The town of Eshowe in KwaZulu-Natal has an indigenous forest snaking through its centre. From the depths of this forest, where tiny blue duiker skitter around in the undergrowth, the sounds of the taxi rank are clearly audible — pumping bass and singing voices. It is a place of many sharp contrasts: the natural and the manmade, the modern and the traditional. 

In 2019, MSF Eshowe (as the project was known internally) came to international attention after announcing the results of major population studies by Epicentre, a non-profit organisation that provides epidemiological expertise to MSF operations, which showed that the UNAIDS 90-90-90 treatment targets had been achieved in the project area. 

When UNAIDS came up with the targets in 2014, modelling suggested that achieving them would enable the world to end the Aids epidemic by 2030. The achievement of 90-90-90 by MSF and the KwaZulu-Natal Department of Health was therefore noteworthy, not least because it happened two years ahead of the deadline, and in an area of intense HIV stigma and high HIV prevalence.

MSF’s southern Africa director-general, Andrew Mews, underscored this in a speech he made at the Eshowe project’s official closure event. 

“I heard about Eshowe’s achievement of 90-90-90 on a Nigerian television station while working for MSF in Nigeria in 2019. Two days later, the vice-president called me up and said, ‘We are struggling with PMTCT [prevention of mother-to-child transmission] in Lagos, yet we hear this town in South Africa achieved 90-90-90. How did MSF do it?’ And we had an exchange,” Mews said. 

MSF’s Eshowe project was both more and less than it was purported to be. The project’s start, for example, was as rocky as it was ambitious. 

Tom Ellman, the director of the Southern Africa Medical Unit (Samu), explained that MSF’s earlier HIV projects in Khayelitsha (1999-2022) and Lusikisiki (2002-2006) had demonstrated that it was possible to treat people with antiretrovirals (ARVs) in even the most challenging contexts, “and in the face of HIV denialism and a global rejection of the idea that ARVs could become affordable. 

“The big challenge for the HIV community in 2009 was: how do we get everybody on treatment? There was growing global belief, given impetus by the seminal HPTN052 study, that if you put everybody on treatment, nobody could transmit the disease. This, together with deploying all the prevention knowledge we had at our disposal, could end the pandemic,” he said.

“‘Undetectable equals untransmissible’ was the slogan of the time, and the strategy that was proposed for achieving this became known as ‘test and treat’. 

“A group of influential people in the HIV community within MSF were keen to demonstrate that ‘test and treat’ could succeed in the real world, but a 10-year commitment to throw the proverbial kitchen sink at the epidemic was a difficult sell internally, because by this time South Africa had moved far beyond the HIV denialism of the Thabo Mbeki years and was rolling out ARVs at an unprecedented scale,” Ellman recalled. 

The team that motivated (successfully, in the end) for a “test and treat” project in southern Africa included the former coordinator of MSF’s Lusikisiki project, Hermann Reuter, a prominent Treatment Action Campaign (TAC) organiser who featured in Jonny Steinberg’s Three Letter Plague: A Young Man’s Journey Through a Great Epidemic. 

“The idea was to pilot a simple model that was going to show how, by drastically scaling up treatment and then treating everyone who tests positive in a smaller district, we could decrease the number of new infections, as well as mortality and morbidity,” said Reuter, adding that colleagues of his came up with the phrase “Bending the Curves”, which ultimately became the name of the project, “referring to the curves of HIV incidence, morbidity and mortality”.

MSF looked at many areas in southern Africa where HIV incidence was known to be high but zoomed in on KwaZulu-Natal, where the healthcare system was relatively robust. Ultimately, King Cetshwayo District was chosen, both for its high burden of disease and the supportive attitudes of prominent leaders in the district department of health.  

Dr Hermann Reuter. (Photo: Daniel Steyn)

‘We knew we were in the right place’

In 2013, two years after the project launched, Epicentre undertook a large-scale population survey, which provided the data against which the Eshowe project intended to measure the impact of its activities.

“The results showed that one in four people had HIV, so we knew we were in the right place,” Reuter said.

MSF set out to massively scale up testing but came up against deeply entrenched HIV stigma.

“We were working in areas where HIV and TB were equated with witchcraft and talking about sex was simply taboo. We realised it was important to work closely with traditional leaders, as this is a traditional area in which the word of the chiefs carries a lot of weight,” said Ntombi Gcwensa, the project’s patient support manager. 

Reuter said this signalled a change in approach for MSF, which in Khayelitsha and Lusikisiki had worked closely with the activist-led TAC, “where the guiding idea was that the people living with HIV are the leaders, and you actually try to challenge, a bit, the traditional, chauvinistic judicial structure. But King Cetshwayo District is indeed a deeply traditional area, perhaps requiring a less confronting approach, although I am still not convinced that we went in the right direction, because when patients do not lead, who leads when your organisation pulls out?”

Individuals with a proven track record of working with amakhosi (clan chieftains) and izinduna (headmen) were hired to drive MSF’s door-to-door testing programme. To do this, they convened representative committees. 

“We had one group for the amakhosi called Ubuhlakani Bendabuko, meaning ‘traditional wisdom’. We had another for izinduna, the representatives of the amakhosi in the community, who are the key to getting things done, and we had a group made up of influential women, which we named ‘Omama besizwe’, meaning ‘mothers of the nation’, and they were key to a number of things, like teaching us how to talk to traditional families about sensitive topics such as sex,” said Musa Ndlovu, MSF Eshowe’s former deputy field coordinator. 

