The World's Largest HIV Clinic

Helen Joseph Hospital serves the central South West population of Johannesburg. It is named after an anti-Apartheid women’s leader who narrowly survived several assassination attempts. This moderately-sized 600 bed hospital houses the Thembalethu Clinic. Thembalethu means “Our Hope”. This is the largest HIV clinic in the world; currently around 10,000 patients are receiving ARVs, with another 5,000 not yet initiated on therapy. The sheer size of this clinic is daunting, however despite the throng of patients bustling through, patients didn’t seem to be queuing for long, as several processes have been set up to ensure efficiency. For example, patients receive a text message on their cell phone to remind them they have an appointment the next day (this is only just being introduced at Guy’s and St. Thomas’ in London). Appointments with several different members of the medical team are co-ordinated for the same visit. There is a team analysing bottlenecks and working to smooth these.

Given the size of the clinic, there are only two people working in nutrition: a dietitian, and a nutrition assistant. There are two problems here.

Firstly, patients being referred to the dietitian are screened so that only the most malnourished or those with the most difficult issues are seen. Many patients are not seen, and I am sure go on to develop problems which could have been avoided.

Secondly the dietitian Elsbeth is a Community Service dietitian. The system in South Africa is that as soon as you qualify as a dietitian, doctor or pharmacist, you must spend your first year of work in “Community Service” before being allowed to work in a job of your own choice. In effect the community service posts tend to be rural, difficult to fill, or somehow “less desirable” posts. It is a great pity that the single dietetic post at the worlds’ biggest HIV clinic has been designated a community service post. Elsbeth loves the job, and has done amazing things in the 9 months she has been in post. She would love to stay on, but must leave at the end of the year for a new dietitian fresh from college to start in post.

I spoke with the doctors about this. They agreed that the situation was less than perfect, and pointed out that most ARV clinics are faced with the same issue – not just with dietitians, but across the board with health professionals.

In my opinion, South Africa must review this policy. Initiating people onto ARVs is only the first part of the battle against HIV. Keeping people well on ARVs is an equal challenge, and requires continuity of care, and a degree of specialism amongst the health professionals working in the field.