in South Sudan, working care setting. This basic nursing skill is As a nurse, I provided regular nursing in the midst of a cholera outbreak. I very important when it comes to Ebola care to patients. Once in full protective

HIV Nursing Matters | September 2015 | page 36 profile article

the high-risk zone is also limited. That was also challenging!

What did you find particularly difficult in your day-to-day life on the project? A no-touch policy is implemented throughout our Ebola assignments. But sometimes, a patient or a colleague would simply need a hug to comfort them. I wasn’t able to hug anyone unless I was fully protected by the Hazmat suit. That meant not even being able to hug fellow colleagues who might have had a challenging day. But the precaution was necessary, as one could not be sure who might be infected with the virus and who might not.

Were there any moments in particular that left a deep impression on you? It was a challenge dealing with the sadness that comes from patients dying inside the Ebola CTC. Staff in the CTCs gear, a nurse can touch patients and Was it a difficult decision to were not able to be around patients at provide, with challenges, the basic undertake work in an Ebola all times, so an even greater sadness care they need. This included cleaning context? came from knowing patients might soiled patients and beds when patients Before going to West Africa, I asked sometimes die while alone. Early in were too weak to clean themselves, myself if I was prepared to risk death the mornings, at 6:30am, I would visit administering the necessary oral and should I contract the disease. I had and talk to patients in the visitor’s area IV medication, inserting IV-lines, and to get my head around the idea of through the chicken wire separating drawing blood. I also ensured that what might happen before I left on my patients from their families. On my dying patients were as comfortable assignment. It’s getting easier for health visits the patients and I would count as possible, and helped feed weak workers to make the decision to go now, the days to help determine if they had patients. We asked healthier patients to though, because there is the possibility finally entered the stage that meant assist with cleaning and feeding when of receiving the vaccine to prevent the their chances of survival were high. My the medical staff were not present in infection. happiest moments came in informing the high-risk area. As the Medical Focal patients that their blood results showed Point at the MSF Ebola Treatment Centre How did you feel working in the they were free of the Ebola virus. where I worked, I was responsible for areas of the Ebola CTCs where the daily medical activities in the centre the risk of contracting Ebola What have you learnt from this and staff health care. was so high? experience? We were very careful to make sure the This experience confirmed to me that What stands out for you from full protective equipment was properly choosing to follow my heart first and your work in West Africa? fitted at all times – which means brain second is the right choice. I do of I was very humbled by my Sierra covering up from head to toe with course still contemplate things to make Leonean colleagues. As fieldworkers protective disposable material. I didn’t sure my decisions are made based on a with MSF in Ebola assignments, we find it too difficult to work in the what good balance of emotion and rationale only stay for a few weeks at a time. But was termed as ‘high-risk zones’ once I – but I believe one should take up the the staff who come from, live and work made a head shift about all the layers opportunities presented to us in life. in West Africa worked in these projects of personal protective equipment. The for months on end, risking their lives for Hazmat suits hinder real eye contact the men, women and children in their with patients – so that is something to communities. get used to. The time one can spend in

HIV Nursing Matters | September 2015 | page 37 IT’S MY LEGACY

L de Kock, BSc (Hons), MA Quality Improvement and Training Department, The Aurum Institute Improvement will only happen when it is planned for and when professionals like you and I see it as being central, rather than peripheral, to our professional roles

Have you ever had that moment when you stand back and think: what will people remember me for? What difference have I made with my time as a professional? I’m sure we all have, and continue to contemplate similar questions. As health care workers, we Not Poster child for have an awesome opportunity and professional professionalism responsibility to truly make our legacy at all felt and count. I despair at times when I hear questions/statements like, “Why should I do Quality Improvement (QI)?”; of people rank themselves between an 8 and a 10 (see above). When I ask for “QI adds too much work to my current qualities of a professional, I am flooded with a range of responses: load”; and “It’s not my job”. Today I hope to address such naysayers by Courteous Organised answering the question, “Why QI?”. Honest Punctual Good subject matter Respectful Ambitious knowledge Why QI?

