An innovative approach to community co-operation for HIV testing in rural Malawi may prove the blueprint for achieving the United Nation’s Aids 2020 vision, colloquially called 90-90-90, writes Nicola Jenvey for MedicalBrief.
An ambitious treatment target to help end the HIV/Aids epidemic, 90-90-90 aims to ensure by 2020 that 90% of people living with HIV know their status; 90% of people diagnosed with the HIV infection are receiving sustainable anti-retroviral (ARV) therapy and 90% of people receiving ARs will have viral suppression.
In 2012 the Elizabeth Taylor Aids Foundation launched a pilot project in Mulanje, a district in south-east Malawi home to 570000 people, but without adequate access to healthcare and a high HIV prevalence. Around 5% of the population are under the age of one year; 23% are women of child-bearing age and the adult HIV infection rate is 17.1% against a national average of 9.1%.
The initiative, adopted after the actress had assisted HIV-positive people left stranded from access to ARVs after Hurricane Katrina hit New Orleans by providing mobile medical clinics, has at its core HIV testing and providing ARV treatment to those in need.
However, the foundation discovered only one man was being tested for every five women and sought to understand the socio-economic and psychological reasons behind this disparity. The outcome and the innovations the foundation subsequently adopted led district health officer Khuliena Kabwere to announce during the 21st International Aids Conference in Durban that the foundation was wholly investing its resources into Mulanje on the belief its interventions will achieve the 90-90-90 dream.
Global Aids Interface Alliance (GAIA) CEO Todd Schafer said in focusing research on a single area, the Elizabeth Taylor Aids Foundation and GAIA can showcase what can be achieved in the fight against Aids.
GAIA, the foundation and the US President’s Emerging Plan for Aids Relief (PEPFAR) work together in Malawi.
PEPFAR’s senior technical advisor Dr Heather Watts said partnerships were key to resolving the HIV/Aids epidemic and achieving an Aids-free generation, but there were several issues that had to be overcome, including the psycho-social barriers to HIV testing in men. These include the stigma attached to testing positive; the fear a positive result signals a death sentence and the feeling that clinics are female spaces.
Kabwere said the pilot study introduced 48 testing sites across the district with 194 counsellors and in the past three years has tested 80000 people annually. The approach centres on HIV testing being the gateway to care – and last year 83000 people were tested of which 25000 had never been tested previously.
However, 71% of those tested were women reflecting the need to change the approach to bring men into the clinics, specifically dealing with the lack of privacy men felt in these environments and an infrastructure perceived as male-unfriendly.
Kabwere said the clinics shifted their approach to open up on Saturdays as “men days” and six months ago introduced door-to-door home visits where families can be tested in the privacy of their houses. Both approaches used buy-in from the local traditional and religious leaders.
Grassroots Soccer director Sarah Miller said another approach has been using soccer to educate and mobilise the youth to overcome the health challenges. Initially founded in 2002 by Zimbabwean soccer players, the project has currently reached 1.2 million youth and has been working with GAIA in Malawi since 2014.
The model trains youth leaders, typically aged 20-28 years to be marginally older than the key audience, but still sufficiently young to “speak the lingo”, to mentor youth via a 12-hour sports and educational programme. Key to the initiative was getting youth to test for HIV and providing the support throughout and after the process.
“The 99% retention rate over the past 30 months indicates the project has been effective in creating adolescent agents for change and inspiring the youth to take action in their communities,” Miller said.
Elizabeth Taylor Aids Foundation Malawi country director Joyce Jere said the study results had shown getting community buy-in and “going to places where men hide” were solutions to boosting male testing and an overall community status awareness. The door-to-door testing had proved specifically successful with 98% of those visited being willing to undergo testing in the privacy of their homes and with their partners.
“We can be effective in getting men tested by approaching them in male-friendly environments, while the shift in approach, specifically the door-to-door testing, reaches out to the children who have fallen through the cracks,” Jere said.