Before 2000, the health situation in South Africa was dire: AIDS was killing 1,000 people daily. The drugs needed to treat HIV existed but they were priced far out of reach for the vast majority of South Africans - U$10,000 per year, for life. Pharmaceutical companies manufacturing antiretroviral (ARV) drugs refused to lower prices, or allow generic competition. Treatment required complicated cocktails of expensive drugs.

Dr Eric Goemaere and colleagues opened MSF’s first HIV treatment programme in South Africa in 2000, in Khayelitsha. Sick people flocked to the MSF clinic seeking treatment. At first, MSF was only able to treat 180 people with ARVs, forcing clinic staff to make harrowing choices of who would receive care—and who would die. “The majority of people [coming to our clinic] could not walk anymore. They were brought literally in wheelbarrows or carried on the backs of their relatives. People were dying in the waiting room,” Dr Goemaere recalls. Later they relied on generic drugs smuggled in from Brazil.

Back in 1997, President Nelson Mandela’s government passed an act that allowed the health minister to cancel patent rights to essential drugs or import generic versions in order to make low-cost medicines available to people who need them. The Pharmaceutical Manufacturers’ Association (PMA), a group representing 39 pharmaceutical corporations, responded by suing the South African government, claiming this act contradicted the country’s constitution and a new international agreement on intellectual property rights by the World Trade Organisation.

Uniting MSF and activist groups like the Treatment Action Campaign, the protracted case culminated in 2001, on the back of MSF launching the “Drop the Case” global advocacy campaign. Within weeks, MSF’s online petition garnered 250,000 signatures from people in 130 countries, including many public figures. Bowing to pressure the PMA formally dropped the case in April 2001.

In 2002, the MSF team presented results from the Khayelitsha project at the 14th International AIDS Conference. The findings were impressive: two years after the program’s launch, 91% were still adhering to their treatment, allowing HIV-positive people to live longer, healthier lives and preventing transmission of the virus.

In 2000 an estimated 4.2 million South Africans were infected with HIV. Promising scientific evidence from clinics in Thailand showed that the proper administration of a drug called AZT, or zidovudine, during pregnancy could halve the chances of transmission of HIV from an infected pregnant mother to her foetus. This treatment protocol came to be known as prevention of mother-to-child transmission (PMTCT).

Despite scientific evidence on the effectiveness of PMTCT, the AIDS-denialist views of then-President Thabo Mbeki and former health minister Manto Tshabalala-Msimang significantly delayed developing a national PMTCT program – resulting in thousands of infant infections and subsequent deaths. A landmark court case brought against the South African government by the Treatment Action Campaign ensured the drug nevirapine was made available nationally by order of the Constitutional Court in 2002 and a national PMTCT program was eventually implemented in 2004.

Prior to that MSF was clandestinely treating patients with unregistered ARVs. The provincial government of the Western Cape started the first PMTCT program in South Africa in Khayelitsha as a demonstration project at primary-healthcare-level in 1999 – despite opposition by the Health Ministry. The University of Cape Town was tasked with the monitoring of this pilot, and MSF offered technical support.

After complex negotiations, MSF opened the first service for pregnant, HIV-infected women requiring antiretroviral therapy (ART) in Site B, Khayelitsha in February 2000. MSF extended the HIV services and ART to everyone who was eligible, according to World Health Organization guidelines, and to two further sites in Khayelitsha. However, legal and regulatory barriers to generic ARV imports delayed services and drug supplies until 2001

In 2011, MSF started an ambitious project in partnership with the KwaZulu-Natal Department of Health, building on the success of patient-centred community models of care. The project is a partnership with the provincial health department and other NGOs, covering ten clinics and two hospitals in the Eshowe and Mbongolwane districts. It employed a range of community-based interventions and collaborations – from partnerships with traditional healers and home-based HIV testing, to supporting health facilities and training nurses – to change the course of the HIV/TB epidemic in a rural area with a very high rate of HIV.

In 2019, MSF announces that the project surpassed the United Nations HIV program’s ambitious 90-90-90 targets, a year ahead of the deadline.

