Indyplus AIDS series by Jeremy Laurance

 

Thursday 21 November 2013 20:13
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It is two years since scientists declared the ‘beginning of the end’ for Aids. So has their optimism been justified? Jeremy Laurance embarked on a five-week, 5,000-kilometre journey through Africa to test the claims. In the first part of a week-long series, he travels to the place where it all began

Day One Kasensero, Uganda

It is a rough road to Kasensero on the western shore of Lake Victoria in south west Uganda and a rough town at the end of it. A bone shaking hour after leaving the main Uganda–Tanzania highway, we crested a ridge and got our first glimpse of the “hot zone”, the epicentre of Africa’s Aids epidemic.

The corrugated iron roofs, clustered at the water’s edge, glinted in the afternoon sun. Twenty minutes later we were down among the fishing boats - 40ft long wooden canoes with outboard motors, at least 150 of them – drawn up in tight formation on the beach.

Kasensero may one day become a tourist destination as the site where the first stirrings of the holocaust that has so far claimed 30 million lives around the world were identified in Africa. It was here in the early 1980s that Ugandan researchers spotted a new syndrome they termed “Slim” disease, (because it turned sufferers into walking skeletons) publishing their findings in 1982.

One day tourists may come, perhaps - but not today. The beach was not a comfortable place to be. Red-eyed fishermen, many of them drunk at 4pm, leered at my blonde 25 year old daughter, whom I had brought along as my photographer. Others leaned on their boats, counting out wads of banknotes, as they traded huge silver fish with crimson gills from the day’s catch.

“Take me to London,” joked one man, the alcohol heavy on his breath. “Bring us money,” said another, his friends laughing. “Hey sister,” yelled a third, making a mock lunge at my daughter.

Two years ago Western political leaders began speaking about the “end of Aids”. Barack Obama and Hilary Clinton foresaw a time when the disease might be beaten, and The Economist published an influential article asking if its days were numbered.

Their optimism was based on research that heralded a step change in the battle against the virus. It had shown that the anti-retroviral drugs (ARVs) which had already saved millions of lives also dramatically reduced transmission of the virus, by as much as 96 per cent.

For the first time the world had a weapon that could potentially defeat Aids, but which did not rely on changing sexual behaviour – notoriously difficult to achieve. Every person put on treatment meant one fewer to spread the contagion. In September this year the deputy head of Unaids, Dr Luiz Loures, declared the Aids epidemic could be over by 2030.

It is a pity Mr Obama, Ms Clinton and the rest were not able to visited Kasensero, 250 kilometres south west of Kampala, Uganda’s capital, in Rakai province. Almost 30 years since those first cases of Slim were described, the town now has what is almost certainly the highest level of HIV infection on the planet. And it is rising, not falling.

One in every two women and a third of men carries the virus in Kasensero, according to a 2012 survey by the Rakai Health Science Programme (RHSP). Among sex workers, the prevalence is 75 per cent.

There are no comparable figures from earlier decades but the researchers estimate in the 1990s, 25 per cent of the population of Kasensero was infected, suggesting the prevalence has increased by half, to its present level of 41 per cent, in the last 20 years.

It is a town of shacks and hovels, crumbling in the dust, wholly dependent on the trade in fish. Few among its 30,000 inhabitants are permanent residents and fewer still over 40. Fishing is a risky, uncertain trade suitable only for young, fit men - marauding gangs of them - who are paid daily, in cash, according to that day’s catch. They spend their money on beer, drugs – and sex.

In a hut on the beach, the town’s chairman Lawrence Muganga, described how sex workers from across the border in Tanzania and as far afield as Kampala responded to the demand. “They call their friends and ask: ‘Is business good? If it is a good season [for fishing], there are many coming.”

Tacked to the hut door outside is a sign advertising free condoms but when Mr Muganga pulled down the white cardboard box from where it was stuffed in the eaves, no more than a dozen of the 100 it contained had been taken since it was delivered by the local clinic a week earlier.

“Very many prostitutes come here to sell their bodies. So you have to teach them to use this one to protect themselves,” he said, without conviction.

Behind the beach, rows of curtained doorways concealed the bars and brothels that lined the streets. Jane Namutebi, 31, rented one of the cell-like spaces for 60,000 Ugandan shillings a month (£15).

