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This is an amazing story.
It is the story of Eshowe, a place in a corner of South Africa, in Zulu territory that, without many elements in its favor and several problems in tow, achieved what seemed impossible: reduce AIDS to its minimum expression.
We are not talking about just any place.
In Eshowe there is plenty of poverty, lack of employment and above all, it is one of the hotspots for HIV in South Africa, the most affected country in the world, where some 7.5 million adults and children carry the virus, 200,000 are infected each year and others 75,000 die, according to UNAIDS.
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In Eshowe, where a decade ago one in four people had HIV, they have managed to reach and exceed the goal set by the United Nations for 2020, known as 90-90-90, that is: that 90% of the HIV-positive population know their status, that 90% of them are taking antiretroviral treatment and that 90% do not have a detectable viral load.
Here they have exceeded expectations and, in addition, they have achieved it a year ahead of schedule: in 2019, their 90-90-90 was 90-94-95, higher than the average for South Africa, which is 85-71- 86.
And how have they achieved this?
You have to travel there and see it.
Eshowe is a two-hour drive from the airport in Durban, the capital of Kwazulu Natal, in southeastern South Africa and is the main city in the uMlalazi region.
It is an eminently rural area, with a population of about 215,000 inhabitants, of which 14,000 reside in the urban nucleus, where some shopping centers, innumerable formal and informal stores, a couple of churches, a lot of traffic of people and street life crowd ... Here is also the headquarters of Doctors Without Borders, who started in 2011 a strategy called
Bending the Curves
.
Any explanation focused on the reports in this regard is even tedious: many figures, many acronyms, many definitions of approaches, of strategies, of the actors who took part ... But, in summary, what was done here was to put everyone world to work.
And when it is said to everyone, it is to everyone: to the small rural clinics, to the large provincial hospitals, to community leaders and healers, who have the full confidence of the neighbors, especially in the countryside, to the volunteers, school teachers ... Always in alliance with the Government's Health Department, whose complicity was essential to carry out any campaign.
They were all given very specific objectives: to prevent new HIV infections, increase testing for the virus, facilitate patients' access to medical care and support them to strictly follow treatment, something essential to control the illness.
The work was carried out through extensive information and awareness-raising work, but, above all, through a tool that proved fundamental: bringing medical services closer to people instead of waiting for them to go in search of those who , on the other hand, they did not even know of its existence.
To do this, it was not necessary to set up huge and expensive infrastructures, but quite the opposite: a walk through Eshowe, through the city, discovers some simple points of attention to the patient that, at first glance, may seem like little thing: they are decorated white metal containers with the red ribbons of HIV, with slogans such as Stop TB (stop tuberculosis) ... Well, it was in these small rooms where services such as HIV and tuberculosis detection tests began to be offered, but also other very useful ones: such as the measurement blood sugar (in this country more than 4.5 million adults, 12.5% of all, are diabetic), blood pressure testing, pregnancy tests, contact tracing, distribution of male and female condoms ... To have a rough idea of the impact: each year, between 2015 and 2018, an average of 1.35 million condoms were distributed from the two hospitals, the ten clinics and countless health posts like this one.
Simangele Dube, a community health worker and member of the Shintsha Health Initiative (SHINE), a local NGO founded by a group of women living with HIV, has been working in one of these facilities, along the main street of Eshowe, for a couple of years. also participates in this initiative.
There is hardly room for the chair and table with all the work material inside, but you do not need more.
“
Clients
[no one says patients] know me, I sit here and they tell me their concerns, because sometimes they come with many problems;
sometimes they don't understand anything about HIV or sexuality, ”she says about her work.
In addition to counseling on sexual health and doing screenings, she mostly saves her neighbors the walks to the hospital when they simply have to pick up their drugs.
“I have a list with the names of the patients and I give each one what is prescribed, but not the new ones;
They have to go to the hospital, there they prescribe the treatment, and then they send me the information and they can come.
