Did you know that the best way to reduce new HIV infections is to ensure that patients remain on treatment and become virally suppressed?
An innovative case management approach, introduced by Health Systems Trust in uMgungundlovu District, is helping patients to stay in the system, adhere to their treatment, and become virally suppressed.
uMgungundlovu District in KwaZulu-Natal currently has the highest HIV prevalence in the world.
Case management focuses holistically on each individual and recognises the variety of factors that affect patients' ability to adhere to treatment, from transport and nutrition to depression and family problems. Case Managers develop a comprehensive plan for each client that focuses on both psychological and clinical care.
Phetha chatting with her case manager Nokwanda Mbele
Ntombenhle Phetha (33) was about to stop taking antiretroviral medication when an HST Case Manager contacted her and changed her mind.
"The Case Manager came to my house just after I'd decided I wasn't going to go back to the clinic, because I was very unhappy with the care I was getting there. It was always difficult for them to find my file and the nurses spoke badly to me. I'm also being treated for depression and they would call me for an appointment on one day for my psych meds and on another day for my ART. Sometimes I would queue for hours only to find they didn't have stocks of the medicine I needed."
Unemployment and poverty also leads to patients quitting ART because they don't have enough food at home. "It is difficult for people to take their treatment without eating a meal first. How can you take meds on an empty stomach?" says Phetha.
Phetha is a lesbian, which has created many family problems. "These problems led me to think about suicide quite often, which is why I got depressed and had to take these psych meds."
Nokwanda Mbele was assigned to Phetha's case and has been instrumental in keeping her on treatment. "Nokwanda had noticed that I'd been missing my clinic appointments. I told her I wanted to stop treatment or move to another clinic. Nokwanda promised she would take care of my case so that I don't have to queue for such a long time. She also arranged for me to collect both my treatments at one appointment. I feel like I have a champion, someone who is on my side when I come to the clinic."
Phetha says that she feels much stronger now Nokwanda is acting as an advocate for her as a patient. Nokwanda helps her to remember to take her medications and to attend her clinic appointments. "If I have problems, I can call and explain to her. This makes me feel I am not alone."
Once Phetha has completed 12 months on treatment, and is clinically stable and virally suppressed, she will graduate to the CCMDD programme, which allows her to collect her medication from a convenient pick-up point such as a retail pharmacy without having to queue at the clinic.
Siboniso Cele (39) is a security guard and the father of one child. He works 12-hour shifts in a post far out of town, which makes it difficult to get to the clinic during opening hours.
"This system is much better because now I queue for a maximum of 30 minutes. Before we would wait a very long time, even the whole day.
The Case Manager helps me to keep my appointments by phoning to remind me. After one year, if I am stable on my treatment, I'll be able to join CCMDD and my medication can be collected by someone else from a place like Clicks, or on my way through town to work, I can just stop and collect my medicine."
Cebisa Ngcobo (39) says that the new system not only helps her to maintain her treatment, it also keeps her safe from crime.
"Before this new system, I would have to queue at the clinic very early in the morning while it's still dark. If you came later, you would end up waiting the whole day. When we walked in the dark we would get robbed by the tsotsis who would take our phones and even steal our antiretroviral medicine.
But now my Case Manager helps me to set a convenient time for my appointments and I don't even wait more than 10 minutes. I'm so happy with this system that I encourage others who have been put off by bad experiences in the past to return to the clinic; I tell so many people about it that they say it's like I'm advertising. That's good. People must know that things are getting better now."
Jabulani Mkhize (24) is a chef and has been on ART for almost a year. He says that the introduction of the case anagement system has definitely helped him to adhere to his treatment. "My Case Manager will call to make sure that I can attend my appointment."
"If you know your status, you don't need to be ashamed. Life goes on."
He says that the stigma around HIV is decreasing in his community: "People are more educated about HIV now, to the point that we can even joke about it with our friends. There are also other people in our family on treatment. I am gay and I think there is much more stigma about my sexual orientation than my HIV status. Some of the counsellors and nurses at clinics should be educated on how to engage with us and how to ask questions sensitively."