The project was moving slowly, however, and it was only in 2016 (far too late for some) that MSF started implementing “test and treat” in Eshowe and Mbongolwane. A month later, on 1 September 2016, the government launched a policy of “universal test and treat”, making antiretroviral therapy available to all HIV-infected people regardless of CD4 count. This is exactly what MSF had been aiming to push for in South Africa, using evidence from its own programme. So where did this development leave its Eshowe project?

According to Liesbet Ohler, who joined the project as its medical coordinator in 2016, it made sense for MSF to continue with what it had started.

“It can take a very long time before government policies are implemented, and in fact, the project had already moved on from a singular focus on ‘test and treat’ to a much broader strategy that involved intervening at every level of the cascade of care,” she said. 

If MSF’s earlier HIV/TB projects were known for their innovation, and for mustering the right levels of defiance needed to ensure that those models of care became policy, the Eshowe project, according to Ohler, “took everything that we know you need to do to reduce HIV-related illness and death, adapted it to a unique context, and showed that if you do all of these things sincerely and intuitively, you can make a difference”.

90-90-90

Increasingly, the project framed its goal in a new way — to achieve the UNAIDS 90-90-90 treatment targets in the project area. 

To scale up testing, healthcare workers went door-to-door in rural communities offering HIV counselling and testing (HCT), and a mobile clinic visited high schools and “high transmission areas” like Eshowe’s technical college and the area’s sprawling commercial sugarcane farms. Project staff tested in clinics and hospitals, and from parkhomes located in busy parts of town. Health department nurses were trained to be able to initiate patients on treatment, taking pressure off doctors, and lay health workers were trained to become treatment adherence counsellors, taking pressure off nurses. 

The Eshowe project introduced “differentiated service delivery”, a series of treatment delivery strategies, such as facility and community clubs, that increased the number of ways in which people living with HIV could access treatment and support. These care options were duly included in South Africa’s national HIV guidelines. 

For Gcwensa, it was this expansion of treatment options that made the difference.

“If you want to bend the curves [of the HIV epidemic], you must place individual choice and patient-friendly options at the centre of programme strategies. I think we really showed this to be true.”

The greatest affirmation of the project’s work came after a second population survey was conducted in 2018, to measure progress within the population in the project area, returning results of 90-94-95 (90% of people living with HIV know their status, 94% of those were on antiretroviral treatment and 95% of those had a suppressed viral load), and showing that the UNAIDS targets had been exceeded.

In a detailed analysis of the project’s HIV work, MSF’s Stockholm Evaluation Unit highlighted “the importance of investing in relationships, with community, traditional leaders, government structures, personnel from districts and clinics, TVET College management, farm owners, and CSOs”.

The project duly handed its HIV activities over to the government and other partners in 2018, and shifted focus to TB, aiming to replicate its successful, patient-centred approach to combatting HIV. 

There were TB milestones, too — a study aimed at enhancing TB diagnosis in hospitalised adults almost doubled TB diagnosis, and a similar study for children demonstrated how TB detection can be significantly improved; however, successive Covid-19 lockdowns hampered the work.  

“We remain concerned about the slow pace at which services for drug-resistant TB patients have been decentralised in King Cetshwayo District, in spite of significant investments from MSF in support of this vital process,” said Ohler, adding that there has been some progress: “several hospitals in the district are today managing DR-TB [drug-resistant TB] patients independently, and DR-TB is also being managed at the primary care level, in two clinics and a community health centre, but children with DR-TB and people with extensively drug-resistant TB still have to get treatment from the central provincial DR-TB hospital in Durban, several hours from their homes.” 

At the project’s closure event, the district health department’s deputy director, Mduduzi Mbatha, said, “We will miss your resources, of course, but what was particularly necessary was your voice, and the fact that your status as a non-governmental organisation enabled you to push bureaucratic walls that were previously not moving.”

MSF’s withdrawal does not mean that the organisation is de-prioritising HIV/TB, Ellman said.

“HIV is not over, it remains an incurable disease, and for many marginalised populations and contexts, access to treatment remains inadequate. We know that 90-90-90 isn’t enough. There is a growing realisation that people become fatigued after years of medication and may stop taking their pills every day as needed to fully suppress the virus, or they cycle in and out of treatment. 

“Nevertheless, today South Africa has one of the world’s most impressive roll-outs of HIV services, leaving less of a role for the large vertical projects that used to make up the bulk of MSF HIV activities,” he said.

MSF continues to make major investments in HIV/Aids in places that have been most neglected in the roll-out of HIV services, including the Central African Republic, Mozambique, Guinea and the Democratic Republic of the Congo, with a focus on the populations that are known to be most neglected.

According to Camren McAravey, the operations director for MSF in South Africa, the organisation remains committed to South Africa.

“In October 2023, we launched a new non-communicable diseases (NCDs) project in the Eastern Cape, where NCDs account for half of all deaths. We believe that much of what MSF in South Africa has learned over the last two decades in working with HIV and tuberculosis (TB), including in the recently concluded Eshowe project, is relevant to the management and care of type 2 diabetes and hypertension, and that these lessons can be adapted to transform the ways in which NCDs are identified and managed,” she said. DM