Wearing a long blue dress, she sat in the gloom with two friends, both in revealing low cut tops. “I am hoping to get a big business. The customers are attracted by the women,” she said, indicating her friends. Bottles of Beckam Gin and Royal Vodka stood on the dusty shelf above her.

She was diagnosed HIV positive a year ago. Her three children are looked after elsewhere by their grandmother. Did she use condoms?

“I had them but they are finished. The customers don’t have enough education for safe sex.”

All along the shores of Lake Victoria, the story is the same. Fishing, by its nature, is uncertain and risky. Fishermen move from place to place, wherever the catch is good. They are young men, with plenty of cash, living in communities with few families, few older people and no constraints. Drownings are common and alcohol cheap and ubiquitous. By comparison with the risk of going out on the lake, the risk of HIV is remote.

“These are very isolated communities with very basic services”, said Asiki Gershim, project leader at the UK Medical Research Council in Masaka, 80km from Kalensero. A recent survey found more than half of fishermen said they had had more than one partner in the previous three months. Serotyping shows fishermen spread the virus into the general population when they return to their home villages. They, not truckers, may be the crucible of the African epidemic.

The story of Aids in Africa has been told as if it were a single epidemic which has swept the continent, mainly – and uniquely – spread through heterosexual sex.

But the truth is, as always, more complex. There are hundreds of separate Aids epidemics in Africa, each following its own trajectory, each with its own drivers.

Rakai province has the highest HIV rate in Uganda, driven by its fishing communities. At 12 per cent it is almost twice the national rate. Across the continent infection rates have fallen dramatically in the last two decades but worryingly, and uniquely, in Uganda the national rate has turned upward again, from a prevalence of 6.4 per cent in 2005 to 7.3 per cent in 2012.

Uganda was the first African country to be hit by Aids in the 1980s, the first to respond, and the first to see a dramatic fall in infections, a pattern since followed by the rest.

The recent resurgence of the virus in the country has aroused fears that it may signal a new continent-wide reversal, putting paid to heady talk in the West about the end of Aids.

“I am very concerned there is complacency,” said Peter Piot, director of the London School of Hygiene and Tropical Medicine and former director of Unaids. “As one commentator said [in response to talk of the end of Aids], what have they been smoking? People are not looking at the complexity of the epidemic. Uganda was the first country that achieved results – it may be the first where we see a rebound, and others follow.”

Special factors are at work in Uganda. The president, Yoweri Museveni, marking his 28th year in power, was the most outspoken leader on Aids in the 1980s, as he watched it decimate his troops. But in recent years his enthusiasm has waned, some say under the influence of his evangelical Christian wife, Janet Museveni, who preaches abstinence.

Kenya, which had a tourist industry to protect, was slow to acknowledge the epidemic in the 1980s and slower still to act. But it was quicker than Uganda to recognise that generalised behaviour change campaigns were failing and it was essential to tackle the disease in key groups such as sex workers, fishermen, truckers, men who have sex with men and injecting drug users.

The result has been a steady fall in new infections in Kenya, one of the great success stories on the continent. Yet even here, 100,000 people are becoming newly infected with HIV each year, almost twice as many as are going on treatment with ARVs.

I heard the same phrase repeated endlessly on my journey – “you cannot mop the floor with the tap still running. “In Uganda, Kenya, Malawi and Zambia 80-100 per cent of Aids funds come from donors. Without further big reductions in new infections the situation is unsustainable.

“We have to try and switch this disease off,” said Dr Clement Chela, director-general of the National Aids Council, in Zambia.

In Nairobi, Pamela, a sex worker, showed us one way that might be achieved. She led us on a winding route through foetid alleyways in the centre of the city to the Somerset Club, an anonymous doorway under an illuminated sign for Tusker beer.

At the top of a flight of stone steps, five women in short skirts and tight trousers sat on a row of chairs, waiting for customers. A tall elegant woman descending from an upper floor grabbed my crotch as she passed. “Muzungu (white man),” she yelled, cackling with laughter.

As we stood chatting to Wilfred, the manager, a chewed matchstick between his lips, there was a sudden flurry of business. The women appeared leading their clients – one a bald man leaning on a crutch – calling to Wilfred as they passed, who handed each two condoms and a piece of tissue, before they disappeared into the bolted cubicles beyond. It was an impressive demonstration of safe sex– and a world away from the brothels of Kasensero.