"Case management entails closer and more regular communication with patients – proactively managing their condition before they withdraw or disappear from clinic engagement," says Nomvula Radebe, HST's District Co-ordinator for uMgungundlovu. "This begins the minute after diagnosis, so that there is no delay in linkage to care. The key actions are clustering, documenting and reminding – all the while carrying the patient through a supportive care plan."
To access the first edition of HST's Phakama Digest – which features an in-depth perspective on the technical aspects of implementing the HIV Case Management Model – go to: https://www.hst.org.za/publications/HST%20Publications/PHAKAMA%20DIGEST%20July%202019.pdf
Thandeka Radebe (31) is a Youth Ambassador, focusing on the lesbian, gay, bisexual, transgender and intersex (LGBTI) sector. She is originally from Mpophomeni in KwaZulu-Natal.
"As youth, we are not only infected and affected by HIV, but we are also located within a complex set of social ills such as violence, youth unemployment and gender-based discrimination, which are all root causes of HIV.
A young woman who tries and fails repeatedly to find a job is vulnerable to 'blessers' – older men with money. She needs to engage in this kind of transactional relationship to survive and help put food on the table at home.
We also see a sharp rise in HIV infection among young men who are not gay, but are sleeping with other men just to get money. These young men are not educated about keeping themselves safe when they have sex with other men.
Many lesbians in the townships do not feel safe in their own communities because of this thing called 'corrective rape' − when men attack and rape lesbians, saying that they will 'convert them to be straight'.
As a woman in South Africa, you are not safe. If you are a lesbian, you also have to worry about being targeted by people who want to rape and kill you for being a lesbian. These are the things we are facing.
So, it's important that we understand this full picture when we are trying to address HIV. If we don't understand this complex context, it will be difficult for initiatives to make any headway.
I'm lucky in that I personally have never encountered any real negativity or lack of acceptance for being lesbian; but across the country, especially in townships, I notice that there is still an 'us and them' situation between homosexuals and heterosexuals. People say that they accept you, but you will still hear homophobic comments.
Sometimes the people making these comments don't seem to understand how prejudiced they are. So, if they see a picture of a lesbian couple, you will hear comments like 'Oh, she's so beautiful. How can she be a lesbian? What a waste!' How is a woman being loved by another woman 'a waste'? Because she is not sexually available to men?
People also seem to think that if I'm a lesbian I'm not actually a woman. They literally say: 'I don't see you as a woman'. This is not real acceptance − it is maybe tolerance. Those are not the same thing.
There's a long journey ahead and a lot still to be done. People still think that 'intersex' is the same as 'transgender'.* Lesbians are still called 'gays', even though that is a word that refers to male homosexuals. Bisexual people are called 'twin plugs' which is very disrespectful.
I joined HST's team of SA SURE Youth Ambassadors because I want to educate young people about LGBTI issues and human rights in general.
We need to deal with the many root causes of HIV to put a serious dent into this epidemic.
* 'Intersex' is a general term used for a variety of DSDs (Disorders of Sex Development) are medical conditions involving the way the reproductive system develops from infancy (and before birth) through young adulthood.
* 'Transgender' relates to a person who suffers gender dysphoria or a feeling that they have been 'born into the wrong body'.
My name is Khawulani Dinangwe. I'm 32 years old and I am a Nurse Clinician at Health Systems Trust. I went to school in the deep rural areas, near Underberg and close to the Lesotho border. After school I moved to Pietermaritzburg to further my studies. I fell in love with nursing because of my background, coming from a community with a high prevalence of HIV and TB where I saw the terrible impact of these diseases.
I grew up wanting to be part of the forces helping to combat these diseases and help the community. I finished my Diploma in General Nursing in 2010, and then did community service in a hospital near my family home. In 2012 I did a Postgraduate Diploma in Primary Health Care, and completed a number of short courses such as Nurse-initiated Management of Antiretroviral Treatment (NIMART).
In 2017 I joined HST, which has given me the opportunity to reach my dream of working with communities to combat HIV and AIDS. Working for the SA SURE Plus Project has enabled me to work hands-on in our focus on reaching the UNAIDS 90-90-90 targets to help end the AIDS epidemic by 2020.
'90-90-90'; means that 90% of all people living with HIV will know their HIV status, 90% of all people with diagnosed HIV will receive antiretroviral therapy (ART), and 90% of those on ART will be virally suppressed.
