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May 13
Working at the coal-face of our HIV response

This week we will be profiling some our incredible staff who work at the coal-face of our HIV response.

Today we introduce Hlengiwe Masuku, Psychosocial Care Advisor in eThekwini.

“I provide support and counselling for clients who are newly diagnosed with HIV, as well as supporting youth clubs in peer education, and referring clients on to other government services like accessing childcare grants.

My role involves a lot of work with the youth on HIV, sexually transmitted infections (STIs) and teen pregnancies as well as HIV testing and treatment.

After the patients learn their status, I come in to do ‘deep counselling’, because most of the time, they are in shock. I ensure that by the time they leave the health facility, they have a clear understanding of what is going on and what is going to happen in their life. If they take treatment, they need to know all the side-effects. I also do follow-up to see how clients are getting along with their treatment − especially the youth, as they tend to be in denial about HIV.

Even if clients test negative for HIV, I still do health talks to tell them how to stay negative and how to protect themselves, and also educate them about STIs and pregnancy.

We face different challenges with different groups of clients: Men don’t like to test at all. They have a fear of knowing their status, a fear of stigma. Men really don’t like to come to health facilities because they say they are treated unfairly. They will come and test and be initiated on antiretroviral treatment, but then you never see them again. This means that their viral load will never be suppressed and they will continue to spread the virus.

Even if they start treatment, it is difficult to get them to adhere to the regimen because they don’t want to be seen going to the clinic and coming back with a parcel of medication. They believe that everyone will say that they on ART, even if they are picking up pills for another chronic disease like diabetes.

One of the initiatives to assist our clients with this concern is the Chronic Central Medicines Dispensing and Distribution (CCMDD) programme, which enables patients who have been stable on their medication for 12 months to collect pre-packaged medication discreetly from a number of convenient pick-up points, including retail stores like Clicks. 

I’d say that about 80% of youth understand what HIV is. The problem is that knowledge does not protect them from the circumstances in which they find themselves. If a teenage girl lives in a home where there is no food, she will have transactional sex to get groceries. Those older men hold all the power, and make it clear that they will not buy groceries for the girls if they don’t have sex without a condom, so it’s difficult to say that these girls are making a choice. Do they let the family starve or do they put their own lives on the line? Others are attracted to older men because they want fancy things like weaves and cell-phones. They feel they will never find jobs anyway, so this is their only chance to get the things they see others having.

I find it very sad to see more teen pregnancies and HIV infections resulting from this trend.

The youth are also affected by the culture of crime and violence in South Africa. I had a young client who came from the rural areas and was totally lost. Her father had been quite a tough guy, who owned a shebeen. He was shot dead and after he passed, she went looking for men to play that protective role. She ended up with three children and being infected with HIV because she was looking for love which she was not getting from her mother at home. 

Many of our children have lost their parents in terrible conditions or have even been abandoned by their grannies. We need to remember that these children are orphaned, growing up without love or guidance, and then going on to repeat the cycle with their own children.

We must reach the 90-90-90 targets and ensure that 90% of HIV-positive people know their status and are adhering to treatment so that they become virally suppressed and can no longer pass on the virus.

I do this work because I want to make sure that young people have the opportunity to live full and healthy lives and leave a strong legacy of children who know their value in this world.”​

April 24
Breaking the cycle of HIV for my daughter

"My mother died of AIDS, and recently, at the age of 22 I was also infected.  But I am going to make sure that I break this cycle for my daughter," says Pearl Ngcobo*.

At first glance, Pearl looks like any other young student at the UNISA campus in Pietermaritzburg, but it soon becomes apparent she has not had an easy life.

"I started attending the clinic because my friend told me that you can get a Pap smear here. Our SRC also told us that the clinic is for students so that they can test for HIV, TB and STIs."

Pearl says that the campus clinic is ideal, as she was unable to use the health facility in her home community due to ill-treatment and lack of confidentiality by clinic staff.

"At the clinic they keep the consulting room door open and everyone in the queue can hear your business. Also the nurses will tell your parents if you come to the clinic. I know this because our neighbour works at the clinic and gossips about everyone and their medical issues."

Pearl says that the on-clinic campus, which uses a youth-friendly approach, has made her much more comfortable about seeking health care. "When I come here I feel much better and more grounded. It's because we have this clinic and these nurses are different that made me ready to test for HIV," she explains.

"When I first started feeling sick, I was quite traumatised and couldn't think straight. The nurse here was very calm and reassured me that even if I were HIV-positive, it's not the end of the world. She told me that HIV is a chronic condition like any other and can be managed with medicine. Nowadays it is only one tablet a day."