Only once they have the diagnosis and the medication adjusted ”, he clarifies.
"The reason that we cannot give medication to new patients is because someone is starting ARV treatment, they need to be monitored by a doctor to see if they have side effects and finish adjusting the doses", completes Celiwe Dlamini-Ndlovu, sub-coordinator of MSF projects in Eshowe.
A few kilometers away is the Eshowe bus station, with its endless comings and goings of travelers.
This was another of the strategic places where a point of care was placed with the same services as the previous one, but this one, with a particularity: it is only for men.
“They can go with their partner, but not a single woman.
The nurses and the entire team are men, so they feel more comfortable and confident ”, reports Dlamini-Ndlovu.
Information on circumcision is also given here, a practice that, if performed by a doctor in a suitable healthcare setting, is recommended to prevent HIV because it removes the foreskin tissue, which is especially vulnerable to the virus, and because the area under the foreskin is easily scratched when having sex.
“When the project started, 20% of the men were circumcised.
Now this figure has risen to 50%, ”reports Liesbet Ohler, doctor and medical coordinator at Eshowe.
Going where no one else did
What there is hardly in the urban nucleus of Eshowe are houses, because the majority of the population lives in the countryside, widely scattered in small nuclei of no more than two or three houses, through a very extensive area of mountains, forests and crops, mainly of sugar cane.
This is the rural area of Mbongolwane, where mangoes, eucalyptus and acacias abound, and where cows can graze practically where they like most, because everything here is lush and green comparable to that of an Asturian landscape.
This was an added problem when getting started to reduce HIV numbers, as unpaved roads are not the most suitable for traffic and public transport is not abundant either.
Also for these same reasons, the neighbors lacked access to sanitary services.
To reach these populations, expeditions were organized that crossed the entire territory.
At that time, Radoslav Antonov, MSF's project manager in the Kwazulu Natal region, was already there, describing those days as “the most exciting of his life”.
Every morning dozens of vehicles left the city armed with a GPS and lost the whole day on all those red dirt roads.
Between 2012 and 2018, more than 120,000 tests were carried out with this home service.
More health points were also installed in strategic places, following this spirit of bringing services closer to the population.
“One of the advantages of the mobile units that went door to door and of the health posts that we installed is that people could choose the best way to get tested for HIV: at home, in their town or far from it,” he explains. Ohler.
The importance of being able to decide has much to do with the discrimination that HIV-positive people have suffered for decades, and continue to suffer, although to a lesser extent.
Lungelo Shezi, a nurse from the South African public health service, works in one of these rural infrastructures, the Ngudwini health center, who says that they treat about 1,300 people a month there.
For Shezi, the hardest part of her job is achieving adherence to medication.
"Sometimes the patient tries to make sure that no one in his family sees that he is taking medication and it is difficult to get it when you live with many people," he reasons.
That is why one of the current challenges is to return those who abandon treatment to the fold.
“We call him by phone, and if we can't find him, we talk to the referral clinic to see if they can find him, but it's not easy because sometimes the address they leave is incorrect, sometimes we find that the patient lived with his partner and if They have broken up, he has left, and you ask the couple and he says he does not know where he is.
The steps are: first a phone call and then a physical visit ”, he resolves.
After having managed to control HIV, the new battlefront that emerged was that of tuberculosis, a curable but deadly disease if left untreated, which kills 1.5 million people a year around the world .
This, in addition, is especially primed with HIV positive people, since their damaged immune system opens the doors to the so-called Koch bacillus.
In Eshowe the numbers are also scary, with a prevalence of 717 cases per 100,000 inhabitants, higher than the South African average.
"HIV is a complicated disease in the sense that someone who is HIV-positive can have active tuberculosis, but symptoms are not detected because their immune system is not responding because of how weak it is," Ohler cautions.
To achieve this, the same protocols that have proven so successful in reducing HIV are being applied.