Prostitution is a feature of every city in the world, but in Africa it has exploded in the last decade, driven by a growing economy and the power imbalance between men and women.

There are an estimated 45,000 sex workers in Nairobi and as the numbers have increased the price of sex has fallen. In Kampala, prostitutes line the streets near the Speke Hotel and sell sex for as little as 3,000 Ugandan shillings (75 pence).

Other countries are witnessing the same trend. “Sex workers are growing,” said Frank Chimbandwira, head of HIV at the Ministry of Health in Malawi. “Mines are opening, roads are being built, men have cash to buy sex – the development agenda brings risks,” said Dr Clement Chela head of HIV in Zambia. “There has been a mushrooming of sex work,” said Maria Sibanyoni, head of the sex workers programme at the University of Witwatersrand in Johannesburg.

Despite these trends, among some groups HIV infection rates are sharply down. In Nairobi, the first clinic for sex workers opened in 1985, and there are now nine across the city offering free condoms, HIV testing and treatment. The incidence of new infections has more than halved since 2005.

Crucial to the success of the strategy has been the recognition, which has been slow to dawn, that professionals are no good for giving advice. They are not listened to. Inroads into the HIV epidemic in Africa have only begun to be made with the appointment of ‘peer educators” – members of the target community who have been trained to pass on the message to their peers.

Pamela, is a respected peer educator, and is known and trusted on her patch. Aged 39, she has a round face and gentle demeanour.

Two minutes after leaving the Somerset Club we are sitting with another sex worker, Mary, in Modern Green, a higher class establishment round the corner. It is 5pm and a dozen women in clinging dresses and earrings, showing cleavage and thigh, are sitting at tables in the dingy upstairs bar.

I buy Mary a Guinness, her second. She says she can drink nine. I pick up the bottle looking for the alcohol content. “6.7 per cent” she shoots back at me, smiling.

She has on a red dress, red earrings and is smart and well spoken. She is 28 and has been a sex worker for five years. Does she use condoms?

“Of course”. She fixes me with a look of horror. “No condom, no sex.”

Behind her a drunk man is fondling a woman who is studiedly ignoring him and reading the paper – until he produces his money. Sex here costs 500 shillings (£4) plus 300 shillings (£2.30) for a room, for ten minutes.

After we leave I ask Pamela about the “no condom, no sex,” claim. It depends, she says, on whether the client or the sex worker are drunk (often both) or whether the client is offering more money for “live sex,” a common demand. “If they are very drunk, they don’t care,” she says.

Yet there is little doubt of the value of what she is doing. Peer educators are now being used across the continent – “expert mothers” trained to promote antenatal care, “expert patients” to advise on treatment with anti-retroviral drugs, “community mobilisers” to bring men for male circumcision, and sex workers like Pamela to promote regular HIV testing, treatment for STIs and condom use. Nothing can be achieved in Africa’s intensely hierarchical society without peer educators.

But while Kenya has done a good job with its marginal populations like sex workers, the challenge remains how to reduce infection rates in the general population where the bulk of transmission occurs.

Most sex workers are infected not by their clients but by their long term partners, when condoms have been dropped. It is the same in the general population – condoms may be fine for casual affairs but their use in a long term relationship signals mistrust.

“It is love and trust that makes women vulnerable. Love is the problem,” says Jane Thiomi, manager at LVCT, a Kenyan HIV organisation.

In Kenyan society, as across the continent, it is accepted that men will have more than one partner – and the wealthier they are the more mistresses they will support.

“Even when the mistress is exposed and the wife goes to her mother to complain, the question the mother will ask is: Is he taking care of you? [Infidelity] is not taken seriously,” says Ms Thiomi.

The frequency of multiple overlapping partnerships is said to be what distinguishes sexual behaviour in sub-Saharan Africa from the rest of the world – and is a key driver of the heterosexual epidemic. Yet its lethal consequences are ignored. A recent advertising campaign urging straying lovers to be careful with the catchline: “Weka condom mpangoni!” (Put a condom in that relationship) was banned after protests from church-based organisations.

