Orange juice spills over three-year-old Vultari Chauke’s chin. In her tiny, sticky hand are two more segments of fruit — she’s holding on to them for later.
For now, Vultari’s keeping an eye on the bugs buzzing in the orchard around her. The air smells of warm soil and rain.
It’s the end of the citrus season in Hoedspruit. All the oranges have been picked and packed for sale or export.
Most workers will now move on to their next job: farms where they can pick mangoes or plant other fruits and vegetables for the next season. Each year, thousands of seasonal workers stream to Mpumalanga to do such jobs.
Vultari’s mother, Amelie (34), is one of them.
In 2012, Chauke came to South Africa from Mozambique to find an income. "I work on a farm in Hoedspruit [on the Mpumalanga-Limpopo border] where I plant pumpkins, corn, sweet potatoes and mangoes," she says, putting her arms around Vultari, who is sitting on her mother’s lap.
But moving around for work had huge implications for Chauke’s health because she required monthly medication.
Chauke is HIV positive.
"When people go home to another province or country, the people at that clinic don’t always know what care they need, " Shandir Ramlagan, a researcher at the Human Sciences Research Council’s HIV Unit, explains. And some might not want to tell a new community they have HIV, which means they won’t take their medication. People are afraid they’ll be treated badly or won’t get jobs, he says.
Vultari takes a bite from one of her two remaining orange slices. "My child was born in South Africa," Chauke explains. "I met her father when I moved here."
The farmer she worked for suggested that she visit a clinic at the Hlokomela Training Trust. The organisation helps farm workers with HIV to get antiretrovirals (ARVs) and also gives pregnant women access to services that can prevent their babies from contracting the virus from their mothers.
South Africa has reduced its mother-to-child-transmission rates at six weeks from about 30% in 2004 to below 2% in 2017 by implementing such prevention programmes, according to health department figures.
The country’s national HIV plan aims to reduce the rate to below 1% by 2022 at 10 weeks.
By 10 weeks, more time has passed in which babies could get infected with HIV. So, measuring infection rates then is more impressive than at six weeks, says researcher at the South African Medical Council Ameena Goga.
Chauke strokes Vultari’s arm, smiles and says: “They gave me treatment to protect me and my child.”
Gone: When the fruit is packed into boxes, many farm workers disappear, making it difficult to keep them on HIV treatment. (Dylan Bush)
Inside the box, there are 30 yellow paper files of people who did not return to the clinic to get their HIV medication. "It’s so difficult to find these patients once they go over the border, or even to other parts of South Africa," says senior nurse Glenda van Wyk.
The clinic at Bavaria is one of 10 satellite units Hlokomela runs on farms in the Hoedspruit and Phalaborwa areas. Altogether, the clinics care for about 3 000 farm workers each month.
Migrant workers who have moved 100km from their hometowns are 50% more likely to contract HIV than those who don’t move around, a 2017 study in the journal AIDS found.
A 2010 PLoS ONE study conducted in Lesotho over the course of a year found migrants to South Africa were seven times more likely to default on their HIV treatment than people who stayed in the country.
But bringing healthcare closer to farms, such as in the case of the Hlokomela clinics, is helping to change this.
They're not only good for workers' health, they're good for business too.
The organisation’s data reveals 86% of Hlokomela’s patients use their treatment so well that the level of HIV in their bodies has become so low that it’s scientifically impossible for them to transmit the virus to others. Researchers refer to this state as “being virally suppressed”.
To stay virally suppressed, patients have to keep taking their medication for the rest of their lives at the same time every day. But once the fruit has been packed it becomes difficult to monitor whether people continue to take their treatment as many of the workers disappear.
Hlokomela nurses have weekly meetings in which they discuss how best to reach people who don’t return to clinics for treatment. If patients can’t be tracked the nurses have to be creative.
Because workers often share cellphones or lose access to phones when they move on to a new job, not even an SMS reminder will necessarily reach the right person, says Hlokomela’s director Christine du Preez. "In that case, we have to send a message with a family member or someone we think might bump into them."
