As people shun clinics, doctors fear a non-Covid-19 death spike

Thousands of South Africans are avoiding health facilities, shunning life-saving treatment out of fear of being infected by Covid-19 and being harassed by police.

Even mobile clinics that provide HIV, TB and contraceptive services have reported a huge drop in clients – possibly because all health services are being associated with Covid-19.

“Head counts at some Johannesburg clinics are down by between 30% and 70%,” says Professor Francois Venter, an infectious diseases doctor at Wits University’s Faculty of Health Sciences. 

“These clinics are delivering absolutely essential services. We are going to spend the next six months cleaning up this catastrophe – the lack of contraception leading to unintended pregnancies and increased demand for terminations, diseases from lack of immunisations, untreated diabetes. We are likely to see a wave of mortality linked to HIV and TB. The HIV and TB programmes have been doing well and we could lose all that progress,” adds Venter, who is also a member of the Ministerial Advisory Committee on Covid-19.

Periodic clinic closures when health workers test positive for Covid-19 has fuelled community fear of being infected if they venture into clinics.

The health department “has observed this legitimate fear” people have of health facilities, says Popo Maja, the department’s director of communications.

“We are developing messaging to encourage people to observe the Covid-19 preventative measures when accessing health services – wearing masks, sanitising hands and physical distancing. The managers at our facilities have also been requested to ensure that stringent infection control measures are adhered to throughout the facilities.”

Anele Yawa, the Treatment Action Campaign’s (TAC) general secretary, says that while he “appreciates our government’s efforts on Covid-19, we are really dropping the ball when it comes to HIV and TB”.

“What is coming out from our consultations with provinces is that clinics have stopped offering viral load or CD4 testing for people with HIV,” says Yawa. This means that health workers won’t be able to tell whether ARVs are working to suppress the HIV.

During the Level 5 lockdown (from 27 March 2020 to 1 May 2020), new TB tests plummeted by almost half, according to a report by the National Institute for Communicable Diseases (NICD).

The NICD report blames this “dramatic decline” in tests on the lockdown’s restrictions on movement and a lack of public transport.

But Lebohang Mokgate, chairperson of TAC’s Vukuzakhe branch in Gert Sibande district in Mpumalanga, says many people avoided clinics because of security crackdowns.

“People are scared because the police are everywhere and they do beat people,” said Mokgate, who is based in Volksrust. “They arrested a man who went to fetch his ARVs because he wasn’t wearing his mask. He showed them his ARVs, but he still spent the night in prison and had to pay a R1,000 fine.”

Yawa agrees: “The militarisation of the Covid-19 response has caused fear and resistance. Many people have been shot at and harassed. Some people in rural areas, who have to walk a long way to fetch medicine, were afraid to do it because they did not have a permit to travel. The police and army could have approached this in a different way by showing that they were there to help communities.”

Thousands of people living with HIV have defaulted on their antiretroviral drugs and TB medication. In Gauteng alone, almost 11,000 HIV and over 1,000 TB patients failed to collect their medicine since the lockdown started on 27 March, according to the provincial health department.

TB is South Africa’s biggest killer and an estimated 63,000 people die of the bacterial disease every year, followed by diabetes. We have the biggest HIV epidemic in the world, with almost eight million South Africans living with HIV – one in five of those aged between 15 and 49.

Impact on TB

Countrywide, entire TB hospitals and wards have been converted to address Covid-19 while staff have been redeployed. Many community health workers who used to trace TB defaulters have been redirected to do Covid-19 screening.

Recently, nurses protested the conversion of Empilweni TB Hospital in Port Elizabeth to a Covid-19 facility. Meanwhile, TB wards in various hospitals, particularly in the country’s pandemic epicentre, Cape Town, are now Covid-19 wards.

Dr Anja Reuter, Medecins sans Frontieres’ medical manager of drug-resistant TB (DR-TB) in Khayelitsha, is worried about how few new TB and DR-TB patients have been detected since the start of the pandemic.

“There is a significant overlap of Covid-19 and TB symptoms as both may present with fever, feeling unwell with a cough or tight chest,” says Reuter, but because of the focus on Covid-19, TB cases might be overlooked. “Healthcare workers need to be trained to detect both.”

She is also concerned about whether current TB patients are able to take their medication, particularly if they are going hungry: “DR-TB patients have to take up to 20 tablets, many of which cause nausea. This is very challenging on an empty stomach.” 

