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Roselyne Sachiti Features, Health & Society Editor
Thousands of Zimbabweans live and work in neighbouring South Africa. Since the days of Wenela, Zimbabweans have travelled the length and breadth of the neighbouring country seeking jobs in the mines, etc.
Today, South Africa, the economic hub of Southern Africa, is as much as home to the thousands of Zimbabweans living there. Each month, thousands of Zimbabwean cross- border traders also travel to the neighbouring country for business.
What happens in South Africa in terms of health successes and failures also has an impact on Zimbabweans living and working in that country and families they leave back home.
At the South African Aids Conference in Durban recently, the international medical humanitarian organisation Médecins Sans Frontières (MSF) released findings from a follow-up survey of its community-based HIV/TB project in Eshowe, KwaZulu-Natal.
The latest findings show how the project has achieved the UNAIDS targets of 90-90-90 one year ahead of the 2020 deadline, with results of 90-94-95.
In the new results, 90 percent of people living with HIV know their status, 94 percent of those were on antiretroviral treatment and 95 percent of those had a suppressed viral load.
The results show the extent to which interventions at community level can successfully reach and directly support more people living with HIV who do not access conventional health services, which is key to getting ahead of the HIV epidemic.
Along with similar findings from several other HIV population surveys, including two surveys also released at SAAIDS, the MSF results provide strong evidence that achieving the 90-90-90 targets is possible in South Africa, along with hopeful data suggesting that the number of new infections is decreasing in certain areas.
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 (HSRC, 2018).
“We’ve shown that it’s possible to reach 90-90-90 in an area with one of the highest HIV infection rates in the country, where one in four people is living with HIV. These results are testament to the full engagement of the entire community. Everyone — from local civil society and patient groups, health staff and traditional health practitioners, traditional leaders and their members — was deeply involved in designing and helping this project to deliver from the beginning,” said Dr Liesbet Ohler, Project Medical Referent, Eshowe.
“Importantly, we have ensured 94 percent of people who tested HIV positive started treatment, including people who are much less likely to test for HIV and link to care, such as men.”
The MSF Epicentre population-based survey, which included 3 286 people aged 15 to 59 years, is a follow-up to a 2013 survey done by MSF and Epicentre in the same area which was performed to inform priority activities.
The 2018 survey found a significant increase in overall HIV status awareness (increased by 14 percent) and in starting people on treatment (increased by 24 percent) between 2013 and 2018. Among men, there were striking increases in knowledge of HIV status (first 90), from 68 percent to 83 percent and on treatment (second 90), from 68 percent to 87 percent.
Preliminary HIV incidence results (which means the number of new HIV infections) show a trend to decrease, from 1,2 percent in 2013 to 0,2 percent in 2018.
This is supported by survey findings which show that among the people surveyed, the proportion of those living with HIV who were virally suppressed increased from 56 percent (2013) to 84 percent (2018), signifying a dramatic reduction in the number of people with the potential to transmit HIV.
However, MSF cautions against interpreting the survey results as an outright declaration of victory, with significant challenges remaining among specific age groups.
“While incidence decreased among women aged 15-29 years from 2,9 percent to 1,2 percent, this figure remains high and points to the continued risk faced by adolescent girls and young women,” said Dr Laura Trivino, MSF’s Medical Coordinator for South Africa.
“Difficulties remain in reaching men, who overall achieve poorer treatment outcomes across the cascade. More than half of young men aged 15 to 29 years diagnosed with HIV are still not on treatment. We hope these findings will help focus our collective energies on reaching these groups who remain the most vulnerable to HIV.”
The “Bending the Curves” project, which started in 2011 before the 90-90-90 targets were set by UNAIDS in 2013, aimed to bend the curves of new HIV infections, and HIV-related illness and death. Numerous activities were launched in partnership with communities and the KwaZulu-Natal Department of Health to prevent HIV infection, increase HIV testing, link people quickly to care, and support their adherence, retention and suppression on treatment. Today the project covers 10 clinics and two hospitals.
Early on, the project invested in community-based prevention and HIV testing strategies, including extensive door-to-door testing by lay workers, with over 120 000 door-to-door tests conducted between 2012 and 2018. Between 2015 and 2018, 1,35 million condoms were distributed annually.
“How did Eshowe get to 90-94-95? I would say it’s the power of partnership. We had the total commitment of the traditional leadership, and close collaboration with the departments of Health and Education at each stage,” says Musa Ndlovu, MSF’s Deputy Field Coordinator in Eshowe.
“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. We didn’t do it for the community, we did it with them.”
However, from operational documentation and experience, MSF believes the following activities listed below have had the greatest impact:
Community ownership and engagement:
Community leaders, local CSOs, traditional health practitioners, community members were directly engaged from the start of the project. MSF staff report that this has driven demand for services and appears to have shifted the community’s overall perceptions of HIV.
Linking communities with HIV testing and basic health services:
Multiple methods of HIV testing and counselling reached deep into communities to find those who simply don’t visit health centres and referring those in need to facilities. People were provided with vital information and guided towards treatment. As trust in HIV services has grown, fixed HIV testing sites which also offer basic health services and referral capacity have been placed within communities themselves.
Reaching men:
Men remain a difficult to reach population in the HIV response. Male-focused services were designed to reach men through community outreach and taxi ranks, yet their success remains unclear. There was collaboration with a local union and the health department on huge efforts to circumcise young men aged 15-34 in the sub-districts. Around 72 percent of males aged 15-19 years and 67 percent aged 20-24 years were circumcised, above the 60 percent target that the WHO recommends to have an impact on HIV incidence reduction.
Door-to-door testing:
Through its Community Health Agents Programme (CHAPs), huge distances were covered to bring HIV testing services closer to the community. The work of the community health workers in building relationships between the community and facilities, linking people to care and supporting counselling efforts has been significant. The Community Health Agents did far more than just test; they raised awareness of HIV, shared information, built trust and encouraged people visit health centres.
Adherence support:
Helping HIV positive people start antiretrovirals and supporting their lifelong treatment journey is essential. Lay counsellors play a vital role in providing testing and counselling services in facilities and keeping people on treatment. At the same time, different ways of delivering treatment and support are very popular with patients, including adherence clubs, fast lane and community pick-ups. Today, 56 percent of eligible patients are in one of these models.
Such positive results show the power and importance of community engagement. Community involvement is considered an important element of most health and development programs. Most importantly, involving communities can also create the sense of ownership necessary to sustain behaviour change beyond the life of programmes in the event donors pull out.
The Eshowe project is also a clear example of how scaling up promotion and implementation of policies, community engagement strategies and behavioural change measures can help countries reach and even exceed the 90-90-90 targets.
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Peter Tanyanyiwa