I could very easily answer this question Not once, however, to my dismay, has By default, are we saying that simply by provi­ding a list of indicators whose anyone mentioned that a professional is ignoring targets and not doing much targets are currently not being met, and someone who meets targets! to improve performance month after we could quite simply close the debate. month is ok, acceptable, the norm and But today I wish to present a more im­ The Websters Ninth New Collegiate a mark of our profession? I truly hope passioned opinion as to why QI is not Dictionary provides a definition for a not! actually a choice, but rather a mandate. professional which includes “Conduct, I will do this by addressing two important aims or qualities that characterise or Not planning for improvement concepts: Professionalism and Humanity. mark a profession or a professional and not respond­ing appro­ person”. Surely one of these rules of priately to indicators that are 1. Professionalism conduct, aims or qualities that mark us not meeting monthly targets is as health care professionals, should not a mark of a professional! While conducting a number of QI be that of being target-driven and meetings and conferences recently, I had improvement-focused? Dr Joseph Juran, provided us with a the opportunity of asking col­leagues very insightful health management whether they considered them­selves We are not dealing with figures, trilogy known as the Juran Trilogy®. He as professionals. Without fail, 100% of but human lives. Our failure to stated that if we are to be successful in those in attendance de­clared themselves meet targets and improve is managing health, then the following as such. When asked to rank themselves not simply a loss of turnover or three aspects must be in place and on a scale of 1 to 10 in terms of profit – it literally can mean a applied: professional behaviour, the vast majority loss of life.

HIV Nursing Matters | September 2015 | page 38 continuous quality improvement

us to do this, we must begin to see the patient as central to what we do and not an inconvenient interruption.

Patient-centeredness should be our aim, our purpose and our outcome. If this truly is our purpose, then what would this patient-centred care really look like? Here are a few practical examples to illustrate the point:

a. Viral load (VL) completion rate

In order for us to meet the third ‘90’ of the current USAID Far too often we create yearly or monthly plans and design 90-90-90 goals, which prescribe that all those receiving ART all sorts of quality control measures to ensure that what we should have a durable viral suppression, we need to ensure have planned for actually happens; but unfortunately, the that we are actually taking bloods for the VL to be measured. improvement part of Jurans trilogy is lacking and often non- A low VL completion rate is a rather widespread problem in existent. The result is evidenced when we continue to miss many provinces in South Africa. Some very practical ideas targets month after month. Simply controlling and monitor­ing have been generated from a primary health care facility in each month will not bring about improvement. Improvement Ekurhuleni, which demonstrates how easy it can actually be to will only happen when it is planned for and when professionals put the patient in the centre of health care, and by so doing, like you and I see it as central, rather than peripheral, to our improve health indicators. professional roles. Through a Root Case Analysis (RCA) process, this QI team 2. Humanity identified four change ideas that have dramatically affected their VL completion rate: The second point to my argument of why QI is simply not • On a monthly basis, generate a list of eligible patients an option, centres on the principle of humanity; the quality using tier.net of being humane. Synonyms include compassion, brotherly • Call patients to remind them of their appointments love, fellow feeling, humaneness, kindness, kind-heartedness, consideration, under­s­tanding, sympathy, tolerance, goodness, • Implement a Fast Queue for VL good-heartedness, gentle­ness, mercy, charity, generosity. • Synchronise ART and VL visits – this can be achieved by Surely these have to be qualities synonymous with health care implementing the following schedule: professionals? Many of us have taken oaths to care for those who cannot care for themselves. In fact, the very first line of At 1 month: At 2 months: At 3 months: ART collection the Nurses Pledge of Service reads: “I solemnly pledge myself ART collection ART collection to the service of humanity and will endeavour to practice my + VL profession with conscience and with dignity”. At 6 months: At 12 months: ART collection Unfortunately, some of us have started taking ART collection + VL the ‘care’ out of ‘health care’. Our jobs exist to serve our patients and to ensure that they receive the best quality service and health we can possibly provide. In order for The new VL process is shown in the flowchart below.