Hlokomela also employs 44 “nompilos” or community caregivers who look after chronically ill farm workers in their homes. In 2017, the nompilos brought basic healthcare to just under 100 patients, according to Hlokomela’s latest annual report.
These workers play a crucial role in making sure people take their HIV medication properly by tracing people who stop taking their pills on farms and getting them back on to treatment.
Glenda van Wyk hovers above a box containing files of patients who have not returned to collect their ARVs. When health workers can't find patients, it's up to nurses like Van Wyk to get creative. (Dylan Bush)
In rural provinces like Mpumalanga, even moving between towns can make it more difficult for people to take their HIV treatment correctly.
Mpumalanga is a "hotbed" for HIV infection, the HSRC’s Ramlagan says.
He explains: "The province’s health systems cannot cope with the people streaming in and out of the province to work in both the mining and agricultural industries."
According to the HSRC’s 2017 household survey, the province has among the highest rates of people infected with HIV — 22.5% — in the country.
Ramlagan says there is no electronic system that connects clinics in Mpumalanga — unlike Gauteng, which also deals with high numbers of migrants, but which has started to digitise patient records.
"Some clinics in Mpumalanga encourage people to take their files with them if they’re moving, but not everybody does," Ramlagan says.
"Even when they do, the information in the files may not be up to date. In theory, a national health department policy requires that all provinces have a central system that pools patient information, but it’s still up to cash-strapped provinces to make sure they run smoothly."
Mpumalanga health department spokesperson Dumisani Malamule says the province has started to register patients electronically in Gert Sibande district, which is a pilot site for the National Health Insurance scheme. The project will soon expand to two other districts.
But, says Ramlagan, “files in Mpumalanga’s clinics are a mess”.
He says the bad state of health information systems in the province could already be affecting how well Mpumalanga is fighting HIV. Only 34% of people on HIV treatment in the province are virally suppressed, a 2017 paper in the Southern African Journal of HIV Medicine found.
Leaving home means leaving your friends, family and social support. But it's worse than that.
Mpumalanga’s viral suppression numbers are among the lowest in the country.
Although ARVs can dramatically reduce the chances of pregnant HIV-positive women transmitting the virus to their unborn babies, some infants don’t benefit from their mothers taking such treatment, because the women take their treatment inconsistently.
A 2018 study, published in the International Journal of Environmental Research and Public Health found that about a quarter of a sample of 700 HIV-positive Mpumalanga women were taking their ARVs incorrectly, or had missed at least one day during the study period of a year.
Ramlagan says the provincial health department’s information systems are so bad that it doesn’t even have the correct baseline data.
"If we don’t have proper data, we can’t be sure we’re achieving what we’re supposed to," he says.
Bhekisisa put this allegation to the Mpumalanga health department, but its spokesperson failed to respond.
Ramlagan warns: “The department is lying to itself.”
Mpumalanga draws thousands of migrant workers each year and as the seasons change, so too do workers' addresses as they follow the work. (Dylan Bush)
As the shadows grow longer in Hoedspruit, farmworkers at Bavaria are finishing up a long day of planting potatoes.
A tractor chugs ahead of the group, and sends up a haze of dust that hangs over them for a while before dispersing.
For farmer Johann du Preez, having the satellite clinic on his property has not only been good for workers but also for business.
Because Bavaria’s workers no longer have to sit in day-long queues at government clinics, the number of days they miss work for health reasons has halved, he says.
Any new project will have its challenges, Du Preez says. When the clinics were first introduced, staff at the satellite clinic found healthy people were queueing as an excuse to miss work.
But the problem disappeared when Hlokomela’s satellite clinic began asking for a fee of R20 to access their services.
He explains: "Even with the fee, people come from other farms to get these services, sometimes passing up to three government clinics. That tells you something of the quality."
Du Preez says most farmers in the region support the idea of having a clinic on their farm. But for many, tough economic times force them to choose cheaper options such as allowing their workers to go to Hlokomela’s clinics on other farms instead.
For mothers like Chauke, the clinics make all the difference: “Here I am always treated well and given all the medication that I need.”
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