For this reason, another of the services offered in all rural health points is the detection of tuberculosis.
One of the ways is by collecting sputum, which is then sent to the nearest laboratory.
Londani Luthulu, 31, who has gone for an antibiotic ointment, returns home with the test done.
"I have no symptoms, but they have performed it anyway, I will come in a month for the results."
In the case of tuberculosis, the added problem is that it is even more difficult to get the patient to complete the treatment, as it is aggressive and has very annoying side effects.
For users like Elizah Buthelezi, 49, a regular at the Isikhugo Sezempilo rural outpatient clinic, this type of service has helped her not to stop treatment, and she greatly appreciates the closeness.
“Here I can pick up the medication without wasting time going to the clinic, because there are none nearby.
If I had to go far, perhaps I would have ended up interrupting the treatment, "he says.
"Another benefit is that when I went to the hospital I found a lot of queues and had to wait for hours, but there isn't any here, I only come once a month, pick up my medicine and leave."
Sbusiso Shang, 31, from the same village, says that he uses this health point to provide himself with condoms.
“I heard about the service from Kathy, who is my neighbor [and community health worker] and she convinced me to take an HIV test;
I had it done last month and it was negative, and I've been using condoms ever since.
Before I did not use, but since I found out that I am negative I started to use them because ... I do not want to become positive! ”, Exclaims this young man, who admits that he has lived until now without worrying too much about his health or contracting any disease .
Above any explanation, Robert Ngcobo, community leader in Eshowe, is clear why this strategy has really worked: the acceptance of the neighbors.
“Once people accepted it it was easy to sit down and talk.
The main problem is denial, but when you accept that you have HIV, you also accept help, you allow yourself to be encouraged and advised, and you start taking treatment, ”he says.
The trust that the population places in leaders like him was also a key element.
From his experience, the main concern that his neighbors convey to him is the lack of food, a problem that must be solved in order to completely bend that curve of AIDS.
"To encourage people to take the medication we try to eat well, because many times that is the first thing they cannot do."
The curanderos also work from this approach, another group that has the support of their fellow citizens.
They practice traditional medicine, in which many people pin their hopes.
Involving them in the strategy was key.
“When they come very sick, I send them to the hospital;
I only treat them when they are better ”, says Sgemegeme Mhlongo from the door of his tiny house, at the very edge of a ravine from which forests can be seen as far as the eye can see.
The role of healers like him in bending the HIV curve.
“If they have HIV, we encourage them to continue taking the treatment;
They trust us a lot because we tell them about their history, their future, ”says the healer.
At 35, he is nothing like the exotic image that has been sold of them: young, dressed in jeans and a shirt and devoid of any exotic adornment.
The only thing that indicates that a practitioner of traditional medicine lives in that tin house are the herbs put to dry on a sheet at the entrance of the house and an idol made of a pumpkin and painted black.
"To attract good luck," he laughs, as if hiding his true meaning.
A model against other pandemics
In the midst of the battle against HIV and tuberculosis, a new enemy has loomed on the horizon: covid-19.
Slindile Majola, a 31-year-old health worker, is on duty at the Sukuma Sahke clinic in the Lugu district, and she tells how to work now that COVID-19 has made people stay at home: the idea is to decongest the clinics, if she and her three colleagues take turns: one stays at the clinic and the other goes by car to the patients' homes.
“We are going to see about three families in the area each time, but if there are more houses that catch us on the way, we stop and do all the inspection.” “During the confinement I had a lot of work because people did not want to go to the clinics because they were full of covid and they were also afraid of catching it, "adds community health agent Lungolo Shezi from her experience.
“Covid-19 is not the first pandemic we have faced, so perhaps health systems are better adapted to deal with it now.
Perhaps not so much in the sense of resources, for example, it would take more oxygen dispensers, but in terms of organization, ”says Liesbet Ohler, from Doctors Without Borders.
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