“Kenyans are very sexually active, but they don’t talk about it,” said Ms Thiomi.

Few believe sexual behaviour in this regard has changed. With economies growing, more men are able to afford mistresses. While Western leaders proclaim the end of Aids, the drivers of the epidemic in Africa are working in the opposite direction.

At the same time, the forces constraining sex have lessened. In the early years of the epidemic behaviour changed because terror stalked the streets. Those infected became walking skeletons covered in sores who died horribly - and people were going to funerals every weekend. “Now people on treatment are completely healthy. We struggle to explain the dangers to young people who have grown up with HIV – there has been a complete change,” said Peter Kyambade, head of the sexually transmitted disease clinic at Mulago Hospital, Kampala.

Like everyone I met in Uganda he blamed the upsurge in infections in that country on complacency – and warned other countries that they should ignore Uganda’s experience at their peril. HIV had been transformed from a lethal infection with only one outcome into a treatable disease, like diabetes. It was no longer feared as it once had been.

“The disease has been with us a long time. People are relaxed. The focus has been majorly on putting people on antiretroviral drugs. We need to focus on prevention again.”

“If other countries don’t address this issue they will face the same challenge. Their advantage is they can learn from us. We need to go back to our communities and intensify our campaigns. We need to remind them: It is not over yet.”

Day Two Nairobi, Kenya

Gloria Gakki should be in line to win $100,000 (£62,000). Her idea for improving the appeal of condoms meets the “grand challenge” launched by Bill Gates who earlier this year offered the prize to anyone who could devise a means of increasing their popularity. She is training sex workers to put condoms on with their mouths.

The Ministry of Defence in Zambia could be a winner, too. It has designed a packet in camouflage colours and labelled it “Full Combat”.

The problem with the condom has never been its effectiveness but its acceptability. Despite 30 years of research and the expenditure of billions of dollars, no one has come up with a better form of protection against HIV. But worldwide only 5 per cent of men use them.

It’s like sucking a sweet with the paper on, its detractors say. You don’t eat a banana without peeling it.

On the wall of Ms Gakki’s office more than 100 different varieties are displayed – flavoured, ribbed, coloured – in their glittering packages. As prevention manager for the Sex Workers Outreach Project in Nairobi she hands out 1.5 million each year, more than any other organisation in Kenya. “If we didn’t have condoms, Nairobi would be on fire,” she said.

Condom use among sex workers in Nairobi has risen from near zero in the 1980s to approaching 100 per cent today. It has been achieved, she said, by “moving the focus from the professionals to the community that uses them”.

But condoms have a fatal flaw – it is called trust. While their use in casual sex has hugely improved over the past 20 years, once couples are established they discard them. To continue implies mistrust.

In Livingstone, on Zambia’s border with Zimbabwe and Botswana close to Victoria Falls, one in five of the population are infected with HIV. A border town with a mobile population, truck stops and cross-border traders smuggling fuel, alcohol and soft drinks it is a magnet for sex workers. Squatting in the dust with a group of a dozen sex workers, Abigail, 27, says she has three boyfriends. “They give you things. I don’t use condoms with them. It is not possible.”

In Johannesburg, a 2010 study found more than 90 per cent of sex workers said they used condoms with clients. But half said they dropped them with boyfriends and partners.

“They trust their boyfriends. That is what makes them vulnerable,” said Maria Sibanyoni, the sex worker programme manager at the University of Witwatersrand.

In Kampala, Molly Businge, the chief nurse at the Kawaala Health Centre, crowded with hundreds of patients on a Monday morning, wiped the sweat from her forehead and flung her handkerchief onto her desk.

“If a man uses a condom, the women will ask him ‘Are you sick?’ If a woman uses one, he will ask her ‘Are you having other men?’ Most people have negative attitudes to condoms. There is very little use by couples,” she said.

Even for those who want them, supplies are erratic. James Mamboleo, 36, a plumber, was lucky. He asked for a box while waiting for an HIV test at the Sokoni Centre in Nairobi and got it – contents: 144.

“How long will they last?” I asked, noting the alcohol on his breath. “Two weeks,” interjected his friend, laughing.

“He is an African man,” said Jane Thiomi, project leader at LVCT, a Kenyan HIV agency, smiling.