Treatment for DR-TB is long and the medication can have debilitating side effects, so most patients qualify for a temporary disability grant, but the government has suspended new applications for temporary disability grants because of Covid-19.

“If people can’t get access to this grant, this might affect whether they adhere to treatment,” says Reuter.

Integrated approach

“I have been grappling with how we can integrate Covid-19 into our services, as it is an infectious disease and another health priority alongside HIV and TB,” says Professor Linda-Gail Bekker, Chief Operating Officer of the Desmond Tutu HIV Foundation. 

“Infection control is key to protect staff. We are looking into installing perspex screens between staff and patients and having consultations outdoors.”

The foundation operates five mobile clinics, providing HIV, TB and contraceptive services to almost 100,000 people in under-served Cape Town communities. But demand for their services was “almost zero” during Level 5 of the lockdown, adds Bekker.

“We usually do 40 to 50 HIV tests in a day. [Last week] we were doing 10. People are worried. Health facilities are being seen as places of contagion. There is also confusion about what people are allowed to do under lockdown. Our staff also express anxiety about going into people’s homes and communities to do tests.”

Meanwhile, TAC’s Yawa is concerned about the large numbers of South Africans who might simply stop taking their ARVs. 

“Covid-19 efforts should be integrated with HIV and TB services. When community health workers are doing screening for Covid-19 cases, they should screen for HIV and TB also. Contact tracers looking for Covid-19 contacts should also look for people who have defaulted on HIV and TB treatment. South Africa initiates a lot of people on ARVs and a lot of people default – even before Covid-19.”

Alison Best, communications manager for the NGO, TB HIV Care, says her organisation has worked with the Department of Health in eThekwini to screen street-based people for both TB and Covid-19, and hopes HIV and TB screening and testing can be integrated into “mass community screening for Covid-19”.

The department’s Maja says the government is trying to ensure integration: “We have had discussions with the SA National AIDS Council and Covid-19 testing has now been integrated into the Cheka Impilo wellness campaign, which tests people for HIV, TB and non-communicable diseases.

 “We are very worried that if we don’t integrate TB and HIV services with Covid-19, the gains we have made against our country’s high burden of diseases will be erased.” 

Keeping vulnerable patients out of facilities

The SA HIV Clinicians’ Society recommends that stable HIV patients are given six months’ supply of ARVs, which would alleviate the problem of people not fetching medicine because they want to avoid clinics.

But this has been complicated by the fact that the department is in the process of changing all patients on first-line ARVs from tenofovir, emtricitabine and efavirenz (TEE) to the less toxic tenofovir, lamivudine and dolutegravir (TLD) combination.

In a letter to provincial health departments, Deputy Director-General, Dr Yogan Pillay, recommends that all patients are given a three-month supply of TLD. 

But clinics in Gert Sibande have only been able to dispense one or two months’ supply, according to a rapid survey conducted by TAC. Mokgate said nurses had told her they were scared of running out of stock.

Meanwhile, Reuter says that people with TB or DR-TB are at high risk of severe Covid-19 illness so routine clinic visits should be decreased.

“But patient support needs to continue, and can be done through telephonic counselling and adherence support, and patients identifying a treatment buddy or supporter at home,” says Reuter.

Safer spaces

Venter and Bekker both feel that a lot more can be done to keep people safe while taking public transport and where people congregate.

“I see red when I see people on top of each other in food queues or queuing for social grants,” says Venter. “This is where there is a role for police to enforce physical distancing.”

Meanwhile, Bekker says she is for “smart distancing”, which prohibits large gatherings indoors such as church services and funerals where viral transmission is relatively easy.

Venter believes non-pharmaceutical interventions (NPI) such as handwashing and masks should be pursued single-mindedly, particularly on public transport: “Everyone getting onto a taxi must get hand sanitiser, taxi drivers must wear the best masks and there must be hand-washing facilities at taxi ranks.”

Yawa laments that local taxis don’t adhere to lockdown regulations, which prescribe that they should only carry 70% of capacity, and says that they don’t offer passengers hand sanitiser.

“A long time ago, we learnt lessons about stopping the spread of TB in taxis, including by getting people to wear masks, reduce crowding and open the windows. People didn’t listen to us then, but perhaps they’ll listen now,” says Bekker. DM/MC

Kerry Cullinan is the Health Editor at openDemocracy.