South Africa’s relentless push to eliminate HIV

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It's late morning and Babongile Luhlongwane is strolling along a dusty rural road in the Valley of a Thousand Hills. Not far ahead, a young man is toiling in the garden. He looks up and waves half-heartedly.

Ms. Luhlongwane, sporting a small backpack and T-shirt reading CHAPS, explains that she is part of the community health agent program, and asks if he has a few minutes to chat.

Hlanganani Thusi shrugs and invites her into the house, where he gets a short course on HIV and other sexually transmitted infections that is contained in a binder of shiny photos and graphics, and he's offered a free AIDS test.

After a bit of hesitation, and some prodding from the affable Ms. Luhlongwane, he holds out his hand and allows her to prick his ring finger with a lancet and spread blood on a slide.

Fifteen minutes later, the results of the rapid test are ready and Mr. Thusi, 27, flashes a smile and gives the thumbs-up when he's informed that he has tested negative.

Ms. Luhlongwane packs up her medical kit and heads off down the road to the next home.

More than 18,000 scientists, activists, clinicians and politicians from around the world gathered for the 21st International AIDS Conference in Durban – 150 kilometres southeast of here – earlier this year. One of the issues that dominated discussion was the goal of eliminating HIV transmission by 2030 with a policy of universal testing and treatment. That is no small feat in a world in which 36.7 million people are already infected – with fewer than half of them being treated – and that sees 2.1 million new infections annually.

But, in Eshowe, the challenge is even more daunting. They don't struggle with the "test and treat" philosophy, but with the nitty-gritty reality on the ground.

In this part of the world, where one in four people are already infected with HIV (and the infection rate in young women tops 50 per cent), is it actually possible, and sustainable, to test every man, woman and child – and do so regularly for the sexually active – and then get pills to the infected every single month, and do so with limited resources and personnel?

"If people test positive, we need to link them to care, to get them on treatment. If people are negative, we need to keep them negative," says Dr. Vivian Cox, a physician with Médecins Sans Frontières (Doctors Without Borders).

"It's a big challenge," she says. That's a staggering understatement.

Yet, in the KwaZulu-Natal province, MSF has had remarkable results: about 75 per cent of people living with HIV in the catchment area know their status; 85 per cent are on treatment; and 86 per cent of those on treatment have a near-undetectable viral load. In other words, they are remarkably close to achieving the 90-90-90 target set by UNAIDS, something that even wealthy countries like Canada have not achieved.

Dr. Cox said reaching that elusive goal requires relentless work, including offering testing treatment in innovative and varied ways, and aggressively promoting prevention, including condom use, male circumcision and talking openly about issues such as sexual violence against women, and the rights of sex workers and men who have sex with men.

In addition to community workers who go door-to-door offering testing, MSF has mobile clinics that travel to farms and community events, and small permanent clinics in Eshowe, a town of 14,000 that serves as the regional hub in the agricultural region where sugar cane is the principal crop.

On this day, nurses have set up shop at a small farm that employs about 30 workers. (Some farms in the area employ up to 1,000 people, and half of them are migrants.)

Cabangile Thusi (no relation to the younger Mr. Thusi) has come to collect her monthly supply of antiretroviral drugs (ARVs). The 51-year-old says her mother, sister and two of her surviving children are also infected with HIV.

Ms. Thusi is unsure when she herself was infected, but was diagnosed in 2012 after being hospitalized when she lost weight at a dramatic rate.

A year later, she started treatment with ARVs, when treatment began being offered at no charge.

(South Africa currently has the largest treatment program in the world, with 3.4 million HIV-positive citizens taking a daily pill that contains three drugs. The plan is to make the treatment program universal by 2020 – covering an estimated seven million people.)

The 51-year-old domestic worker says that the mobile clinic is a lifesaver because travelling into town for medical care is unaffordable. She earns the equivalent of about 2,000 rand (about $190) monthly and, with the cost of feeding and housing her daughter and grandchild, "24 rand for a trip to get medication is too much."

Ms. Thusi is unusual in that she speaks openly about being HIV-positive, saying she has no time for stigma and secrecy because "I want my granddaughter to be educated and safe."

Ms. Luhlongwane, the CHAPS worker, said that in her experience, women tend to be pro-active, eager to get tested and treated, while a lot of men "just run away."

"The main reason is they're afraid they might be positive," she says. "But not knowing is not going to make it better, it's going to make it worse."