UNAIDS targets for 2020 were: 90% of all people living with HIV should know their status; 90% of those diagnosed with HIV should be on antiretroviral therapy (ART); 90% of those on ART will achieve a viral load that is undetectable. The results from MSF and Epicentre’s 2018 community survey were a resounding 90-94-95.

The 90-90-90 target is an important indicator of the success of a country’s HIV response, with South Africa’s national results estimated at 85-71-86. The results of the survey there support MSF’s view that community-level interventions can successfully reach and directly support more people living with HIV, who do not access conventional health services, such as hospitals, which is key to getting ahead of the HIV epidemic.

“In the early days of this project, it was almost impossible for people to even imagine talking about HIV. Today people even stop our MSF vehicles and ask for an HIV test. I would say it is the power of partnership. We didn’t do it for the community, we did it with them,” Musa Ndlovu, former MSF deputy project coordinator explained.

Tuberculosis (TB) is South Africa’s deadliest infectious disease. Until recently, globally recommended treatment options available to people with Drug Resistant-TB (DR-TB) took up to two years to complete and included up to 14,000 pills and painful daily injections that caused devastating side effects, including deafness, persistent nausea, and psychosis.

Due to rising numbers of patients with DR-TB, in late 2007, MSF collaborated with local health authorities to pilot a model of care in Khayelitsha that moves management of DR-TB out of overburdened hospitals, and closer to where patients live and work. This community-based patient-centred model of care, enabled clinicians to diagnose and manage stable TB patients at a primary care level throughout treatment, while the smaller proportion of unstable patients were referred for hospital admission.

Early successes of the decentralised model saw increased case detection, strengthened patient support, improved rates of early treatment, decreased time from diagnosis to treatment initiation, improved infection control measures in healthcare facilities, and more effective treatment regimens, as well as cost savings from limiting hospital stays.

As part of its decentralised DR-TB program, MSF also provides strengthened treatment regimens. However, challenges remain due to the provision of adequate DR-TB patient adherence support and access to shorter, less toxic, and more effective DR-TB treatment regimens. Newer oral DR-TB drugs, such as bedaquiline, linezolid, delamanid and pretomanid, significantly improve DR-TB cure rates and cause fewer side effects than injections, but remain largely inaccessible. Ultimately, orally administered drugs also mean that people can take their medication at home, with even fewer visits to primary healthcare facilities.

In response to clinical research and targeted advocacy efforts from MSF and the Fix The Patent Laws Coalition, including a global campaign by MSF alongside people living with TB in 2019, the pharmaceutical company Johnson&Johnson reduced the price of bedaquiline by nearly a third, to US$1.50 per day, in June 2020.

In 2007 MSF began assisting vulnerable migrants, asylum seekers and refugees in South Africa in two projects – one in central Johannesburg and another in Musina, along the border with Zimbabwe.

MSF’s Johannesburg inner-city clinic at the Central Methodist Church provided primary healthcare, mental health support, and referrals to access care in the public health system. As well as newly arrived Zimbabweans temporarily resident in the church, patients came from over-crowded inner-city slum buildings with poor sanitation and limited access to water. Aside from HIV, patients were treated for diseases directly linked to unhygienic living conditions, such as TB and gastrointestinal conditions.

MSF’s activities in Musina responded to an influx of asylum seekers and migrants fleeing political violence and economic collapse in Zimbabwe. MSF soon began also treating migrant workers on a belt of farms along the border. By 2013, MSF-run mobile clinic teams visited farms regularly. To reduce the risks seasonal workers faced running out of ARVs when they returned to Zimbabwe or moved to another farm, MSF provided three-month buffer stocks of drugs and specific information about where to obtain more drugs at their destination.

In 2008 tens of thousands of foreign nationals fled violence in the Gauteng province and again in Durban on South Africa’s east coast in 2015. MSF teams provided medical care and water sanitation services to residents in displacement camps, offering regular mobile clinic consultations, treatment and referrals to hospitals; providing medication for chronic conditions like HIV and TB as well as mental healthcare support. From 2017, onward MSF teams have responded to sporadic impacts of xenophobic violence on healthcare access for vulnerable people.