Pearl's fiancé is also HIV-positive and accuses her of infecting him, which created a lot of turbulence in their relationship. She brought him to the clinic when he also started showing signs of illness.

"He has changed his ways since we came here and got counselling and medical help. Our CD4 counts were very low, so we had to learn to eat healthily. The clinic also gives us Bactrim for opportunistic infections."

For Pearl this is history repeating itself.

"My mother died of AIDS when I was seven and I was raised by my grandparents. They never actually disclosed to me that she had AIDS, but they would throw it in my face during arguments. They also have a lot of anger towards my father and say that he is useless."

Pearl says that this information made her feel worthless and that it didn't matter what happened to her. She started drinking heavily and taking umgwinyo (Ecstasy). "It really helped me to forget a lot of painful things."

She warns that girls from rural areas who are not used to city life should be cautious about embarking on relationships with older men, whether they be on campus or beyond it.

Pearl says that since attending the on-campus clinic, she has met people who are more supportive and make her feel more hopeful about her future and that of her four-year-old daughter. Her child was one of the major reasons she wanted to test for HIV and go on treatment.

"My daughter is HIV-negative and it is going to stay that way. She will not grow up without me. I am going to stay alive so that we don't repeat the same pattern. It ends with me."

Nkule Majola, an HST Nurse Clinician, says that the focus is on offering comprehensive services in a private, welcoming, non-judgemental and friendly atmosphere.

"When liaising with university management, we learned that they have an enrolment of about 12 000 students and daily student walk-ins of about 800 who come to campus to access the library and study groups. With such a high number of students, setting up this clinic was an absolute must!"

"My approach to the students is not just to offer clinical assistance but also psychosocial care. In providing health care, we aim for a holistic approach dealing with the whole person," she explains.

March 22
Educate yourself to fight TB


Photo: Rogan Ward

Carol Zulu may only be 18, but she knows enough about communicable diseases to take care of her own health.

Last year the Grade 12 student from Mpophomeni became ill with flu-like symptoms that she couldn't shake for over a month.

"I lost my appetite, had night sweats and bad pains in my arms and shoulder and feet.  I went to see a private doctor but he said the only problem was that I am overweight so he didn't test me."

Her health continued to deteriorate so a week later she decided to go to the local clinic to test for TB.

"I know the symptoms of TB because I studied it in LO (Life Orientation) class at school. I was still very sick so I went to the clinic and the nurses asked about my symptoms and gave me a sputum test. When the results came back they said I had TB. They also tested for HIV but luckily I am negative.

They also found I had gout in my shoulder and feet from TB."

Other members of her household were also tested for TB and educated on protecting themselves with measures such as opening windows and ensuring that the home is well ventilated.

"My family really helped by reminding me to take my pills, even when I didn't feel like it because the medication made me dizzy. I was on treatment for six months and completed the course of medicine in January this year".

20190320_RWX4614.jpg Photo: Rogan Ward

She says she faced some stigma from girls at school who spread rumours that she was also HIV-positive because she had TB. "I told my teacher at school and some of my close friends. I lost weight when I was sick so people talked behind my back and said I have HIV. They think everyone with TB also has HIV, which is not true."​

She now goes out of her way to educate her peers and neighbours about how to stay TB-free.

"Some people don't know about TB so I advise them that if they have any symptoms they must be tested immediately before it gets too bad."

She says that she pays no attention to the gossipers because "I know my status so I don't care what they say." She continues to encourage others to test for both TB and HIV and to challenge denial: "I tell my friends that we are living with these diseases around us so there is no point in denying it. The only thing we can do is to try to protect ourselves and get tested and treated if you start feeling ill. It really is that simple." ​​


​IN 2017: ​

322 000 people fel​l ill with TB

= 187 000 males, 135 000 females, 38 000 children

  • 220 163 TB cases notified​​​​
  • 101 837 people not notified or not diagnosed​​

8 000 TB dea​ths (including 56 000 deaths among people living w​​​​ith HIV)​

​TB treatment coverage was 68%, and treatment success rate was 82% (operational End TB target is 90% by 2025)

​14 000 people fell ill with drug-resistant TB; 10 259 were notified and put on treatment

​193 000 people living with HIV fell ill with TB; 12 148 were notified; 109 799 were notified and are on ARVs. HIV is by far the highest risk factor for TB infection.

​​​53% HIV-positive people (newly enrolled in care) were on TB preventative treatmen​t​


Source: WHO Global TB Report using South Africa data for 2017


March 12
Prevention is better than cure

The winner of this year's Emerging Public Health Practitioner is 26-year old Kganetso Sekome, a lecturer in public health and community physiotherapy in the health science faculty at the University of the Witwatersrand.

