When public healthcare trumps private

A growing number of inexperienced general practitioners (GPs) with insufficient training in Aids treatment are treating HIV-infected patients — with alarming results.

Often, unethical practices go hand in hand with these cases, and cash-strapped patients are often dumped on to the public sector.

In one such case a Soweto woman with Aids was sold tuberculosis treatment illegally for R800. TB treatment is not available in the private sector in South Africa; only the public sector is allowed to stock and distribute it. After diagnosing a patient with TB, private doctors are supposed to refer the person to the public sector where everyone receives TB medicine free of charge.

“All I can think of is that the doctor stole the TB treatment, or had someone steal it for him from a public clinic,” said Moyahabo Mabitsi, the doctor who ended up treating this patient at a Soweto public clinic after she ran out of money. “It’s a shame that desperate patients are abused in this way.”

At the Nthabiseng HIV/Aids clinic at Chris Hani Baragwanath Hospital in Diepkloof, Sister Fikile Mavuso admits at least 10 “problematic formerly private-sector patients a week”. Many such patients have been put on dual, instead of triple antiretroviral therapy (ART) and a significant number receive ART prematurely, she said.

“We get HIV-infected patients with severe TB, but their GPs have failed to diagnose it. They’re put on ART and TB treatment together, right from the start. All of this has disastrous results. Patients have to be admitted to hospital and we’re left with the mess.” South African national HIV treatment guidelines state that people with Aids need a minimum of three drugs to fight the virus effectively.

If only two drugs are used, patients develop drug resistance and the HIV virus manages to fight the medicine. Patients with TB can’t receive ART immediately as the body overreacts to simultaneous treatment, leading to a dangerous condition called immune reconstitution inflammatory syndrome.

“Private doctors are significantly less experienced in diagnosing TB, as they don’t normally deal with the disease,” said Sindisiwe van Zyl, a doctor at the Anova Health Institute, which works in partnership with the government to provide ART to state clinics.

Van Zyl said: “Sometimes HIV-infected patients have TB even if their sputum tests negative. Such patients can’t be started on ART straight away; they will get very sick. The TB has to be treated first.”

She said it’s common knowledge among well-trained Aids doctors that if HIV-positive patients have CD4 counts (a measurement of the strength of the immune system) lower than 100, there’s an extremely high chance that they have TB, particularly if they also have a cough, drenching night sweats or acute weight loss. “Public-sector doctors, therefore, will automatically treat such patients for TB, but GPs aren’t always aware of that,” she said.

Earlier this year Patience and Theo Nkomo* from Lenasia near Johannesburg were told by their GP in Cresta that they were HIV-infected. Both had CD4 counts far below 100. Theo had a severe cough and his wife had night sweats.

Theo said: “But our doctor didn’t test us for TB. Instead, he put me on antibiotics, which worsened my condition.” When the couple’s money dried up, they visited public-sector clinics in Krugersdorp and Lenasia, where Theo was diagnosed with HIV-related TB and Patience with TB of the stomach.

“For three months I was extremely sick and had no idea what was the matter with me,” said Patience. “I now attend the Thembelihle clinic in Lenasia, where my doctor first made sure I was coping with the TB treatment and then introduced ART and I’m doing much better.”

But Elijah Nkosi from the South African Medical and Dental Practitioners’ Provider Network Management Services said HIV-positive patients in the private sector are reluctant to go for TB treatment because they don’t want to face the long queues at government clinics. “People with jobs can’t afford to queue for an entire day,” he said.

“They beg their GPs, saying: ‘You know my CD4 count is low. But I can’t afford to pay for a TB test and I don’t have time to line up. So, put me on ART and let’s see how it goes. I can go for a TB test later.'” Nkosi said most of the GPs at his organisation have attended courses in ART management. Those who have not, he said, cannot be forced to do so.

“There is no statutory imperative compelling GPs to go for training in how to manage HIV treatment. You can’t charge private doctors with unprofessional behaviour or negligence just because they haven’t attended Aids courses,” he said.

The underdiagnosis of TB in HIV patients is, however, not the only mistake that private doctors make. Van Zyl said: “I’ve also seen several private-sector patients who have been put on the wrong lines of treatment. Patients who should be on first-line treatment (the most affordable regimen with the least side effects) have often been put on end-line treatment (the more expensive drug regimen with more side effects).”

Angela Dlamini* has first-hand experience of this. Soon after a pregnancy in 2006, her Johannesburg city centre GP put her on a four-drug combination regimen, known as salvage therapy, the treatment option that is followed when everything else has failed. Dlamini experienced several side effects and soon ran out of money.

“It seems the doctor wanted to make money from dispensing more expensive drugs to the patient,” said Van Zyl, who now treats Dlamini. “She had a medical aid at the time, but he knew it would run out of funds at some stage. Her blood tests certainly didn’t warrant salvage therapy. She would have done well on first-line therapy.”