You do not see such largesse in Uganda, which has been plagued by shortages. Jennifer, a sex worker for 12 years in the Kisenyi slum in Kampala recalled the “condom crisis” a few years ago. “I used plastic bags. They were held in place with a rubber band,” she said.

Last year, just 58 million condoms were delivered for free distribution in Uganda, barely a quarter of what was ordered. This year supplies have improved – but more than half of the 280 million ordered are still awaited.

Those most vulnerable – schoolgirls – are denied them. It is against the law to distribute condoms to under-18s. Vastha Kibirige, Uganda’s condom czar, described passing a secondary school where a group of girls saw what she was carrying.

“‘Can you give us some?’ they shouted. I said ‘No, I will be in jail.’ They said: ‘What do you want us to do – die?’” she said.

Even where condoms are acceptable they have a major drawback. They are controlled by men. Negotiating condom use is difficult for women – and often impossible.

The female condom was supposed to hand control to women. But it must be inserted 10 to 15 minutes before sex to “warm up” or it is noisy – a key weakness for sex workers. Some have left a single one in place while having sex with different clients – transforming a protective device into a potentially lethal one.

Many in government and charity organisations I spoke to complained they had wasted thousands of dollars on female condoms which they could not give away. Its defenders, on the other hand, claimed the problem lay not with the product but with the marketing. It hasn’t had any. Male condoms are promoted on billboards, in bars and offices throughout Africa.

Regular users say the female condom improves pleasure for both partners, because the man moves inside it and the woman is stimulated by the external ring. In the Kenyan district of Makwene, 200km from Nairobi, men have begun asking for it after it was popularised by the District Aids Officer. “The message was sold right,” said Jane Thiomi.

To overcome these problems researchers have sought alternatives. Tests with microbicidal gels inserted in the vagina to kill HIV have yielded mixed results. While one study found a 39 per cent reduction in HIV infection another, in which women were required to insert the gel daily, showed no effect. Women claimed to be using it in order to get the regular medical check-ups but instead threw it away.

Deborah Baron, the manager of the latest and biggest study at the University of Wiwatersrand called Facts, involving almost 3,000 women at nine sites across South Africa, said: “We know these products work biologically. We have got to find a way to help women use them. I know sunscreen works – but when I go on holiday I get burnt.”

Researchers expected the women to use the gel secretly. In practice eight out of 10 told their partners. Some complained about the quantity they had to insert – 4mls – and said it leaked into their pants.

Dorcas, 28, a shop assistant from Daveyton in Johannesburg, with painted nails, a pink blouse, and gold earrings, who participated in an earlier study, said: “It was so uncomfortable. With lubricant you use a little but with this you had to put the whole thing. I was using it in the morning so when I had sex it had dried out. I was living with my boyfriend – it would have been impossible to keep secret.”

Catherine, 28, a saleswoman, and Khesani, 26, mother of a 20-month-old boy, said they would prefer a daily pill to the gel, which would be easier to use secretly, even though it would mean taking a higher dose of the drug. “You can hide them in the house, take them to work and swallow them,” said Catherine.

The greatest hopes now rest on the vaginal ring, a device made of soft silicone that slow-releases microbicide into the vagina and can be left in place for a month. It is being tested in 5,000 women in five countries across southern Africa (in two separate trials) and the results are due in 2015.

“You put it in and forget about it. Most women say they love it,” said Krina Reddy, one of the trial co-ordinators. “The staff are excited. We do have faith this will work.”

Dr Thesla Panalee, the international co-chair of the Microbicides Trials Network, said: “We have our fingers crossed. It has been a long time coming. We do need women-controlled methods against HIV.”

Day Three: Malawi

They serve coke, cake and gospel music on the 7am bus from Blantyre to Lilongwe in Malawi – and they ask for the name and telephone number of your next of kin before you board. With a chorus of “Jesus, how great thou art” ringing in my ears, I settled down for the five-hour journey with a copy of the Malawian newspaper The Nation – which carried a full page article on “labia stretching”, claimed by some to increase sexual pleasure.

In this deeply religious and conservative country, more than one-in-ten people are infected with HIV – almost twice the rate in Uganda and Kenya. In the antenatal clinic at Queen Elizabeth Hospital in Blantyre 18 per cent of women are HIV positive.