One day prior See Pharmacy Viral load Yes doctor Data (dedicated capturer pre- pre-packs ART patients ART & places room) Symptoms retrieves files reception 1. Vitals in dedicated of patients 2. ART room Dispensary No Home

New VL process

HIV Nursing Matters | September 2015 | page 39 continuous quality improvement

The impact of these changes to the VL completion rate can be seen in the line graph to the left (top).

b. TB screening

Many patients have to wait hours in waiting rooms until they are seen for a consultation. During the consultation, a nurse or doctor will screen them for TB and then obtain the required sputum. Unfortunately, many courier companies who collect the daily specimens, do so in the mornings. Patients who have been waiting all morning to see a clinician and who are required to produce a sputum are too late for that day’s cou­ rier and are therefore asked to return the next day so that their sputum can be collected and transported on the same day to the laboratory. A patient-centred Old process approach can quite easily be achieved

by screening patients while they wait, YES before a consultation. If there is a need for the client to produce sputum, they can do so while waiting to be consulted NO and the courier can take that sputum to the laboratory on the same day. Refer New process to the flowchart to the left (middle). YES A clinic in Bojanala district is currently testing this idea and their initial results are NO very encouraging (bottom left diagram).

Conclusion

QI cannot, and should not, be seen as an option, or something to be done only when there is time or a mandate in place. As professionals, constant striving to meet targets and improvement should be our ‘mark’ – a mark so compelling and consuming that it drives us on a daily basis. Our patients are not unmet targets, but human beings who deserve our best, and deserve services designed with their best interests at heart.

References 1. http://www.juran.com 2. http://www.sanc.co.za/aboutpledge. htm

HIV Nursing Matters | September 2015 | page 40 AWAC C 9TH ANNUAL WORKSHOP ON ADVANCED CLINICAL CARE - AIDS

www.awacc.org 19 - 20 November 2015 Elangeni Hotel, Durban

Online registration is now open: www.awacc.org Enquires to: [email protected] Twitter: @awacc_aids

Answer the quiz on page 44 and you could win one of two free

HIV Nursingentries Matters to this | Septemberconference 2015 | page 41 Competition HIV/TB nursing

Working in the TB room as a nurse is a very challenging task because you are faced with more than TB. Most patients with TB are also co-infected with HIV, so the TB nurse has to be extremely knowledgeable about both infections. A TB nurse has to work with a high volume of patients and s/he risks becoming infected with TB her/himself.

We want to hear about your experiences working as an HIV/TB nurse. What strategies do you use to support patients through treatment for both diseases? How do you keep them motivated, ensure they come for their appointments, make sure people living in the household are investigated, etc.? We would love to publish your strategies for success in HIV Nursing Matters.

Submit your typed piece, not exceeding 1 000 words, by 1 November 2015 and stand a chance to win a free, one-year membership to the Southern African HIV Clinicians Society; and have your piece published in HIV Nursing Matters!

One winner will be chosen by 15 November 2015. The winner agrees to the publication of the story in the December 2015 issue of HIV Nursing Matters and to submit a picture to accompany the article. The judges’ decision is final and no correspondence will be entered into. Please note that only typed stories will be considered. Please submit via email to [email protected]

HIV Nursing Matters | September 2015 | page 42 August 2011 / page 43 August 2011 / page 43 what to do what to do

Quiz questions for September 2015

1. What is the maximum number of days that an individual be detained at Lindela Detention Centre?

Answer……………………………………………………………………...... ………………….

2. Who can be detained at Lindela Detention Centre?

Answer………………………………………………………………………...... ……………….

3. True or False: The Southern African HIV Clinicians Society’s guidelines can be used when prescribing pre-exposure prophylaxis (PrEP) in South Africa?

Answer………………………………………………………………………...... ………………..

4. Currently, which combination of ART can be used when prescribing PrEP?

Answer……………………………………………………………………...... ………………..