Oscar Radebe, a doctor at the Simon Nkoli Men’s Health Clinic at Chris Hani Baragwanath, said: “Many GPs are after money. Their priority is not patient care. Mismanaged patients arrive at our clinic and we then have to do expensive drug-resistance testing and sometimes put them on different drugs. It’s a mess.”

But Nkoli’s GP network said that the HIV patients exchanging private for public health are rarely people who can afford top GPs or well-run private HIV clinics. “The type of patient we’re dealing with in these cases mostly can’t afford medical insurance but is able to pay for a cheap GP visit or cash treatment. Such patients find it impossible to pay for all the expensive monitoring or screening tests that tell doctors whether the treatment is working and what drug regimens to use. Money becomes a huge issue that stands in the way of efficient treatment.”

Nkosi said the reason for the often inappropriate drug regimens private doctors prescribe is because of the difference in antiretroviral drug prices between the public and private sector.

“The government puts out huge tenders for first-line treatment and obtains it at much cheaper prices than the private sector. Other less appropriate lines of treatment the government doesn’t use that often are sometimes less expensive in the private sector and consequently more affordable to our patients,” he said.

Nkosi said his organisation has asked the health department to provide it with a consignment of first-line treatment to provide to patients, but to no avail. “We’ll do the monitoring and patients will pay a nominal fee only. This will ensure that we use the same lines of treatment as government. But our hands are cut off.”

According to Professor Alan Karsteadt, the director of infectious diseases at Baragwanath, there is, however, more to this situation. “GPs often work in isolation without anyone to ask advice from,” he said.

“At a government clinic such as Nthabiseng, junior doctors have access to many mentors with several years of experience in ART management. Private doctors rarely have this luxury.”

Integrated approaches are also easier in the public sector, where nurses, counsellors and doctors work closely together. “Proper HIV counselling mostly doesn’t happen in the private sector,” said Adrian Kreusch, a doctor at Nthabiseng, who also works in the private sector.

“I have found the HIV-treatment failure rate of private-sector patients to be higher than those of public-sector patients.

“I believe it’s due to a lack of counselling. Patients don’t get the time to come to terms with their diagnosis and, as a result, don’t follow the treatment correctly. GPs often have only 10 to 15 minutes to see a patient. They miss stuff.”

Van Zyl agreed: “There is no time to do adherence therapy [in the private sector]. Patients don’t understand how to take their drugs. They sometimes don’t even know what they’re taking. They think the drugs are vitamins!”

In some cases the lack of counselling even leads to babies born to HIV-positive mothers becoming infected. “Women don’t receive proper counselling with regards to breastfeeding. They don’t get told that they should breastfeed exclusively for six months and then they end up with infected babies,” said Van Zyl.

Place to build strong relationships
At the Nthabiseng HIV/Aids clinic at Chris Hani Baragwanath Hospital in Soweto, HIV-infected patients have been queuing since 5am. Inside, all the chairs are occupied and the corridors are filled with people patiently waiting their turn to see one of the doctors. It’s hardly possible to move.

“It’s first come, first served at Nthabiseng,” said Professor Alan Karstaedt, the director of infectious diseases at Baragwanath. “But we try to see patients with jobs first, so that they can leave quickly.”

Nthabiseng was one of the first clinics in South Africa to initiate antiretroviral treatment. Only 20% of its patients are employed. But the situation is not as bleak as it appears. “Patients referred to us are usually on antiretroviral treatment within two to three weeks after their first visit and we’ve never run out of drugs,” said Karstaedt.
Patients collect their drugs every two months from a special HIV pharmacy on the premises and usually see the same doctor at every visit.

“That way, we manage to build strong patient relationships,” said Karstaedt. Once it is established that a patient’s treatment is working well, the patient visits the doctor only every four months for check-ups. An NGO provides sandwiches on most of the three weekdays that the clinic operates.

“The service I receive here is efficient and just as good if not better than the service I would have received at a private hospital,” said a patient. “I used to go to a GP in the Johannesburg city centre and the waiting times there were sometimes even longer.”

All the expensive monitoring tests such as the CD4 and viral-load tests that patients on ART require are done at the clinic for free. “They’re done at two, six and 12 months, then annually,” said Karstaedt.

“If necessary, we sometimes do them even more often than the national guidelines require. We give patients value for their money,” he said. The clinic employs up to 10 doctors and eight counsellors at any given time. “There is always someone to ask advice from,” said Adrian Kreusch, a doctor at Nthabiseng.

“Patients are usually counselled in their mother tongue, so all the necessary cultural aspects are addressed as well.” Here, the adherence rate of patients to treatment is excellent. “More than 80% of our patients are virologically suppressed, meaning their treatment is working extremely well,” said Karstaedt.

* Not their real names

Mia Malan works for the Discovery Health Journalism Centre at Rhodes University