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Sekome won the prize for his submission on clinical practice guidelines for stroke patients in rural hospital settings.

"I first heard of this award in 2015 when one of my lecturers from UKZN won it.  I was so inspired by it being won by someone I knew.

When I was doing my community service in a rural hospital in r Bushbuckridge, I realised that my colleagues weren't using the stroke guidelines or were unaware of them. If these patients don't get the proper treatment after a stroke they could die or become disabled.

When I work with patients I emphasise that it is important to have the family involved throughout the whole rehab process, so that the treatment is sustainable.

Non-communicable diseases like diabetes and hypertension can lead to strokes and this is sadly becoming more prevalent due to lifestyle changes, genetics and a Westernised diet with too much salt and sugar.  There are efforts underway to reduce sugar, such as the "sugar tax" which is already affecting the way people consume cold drinks. But we also need to be aware of how we are training our children's palates when we routinely add unnecessary salt and sugar to food we prepare at home.

We must focus less on curative and more on preventive medicine. We are successfully treating HIV and TB so people are living longer but we now face the challenge of an increase in rising non-communicable diseases.

I'm from Bushbuckridge and I know that people have lost faith in the public hospitals because of poor service delivery.  I grew up in this context so I can relate to the concerns and issues of the community. Each year I send my students to Bushbuckridge for community service and clinical training so that they can give something back and ensure help deliver high quality care.

I hope this award will inspire my students and peers, as well as anyone else thinking about going into public health. We need to tell young public health practitioners not to be intimidated and go ahead and apply for this award. I am still in disbelief that I am the recipient of the emerging public health practitioner award, this recognition will enable me to grow my network and meet people in the health systems trust that I can collaborate with and learn from.


March 08
Girls clubs provide a safe space for young women

​​​On this International Women's Day, we wanted to bring you a good news story about empowerment programmes for girls and young women that deliver results!​

We have all read the worrying statistics from districts like uMgungundlovu in KwaZulu-Natal, where at least one in every five adolescent girls and young women is living with HIV, and by age 16, one in every 10 women accessing antenatal care is HIV-positive. 

What you may not have heard about are the organisations working tirelessly on programmes to reduce the risks of girls and young women becoming infected with HIV. The Community Media Trust (CMT) is running a programme to end the economic exclusion and social isolation that often put girls between the ages of 10 and 24 at risk of HIV infection.

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Heading up the Girls' Clubs programme, which is implemented in Pietermaritzburg and Durban in KZN, are Lerato Maloka and Debbie Van Zyl.

"The pressure that women receive – from society, religion, culture, tradition as well as the biological expectations around childbearing and raising children – make it difficult for women to find themselves," explains Maloka. "The Girls' Club programme has provided a platform for young women and girls to explore and find themselves, and it has been exciting to see these seeds planted, and watching them grow and develop."

The Girls' Clubs are run by local female mentors, aged 18 to 30, who are able to relate to participants' unique experiences and challenges. Weekly meetings of each club of about 20 adolescent girls and young women (AGYW) cover a curriculum on HIV and sexual and reproductive health topics, social skills, safety planning, and financial literacy. Mentors make use of storytelling and role-play to improve AGYWs' negotiation skills and sense of self-worth. ​​​​​​​

"Participants of the Clubs have fun while building friendships and learning important knowledge and skills to help guide them safely through adolescence," says Van Zyl. "An additional bonus has been seeing the mentors blossom into confident, empowered young women, developing their knowledge and skillsets, furthering their own career paths, and accessing much needed employment opportunities." 

The Girls' Club sessions take place in walkable communities and in safe spaces. AGYW in need are referred to appropriate services delivered at local health facilities, including for HIV testing and counselling, and comprehensive sexual and reproductive health, as well as those offered through other partners providing such services in the local area.

The intended impact is to build the protective assets (health, social, cognitive and economic) of the beneficiaries to empower them to transition safely from adolescence into adulthood.

The community mentors trained by the programme say that it is an enriching experience which benefits them as much as their mentees. "As a mentor in my community, parents started to entrust their girl-children with me," says Sanelisiwe Mbatha from CMT in Pietermaritzburg.  "They saw that the programme brought such a positive impact in their lives. I also gained a lot of insight from my interactions with the young women I was working with."

Thandi Phoswa from the Richmond Caregivers Organisation, with which CMT has partnered to implement Girls' Clubs in the past, agrees: "Our area is deeply rural, so people in our community do not want to teach their girls about sex. The project has brought a change to the people's mindset, has brought transformation and brought hope. We are so grateful to DREAMS for giving us this life-changing opportunity."