In 2018, following five years of vigorous advocacy and MSF participating in South Africa’s clinical access programme for the new oral DR-TB drug, bedaquiline, and the country became the first in the world to include bedaquiline as part of its standard recommended treatment. This achievement helped phase out painful, toxic injections and increase access to more effective, more tolerable treatments – a long-standing goal for MSF internationally.

Years of advocacy by MSF and Fix the Patent Laws (FTPL) coalition led the South African government’s newly released intellectual property policy reforms to stop a process blindly handing out patents to pharmaceutical corporations, providing hope to people across South Africa who cannot afford the medicines they need to stay alive and healthy. Until this policy change in 2018, the patent registration system that allowed pharma to easily obtain multiple, undeserved patents on a single drug and charge exorbitant prices, without substantive review.

By partnering with health activists from Section27 and the Treatment Action Campaign MSF formed the FTPL to advocate for amendments to patent laws to prioritise public health and access to affordable medicines. Since 2011, the FTPL coalition grew to include 40 organisations representing a range of disease areas including HIV, TB, cancer, sexual health, non-communicable diseases and mental health. 

This work continued the legacy of MSF signing onto the Durban Declaration at the 13th International Aids Conference in 2000, joining a 3,000 strong march pushing for access to affordable drugs and AZT/ nevirapine for all pregnant women. Ongoing of advocacy efforts in coalitions on the cost of a first-line ARV regimen in the country has dropped the price by 96% since 2000.

In South Africa, sexual violence is a huge problem: 1 in 4 women has been raped in her lifetime and just 1 in 25 rapes is reported to the police. To add to the trauma of sexual violence, survivors often face lasting consequences such as HIV, unwanted pregnancies, and enduring psychological trauma.

Barriers to survivors getting care include the low number of health facilities equipped to provide services, and the fact that most are hospital-based in urban areas. In response, MSF partnered with provincial health authorities in the North West Province to establish of dedicated SGBV clinics at the primary healthcare level since 2015. The objective was to expand access to free, high quality and confidential care for survivors of sexual and gender-based violence in Rustenburg’s Bojanala district, through dedicated clinics, known as Kgomotso Care Centres (KCC).

The KCC model was developed after a 2015 MSF survey showed only 1 in 20 women who had experienced sexual violence reported to a health facility for care. The survey indicated that 1 in 5 SGBV facilities offered no mental health services, 45% didn’t offer any counselling services for children, and nearly 40% provided no suicide risk assessment.

MSF’s approach treats sexual violence as a medical emergency and prioritises the immediate and holistic longer-term health and wellbeing of survivors. Patients who require further care are referred for acute mental healthcare needs, placement at shelters and support to access to legal services.

Located within community health centres, closer integration with community outreach activities to raise awareness and linking survivors of sexual and intimate partner violence to a wide range of comprehensive services, including safe abortion care, became possible.

KCCs are a one-stop shop where MSF teams, including forensic nurses, psychologists, registered counsellors, social workers and support staff provide survivors with an essential package of free emergency and follow-up care. All staff working in KCCs, including MSF drivers who pick up survivors and transport them to centres, are trained as first-responders to SGBV cases.

Working with the North West province health authorities, MSF has expanded access to free, safe abortion care, as part of a comprehensive set of services for survivors of sexual and gender-based violence in Rustenburg.

MSF also supports termination of pregnancy services for women who request a termination of pregnancy (ToP). Some have been using contraception that failed, or ran out due to interrupted supply. Some have been coerced into pregnancy; or become pregnant due to sexual violence.  Others have faced financial and emotional hardship, with and without partners or family support. Unsafe abortion is a procedure for terminating an unwanted pregnancy either by persons lacking the necessary skills, or in an environment lacking minimal medical standards, or both, which can in with life-threatening consequences including severe bleeding, infections, poisoning, uterine perforation or damage to other internal organs. Women who undergo unsafe procedures may need a blood transfusion, major reparative surgery, or a hysterectomy. Some will be permanently disabled, and some will never be able to carry a child again. 