5. True or False: ART can be used for HIV prevention in the form of PrEP or post- exposure prophylaxis (PEP)?

Quiz answers from Answer……………………………………………………………………...... ……………….. 2015 the June Issue 6. Which vaccine can be used to prevent warts? 1. 56%

2. Sex workers and Answer………………………………………………………………………...... …………….. communities with limited or no access to medical 7. In which year was the resolution to improve health systems responses for services migrants passed? 3. True Answer………………………………………………………………………...... …………….. 4. False (19.4%)

5. A high-tech digital x-ray 8. Which age group of girls does the SAfAIDS Young Women Leadership (YWL) Programme train? 6. 259% Answer…………………………………………………………………………...... ……………. 7. Emotional and practical needs 9. Where in Africa does the SAfAIDS YWL Programme take place? 8. 9 - 70% Answer……………………………………………………………………………...... …………………. 9. Sex Worker Education and Advocacy Task Force 10. How many people were infected with Ebola in Guinea, Sierra Leone and 10. 59.8% Liberia?

Answer………………………………………………………………………………...... ……….

HIV Nursing Matters | September 2015 | page 44 wherewhere to go to go

NDoH/SANAC The AIDS Helpline a national toll-free service, operates on a 24/7 basis and Nerve Centre Hotlines is utilised by people from all walks of life in urban and rural areas, in all 11 Any HCT concerns from facility and languages at no cost from a landline district managers should be telephone. reported to the NDoH/SANAC Annually, the Line provides anonymous, confidential and accessible telephonic Nerve Centre Hotline and AIDS Helpline information, counselling and referrals to specific emails for each province: over 300 000 callers. 0800 012 322 The AIDS Helpline plays a central • Western Cape: 012-395 9081 The National Toll-free AIDS Helpline role in providing a deeper preventive [email protected] was initiated in 1991 by the then and more supportive service to those • Northern Cape: 012-395 9090 National Department of Health’s infected and affected by HIV/AIDS, [email protected] (NDoH’s) “HIV/AIDS, STDs and TB but also serving as an entry point in terms of accessing services from • Eastern Cape: 012-395 9079 Directorate”. The objective of the Line is to provide a national, anonymous, government, private sector and other [email protected] confidential and accessible information, NGOs/CBOs. • KZN: 012-395 9089 counselling and referral telephone [email protected] service for those infected and affected Cases presented range from testing, • Free State: 012-395 9079 by HIV and AIDS, in South Africa. treatment, transmission, TB, medical what to domale circumcision, etc. [email protected] In 1992, LifeLine was requested by • 012-395 9087 Mpumalanga: NDoH, to take over the management The AIDS Helpline incorporates the [email protected] of the Line by rotating it between the Treatment Line. The treatment support • Gauteng: 012-395 9078 32 existing community-based LifeLine services were included to complement [email protected] Centres, and manning it with volunteer the services provided by lay counsellors counsellors. In 2000, in response to on the line. The Treatment Line is • Limpopo: 012-395 9090 an increasing call rate, a centralised manned by nurses who provide quality, [email protected] Counselling Centre was established in accurate, and anonymous telephone • North West: 012-395 9088 Braamfontein, Johannesburg, to house information and/or education on [email protected] the AIDS Helpline. antiretroviral, TB and STI treatment.

HIV Nursing Matters | September 2015 | page 45 dear clinician

ASK THE EXPERT

If you have any HIV/TB clinical questions, send them to “Ask the clinician” via [email protected] and you will get an answer in the next issue of HIV Nursing Matters. If your question is urgent, then please state so on your email and the answer will be emailed back to you and still be published in the magazine.

Dear clinician

For how long do we give co-trimaxazole to a patient who is HIV-positive?

Dear nurse clinician

Patients receiving co-trimoxazole should continue taking it until their CD4 count rises above 350 cells/µl. For more info see: http://bit.ly/1JbixME

HIV Nursing Matters | September 2015 | page 46 SOUTHERN AFRICAN HIV CLINICIANS SOCIETY

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