Manning up to the epidemic
The Philandoda clinic run by medical humanitarian organisation Doctors Without Borders (MSF) is tucked away in a discreet corner of Eshowe’s busy taxi rank.
Every week, about 20 men walk through the doors of a containercum-health centre. Many are taxi drivers and travellers, including men in transit to far-flung places such as Durban and Johannesburg. But it wasn’t always like this when the clinic first opened in July. In those first days, community health workers Bongani Thethwayo and Nkosinathi Mpungose were lucky if one man a week walked in through the doors.
That’s when the duo took matters into their own hands. They began walking up and down the rank, popping their heads into the white Siyaya taxis. As drivers and passengers alike waited for each minibus to fill up before it could depart, Thethwayo and Mpungose spoke to the men inside about the services on offer at their clinic — testing and treatment for sexually transmitted infections (STIs), including HIV and referrals for medical male circumcisions (MMC).
MMC has been shown to reduce a man’s risk of contracting HIV through vaginal sex by about 60% and the World Health Organisation now recommends the procedure as an HIV prevention method.
Thethwayo and Mpungose then set out to canvass the area’s traditional leaders in the rolling green hills outside Eshowe, about 150km north of Durban. Because both men are from the area, they were able to develop close personal and working relationships with chiefs.
The duo’s networking paid off.
“In July we saw 138 clients. Eightyfour were tested and only four were HIV-positive. In August we had 209 clients, 159 were tested and 13 were positive. In September the headcount was 215 and we conducted 120 HIV tests and eight were positive. In October we saw 230 men and 149 were tested, nine were positive. So far we have initiated 29 people on treatment from July to October,” says Thethwayo.
An increasing number of men now walk into the clinic each month to talk about issues such as condom use, STIs and erectile dysfunction, he says, which the health facility doesn’t treat but refers men to other clinics for help. And sometimes the men just come to chat about their relationships, something that is a bit of a rarity in these parts.
Mpungose explains that here the notion of “Zulu pride”, or the concept that strength is a defining characteristic of being a “real man”, makes even sickness a sign of weakness. This means men are often reluctant to seek out medical care and this includes HIV testing. Factor in fears of gossip in a small town where your clinic nurse could be your neighbour and the reluctance of men to test for HIV only doubles, he says.
No one knows this better than Thethwayo and Mpungose, who grew up here.
In South Africa, as in many other countries, men test for HIV at lower rates than women. The country’s latest national HIV survey found that about 72% of women 15 years and older said they had tested for HIV, according to 2012 data from the Human Sciences Research Council (HSRC). Only six out of 10 men canvassed could say the same, the research found.
And men who do test are also less likely to stay on treatment. About half of women living with HIV in South Africa are on antiretrovirals compared with about a third of HIV-positive men, research presented at the 2016 International Aids Conference reveals.
Consequently, men are more likely than women to die of Aids-related illnesses, even in sub-Saharan Africa, a region where new HIV infections in women far outpace those in men, according to 2013 research published in the journal Aids.
By offering services for men by men, Thethwayo and Mpungose are hoping to change this and help men to feel more comfortable about seeking out care. If they do, they could help to curb new HIV infections more widely within their community in this hard-hit area, where up to a quarter of people live with the virus, data from the 2012 HSRC survey shows.
And South Africa won’t achieve the latest round of international HIV goals without finding its missing men.
UNAids’s 90-90-90 goals aim to ensure that 90% of people know their HIV status, that 90% of these are on treatment and that 90% of those on antiretrovirals adhere so well to treatment that they have very low levels of HIV in their blood. When people adhere to HIV treatment, the medication can bring the amount of virus in their blood to almost undectable levels. This is known as viral suppression.
Almost two decades of research published in journals such as the New England Journal of Medicine has found that people who are virally suppressed can’t transmit the virus.
So if more people in areas like Eshowe test for HIV and more start treatment, science posits there will be fewer new HIV infections.
MSF has been trying to achieve the 90-90-90 targets since beginning to work in Eshowe in 2013 and says that about three in every four people living with HIV know their status. Of these, about 85% are on treatment and an equal proportion are virally suppressed, according to a 2016 MSF report.
Musa Ndlovu, MSF deputy field co-ordinator in Eshowe says: “We will only know if new HIV infections are falling after conducting a second population survey in 2018, but we do already know that our community testing and treatment support initiatives have apparently contributed, since 2012, to 86% of patients on treatment in the project area having a suppressed viral load one year after being on treatment — very close to achieving the so-called ‘third 90’.
“We estimate that we are also close to reaching the first two 90s. The proportions of people in care, receiving timely viral load tests and succeeding on treatment are higher than the national average.”