In Rustenburg, two MSF nurses performed between 90 to 100 procedures a month in two community health centres in 2018, indicating a significantly unaddressed need in the community.

While legal in South Africa, there is still a lack of providers and many women still struggle to access safe abortions. MSF responds to the life-preserving needs of people. As a medical humanitarian organisation, MSF provides access to safe abortion care available, which dramatically reduces maternal mortality. ToP should be a safe and effective medical act, managed with tablets (‘medication abortion’) or a minor intervention under local anaesthesia (manual vacuum aspiration, or MVA).

In 2004, after a highly publicised court battle, government AIDS denialism and intense advocacy, patient education and empowerment by the Treatment Action Campaign, South Africa finally began its national roll out of ART.

MSF had started the first patient on ARVs already in 2001 in a Khayelitsha project with provincial support and ethics approval from the South African Medical Association to demonstrate the feasibility of providing ART in resource-limited settings. Without generic ARV drugs in the country then, MSF could only afford then to put 180 people on branded ARVs at very high cost.

By 2002, across three primary clinics in Khayelitsha, MSF had started 600 adults and children on ART. At the 14th International Aids Conference, MSF presented the Khayelitsha project results showing that 91% of patients were successfully retained on ART. The project received international recognition from the WHO and UNAIDS as a best practice model for scaling up resource-limited HIV/AIDS treatment programmes. In the same year, MSF opened a project in Lusikisiki, in the Eastern Cape, to prove the feasibility of large-scale provision of ART in a rural setting, with TAC supporting on community education activities.

Since the national ART roll-out, the models of care have evolved to maintain best practice.  In 2006 in Khayelitsha, MSF focused on nurse-led services and by the end of that year, ART care and treatment initiation had become fully decentralised to two clinics. In 2007 MSF piloted the first adherence clubs in Khayelitsha for stable HIV patients to maximize clinic efficiency and support to patients. By 2008 more than 10,000 people had been initiated on ART in Khayelitsha through seven sites in the MSF programme, up to 10 patient adherence clubs were active, and MSF began offering second- and third-line ART regimens.

At the end of 2010, all clinics in Khayelitsha are providing ART and TB treatment. In that same year, MSF handed over 11 health facilities to the City of Cape Town. In 2011, Western Cape health authorities adopted MSF’s patient adherence club model for the City of Cape Town, including Khayelitsha, as well as the MSF model of decentralized DR-TB care across its eight districts.

The innovative Stop Stock Outs Project (SSP) began in 2013 after six civil society organisations came together to tackle the crisis of chronic shortages of essential medicines and children’s vaccines in South Africa. Following strike action by Mthatha pharmacy depot workers resulting in widespread stock-outs at clinics across the Eastern Cape in 2012, MSF collaborated with Section 27, the Rural Health Advocacy Project, Rural Health Doctors Association of Southern Africa, the Southern African HIV Clinicians Society and the Treatment Action Campaign to address the urgent need to monitor stock-outs of essential drugs in primary healthcare facilities, throughout the country.

From stock-outs of anti-retroviral therapy and TB medicines to contraceptives, not only is people’s health put at risk but the reproductive health rights of women are under threat while poor and rural-based patients are hardest hit when money is spent on unnecessary journeys to and from health facilities when their medicines are not available.

Independent periodic SSP surveys on drug stock levels help to assess the extent and impact of stock shortages across public sector clinics nationwide. In addition to surveys, SSP mobilizes patients and healthcare workers to report any medication stock outs that have resulted in treatment being changed, patients being turned away from their clinic and referred elsewhere, or being given an insufficient supply of medication, via Please Call Me, SMS, phone call, email or directly to their website.

Despite the existence of several government initiatives aimed at maximising access for health services, unreliable supply chain and inefficient stock monitoring systems issues persist in South Africa. SSP monitors stock-outs through a ‘hotspot’ mapping process, consistently and swiftly sounding the alarm with the health authorities and others. A growing cache of patient and healthcare worker testimony and data analysis has helped SSP to identify and understand the root causes of medicine shortages so that they, in turn, can offer technical support and advocacy to reduce essential medicine shortages across the country.