Carletonville: Working together for health

Brian Williams and Catherine Campbell report on a community that is committed to preventing the spread of HIV/Aids.

A small town on the West Rand, Carletonville is dominated by the gold mines. It is home to 70,000 miners and 250,000 people who live in the township of Khutsong and the informal settlements that surround the mines. The choice of this site for the Epidemiology Research Unit’s three-year project, which is concentrating on reducing sexually transmitted disease (including HIV), was strongly influenced by the presence of a grassroots pressure group, the Carletonville Aids Action group. Made up of nurses, social workers, trade unionists, local politicians, local health-service providers, traditional healers and religious leaders, the group had been trying for three years to get an Aids project off the ground.

The action group joined the committee overseeing the ERU project, along with representatives of three mining houses, national and provincial health departments, the miners’ union and the South African Institute of Medical Research. Each group had its own problems that had to be addressed and resolved at the outset. The mining houses were sensitive about being blamed for all the problems of the country and were initially very defensive. The union was suspicious of management and needed reassurance about the way the project would be conducted and who would have access to the results. The health-service providers were worried that once the project was over they would have to sustain it, and they were afraid of raising expectations that could not be fulfilled. The community leaders were desperate for the project to start, but wanted assurances that they would be actively involved and fully informed at all stages.

It took nearly a year of meetings and discussions to resolve all the issues. Finally, a detailed plan of action was agreed on and approved by the ethics committee of the University of the Witwatersrand. The British government, through the Department for International Development, agreed to provide R5 million to fund it for three years, and further financial support was promised by the provincial department of health and support in kind by the other major stakeholders.

The project started in January and is concerned both with the development of effective interventions and with evaluation of their impact. The intervention side has two arms — management of sexually transmitted disease, and community-based education and condom distribution. Medical staff are taught to treat patients with suspected STDs immediately on the basis of their symptoms alone, rather than sending off swabs for laboratory testing and hoping the patient will return a week later for results and treatment. Local doctors, including GPs, staff in the mining clinics and traditional healers, are given a week’s training course in the use of a specially developed STD symptom chart that indicates the most likely diagnosis. If it seems highly likely that a patient has gonorrhoea and possibly chlamydia as well, he or she will be treated for both. The drugs are safe, so there is no risk of over-treatment.

The other arm of intervention is education. Both miners and commercial sex workers living in the informal settlements around the mines are being trained to educate their communities about the symptoms of STDs, the threat of HIV and the need for safe sex. They act out brief, role-playing exercises in bars and other gathering places, start discussions and distribute condoms. They are paid a small honorarium for their work, and the women, in particular, have set about their task with a proselytising zeal.

The job of the ERU is to evaluate the impact of this work. We have just completed a baseline survey of 2,000 people from both the mines and the general community. Using a question-naire translated into five languages, we elicited information about sexual networking, numbers of sexual partners and their ages, use of condoms, as well as more general socio-economic questions. At the same time, a nurse took a blood sample from each respondent. This was then tested for syphilis, gonorrhoea and chlamydia. If a person had any of these diseases, he or she was informed and referred for treatment to either the mine or provincial health services. The blood was also tested for HIV, but respondents were told at the outset that the result of this test would not be given to them. If they wanted to know their HIV status the people running the intervention would refer them to other clinics where they could be counselled.

The survey will be repeated next year and the year after. The data will be supplemented with information from in-depth interviews and focus group discussions. Interviews with doctors, nurses and traditional healers, exit interviews with patients and partner notification slips will be used to assess the STD treatment services. The management of the project will also be monitored, paying particular attention to the contribution of the stakeholders — including mine management, the trade unions, national and provincial departments of health and grassroots community organisations.

We have learned many lessons in the course of launching the project: the importance of social and biomedical scientists working closely together on practical intervention and the need for careful evaluation if we are to use our experience in Carletonville to design and implement similar projects elsewhere. Furthermore, while the active participation of the local community is essential, they could not do it on their own. For three years they had been trying to put together a programme but lacked the scientific support and necessary contacts with experts in the field.
We also learned the importance of ensuring that all stakeholders are fully committed to the project. Although this probably delayed its start by up to a year, it would almost certainly have foundered if we had not taken the time to address all their concerns. The name of the project is Mothusimpilo — working together for health. We hope it will become a model for other projects throughout South Africa, so that the tide of the HIV epidemic may finally turn.