Maloka says that while the programmes are delivering much-needed services and support to girls and young women, on this International Women's Day we need to stop and take stock of the status of women. "I believe that until society and culture changes the way that women are viewed and treated, we will not make the progress needed in order for all women to be safe and empowered and able to achieve their dreams."

October 16
Developing a model for strengthening community health worker programme implementation in South Africa - Rene English

HST's Naomi  Massyn attended the 5th Global Symposium on Health Systems Research held in Liverpool, where she presented a poster on behalf of Rene English, HST's director of Health Systems Research.

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The poster on "Developing a model for strengthening community health worker programme implementation in South Africa" is available below.​​​​

October 15
@#HSR2018 - HST lead author Dr Linda Mureithi presented the findings of a qualitative multi-case study

​@#HSR2018 - HST lead author Dr Linda Mureithi presented the findings of a qualitative multi-case study: 

 "Emergence of three general practitioner contracting-in models in South Africa", published in the International Journal for Equity in Health and co-authored by Mr Michael Burnett, Mr Adam Bertscher and Dr René English. 

The paper explores the early inception and emergence of the GPCI and describes three models of contracting-in that emerged and interrogates key factors influencing their evolution. Findings from the decentralised-purchaser model show the importance of local context, provincial capacity and experience for influencing evolution of the models.​

The published article can be accessed here:

October 12
Meaningful partnerships for health − the role of communities

Neziswa Mdaka, Cross-site Facilitator  for HST's SA SURE Plus Project, attended the session hosted by Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), entitled 'Meaningful partnerships for health − the role of communities'.


The presenters were Gavin Reid (GFATM), Kumanan Rosanathan (World Health Organization), George Ayala (The Global Forum), Helen Chorlto, (Pediatric-Adolescent Treatment Africa − PATA) and Jerome Pfaff (United Nations Children's Fund – UNICEF).

It is clear that as we celebrate the 40th anniversary of the Alma Alta Declaration, there has been little progress towards one of its core principles − community involvement in the strengthening of health systems. As we move forward in the era of Sustainable Development Goals, we must consciously embed people-centred approaches and sustainable community participation for stronger health systems. ​

This requires navigating through legal issues associated with community engagement and power relations, and respecting the human rights facets of gender, religion, culture and language. Strong leadership means relinquishing power to others.


October 12
Back to the future: Making the global health agenda local with a return to Alma Ata

by Jackie Smith – SA SURE Plus Programme Manager

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This session was run by Save the Children and focused on the importance of governments allocating sufficient funds to primary health care (PHC) so as to provide a stable platform of quality for universal health coverage (UHC).

The examples shared came from countries outside of South Africa, but some of the recommendations apply very aptly to the South African context. Notably, a case study from Zimbabwe reported that, against the backdrop of an 85% unemployment rate, the issue of collecting taxes to pay for UHC is almost a non-starter, as most of the recipients are living below the poverty line.

Nonetheless, it is encouraging to hear that with Zimbabwe's change in leadership, civil society has been afforded a more participatory role in discussions on health budgets, leading to some promising results.

Key conclusions:

  • No country will achieve UHC without first providing PHC for all.
  • Governments should mobilise domestic resources to increase investment in PHC.
  • How money is spent is as important as how much is spent.
  • External donor support should be invested in strengthening PHC.
  • It is impossible to measure what we don't know. Analysis of expenditure against programme performance is crucial.
  • PHC is about serving communities and therefore, civil society and community governance structures should play a key role in health budget discussions.


October 10
HSR2018: 5th Global Symposium on Health Systems Research: Liverpool, UK – 8 to 12 October 2018


Ronel Visser, Director of Health Systems Trust's Health Systems Strengthening Unit, attended a panel discussion that focused on identifying the challenges and opportunities for improving uptake of evidence in the journey from research to policy and practice.

The panellists' key observation was if researchers do not formulate a pivotal question – based on the policy-makers' and practitioners' requirements for new knowledge – from which a valid hypothesis and related intervention can be focused, the investigation will lack relevance for policy development and implementation.

In such instances, quantitative and qualitative findings that may be valuable on some grounds are not applicable for specific policy measurement, improvement or efficacy goals – and therefore are not or cannot be used as intended.

An ill-informed or inadequately defined research question lacks the contextual foundation needed to make decisions on the scope, study sample, objectives, methodology and desired data for collection and analysis. These decisions will in turn guide choices for administration and general resourcing of the project in terms of technical expertise, time and money. Overall, the successful design of an appropriate investigation hinges on a sound research question. ​​

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