Viral suppression means that the ART medication has reduced the number of copies of the virus in the person's blood. This does not mean the patient is cured; the HIV virus remains in the body, but in such small quantities that it is undetectable. If the person stops taking ART, their viral load will increase again and they can become very ill.
One of the challenges we face is the high rate of clients defaulting on their treatment, or clients not attending follow-up appointments at the clinic to collect medication. One of my clients, a 20-year-old woman, had been on ART for three months, but during the fourth month she missed her appointments, and came to the clinic two weeks later than scheduled. When I asked why she hadn't been to fetch her medicine on time, she said that she had "extras" at home.
When I asked why she still had medication left over, she replied that when she started ARVs, she was unable to take them at home because she was afraid that her parents would find out and she would be in trouble. We gave her ongoing counselling and she decided to start again, stick to the regime and keep appointments.
Clients like this woman need the help of support groups and ongoing counselling, especially when families respond negatively to disclosure of HIV or taking ARVs. It is really important that thorough counselling is given before ART initiation to make sure that clients can raise and discuss any concerns or obstacles they might face. Now we give her counselling every time she comes to collect her medication.
It's also very important to form adherence clubs in the community. This helps to reduce stigma, provides peer support, and guides clients in adhering to their medication so that they can be healthy and strong.
Thandeka Simelane (24) feels as if HIV was a bullet she couldn't dodge.
She did her best, went to school, stayed faithful and found a job as a domestic worker to support her family. She met her partner and they became engaged in 2013.
"He paid half my lobola and we had a child in 2016," she says. "I thought everything in my life was going well. Then last December my boyfriend went home and while he was away he cheated on me with someone who is HIV-positive. My cousin died of AIDS some time ago, and I still remember it. I don't want to die like that."
Shortly afterwards, community health workers were doing door-to-door HIV testing and she agreed to be tested, with the thought of her fiancé's infidelity on her mind.
"I'm so glad Mfundo (the community health worker) came here because I am pregnant again and too busy working and coming home late, so I would not have been able to go to the clinic for testing. My fiancé wasn't home so I asked him to come back on the Sunday. Mfundo counselled us both together and then tested us."
For Simelane, her initial horror at getting a positive HIV diagnosis has given way to calm acceptance after counselling. "I learned that I can give birth to an HIV-negative baby and I am already enrolled in PMTCT (prevention of mother to child transmission) so I am not worried. I know that if I take my medication I will be fine."
While she is clear that this is not what she wanted for her life, she feels it was almost inevitable. Her goals were a good education and a better life for her children.
"If it wasn't for my fiancé I would still be HIV-negative. But now I am staying with him because we are both HIV-positive. Even if I leave this man and find another one, they will want to have unprotected sex. So it's better we don't keep spreading this thing."
Simelane says that the outreach by community health workers like Mfundo* is invaluable. "I can't disclose to my family because they talk too much and will tell the whole world. I'm afraid of going to the clinic because the sisters shout at you and say 'why are you having sex so young?' It's better to have people like Mfundo who come to our house."
Simelane says that one of the unexpected advantages of being tested and treated as a couple is that she and her fiancé are now communicating much better with each other.
"Can you believe it?' she asks, seized by peals of sudden laughter. "Since we were diagnosed we have been using condoms – and he says it feels just the same!"
Mfundo Dlungwana is just 34, but he has seen it all in his young life. He has been a Lay Counsellor for six years and works for AFSA (AIDS Foundation South Africa). AFSA uses strategies such as door-to-door testing to ensure that they reach as many clients as possible.
"Men don't want to be tested, but as a man I know how to explain to them the importance of testing. I explain to them that HIV is treatable and is just like any other chronic condition such as diabetes. Men say 'we came from a vagina and that is how we will die'. I remind them that it is mostly men who infect women so they need to take responsibility."
Dlungwana says that poverty is a key driver of HIV in uThukela District. "Most of the 'sugar daddies' in this district work in government; they have cars and lots of money. Even if they know their status, they won't use condoms. So you will see a man who is about 45 with a young woman of 16. It's very common."
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.”
"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.
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".
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."
Source: WHO Global TB Report using South Africa data for 2017
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.
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.
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.
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."
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.
The poster on "Developing a model for strengthening community health worker programme implementation in South Africa" is available below.
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