Now this impoverished nation has found itself leading the world with a scheme to tackle one of the worst effects of the Aids virus – its capacity to infect succeeding generations. It has a devised a scheme to offer immediate, lifelong treatment with anti-retroviral drugs to all pregnant women who test positive for HIV.

The scheme is controversial because it involves prioritising pregnant women over other HIV positive adults who only qualify for treatment when they are sick. It has also run into an unexpected problem – high drop-out rates. This has raised fears it could fuel drug resistance.

More than 250,000 babies were born infected with HIV worldwide in 2012. Although the number has halved in the last decade, hundreds of thousands still suffer arrested development, face a lifetime on powerful drugs, and form a reservoir for the continued spread of the virus.

I saw its consequences at Zomba hospital, 300km south of Lilongwe, where one-in-seven of the population is HIV positive, the highest prevalence in the country.

David Saiti, 43, a vegetable seller, had brought his daughter, Elizabeth for treatment. The shock in my interpreter’s voice when he asked the little girl her age was obvious. “Ten,” she said – though she looked much younger. “I thought she was six,” he told me.

I asked Elizabeth what her favourite subject at school was. “Maths,” she answered quietly, adding “I want to be a doctor.” She has spent her life surrounded by them. But when I asked if she knew what was wrong with her, she hid her face in her shawl. Despite 30 years of effort to increase tolerance, the stigma of an HIV diagnosis remains.

Cutting the risk of transmission of the virus from mother to child has been possible for decades, initially with a single dose of an anti-retroviral drug. There have been many changes since in the regimen recommended by the World Health Organisation (WHO) and today the risk can be reduced to below 5 per cent if the mother accepts long term treatment with anti-retroviral drugs.

That is a big if. For many women, making repeat visits to the clinic – often involving lengthy journeys – for tests of their immune system was too difficult. More importantly, it was beyond the capacity of Malawi’s rudimentary health system to provide. Instead, it adopted a public health approach: give anti-retroviral drugs immediately to all pregnant women who are found to be HIV positive, and continue them for life, without the requirement for repeat testing of their immune system.

The effect has been dramatic. Launched in July 2011, the scheme, known as Option B+, has reached 60,000 women, a six-fold increase in a year. The number of clinics distributing anti-retroviral drugs has more than doubled and doctors report significant falls in the number of HIV positive babies being born.

“The trend is definitely down,” said Neil Kennedy, head of paediatrics at Queen Elizabeth Hospital. “Option B+ is fantastic. It is the right answer.”

Other countries are following Malawi’s lead. Uganda adopted Option B+ six months ago, Zambia and Rwanda have similar plans and the scheme is being discussed in Zimbabwe and Tanzania.

“I was surprised how quickly it was taken up. It was unbelievably fast,” said Eric Schouten, formerly of the Ministry of Health and one of the architects of the scheme. “A small African country said to the WHO: ‘We don’t like your guidelines, they don’t make sense’ – and the world is following us.” WHO has since modified its stance to include the regimen.

The main challenge is persuading women who discover they are infected during routine antenatal tests to accept the treatment – and stick with it. Stigma remains a key barrier. “It is a real challenge for women to be told they are HIV positive and to take home the drugs and tell their family they are going to take these for the rest of their life. Many women leave the clinic and throw the drugs away. We never see them again,” said Fabian Cataldo, a researcher with Dignitas International in Zomba.

Breaking the news to their husbands is the hardest task. Official figures from the Malawi Aids Commission suggest around a quarter of women default. Others, such as Medicins Sans Frontiers, say the default rate is higher. “We found nine per cent dropped out on the first day and a further 27 per cent at three months,” said a spokesperson.

If the scheme led to a rise in drug resistance, the consequences could be devastating. The current standard drug cocktail – three anti-retrovirals in a single pill – costs $200 per person per year and is wholly funded by donors. Malawi could not afford expensive second line HIV drugs if the first line failed. “We are worried about resistance,” said Frank Chimbwandira, head of HIV at Malawi’s Ministry of Health.

To improve adherence, Dignitas has trained a team of “expert mothers”, women like Grace who have been diagnosed HIV positive and faced the loss of spouse and home and can counsel women enduring similar trauma.

Aged 39, she was diagnosed in 2007 while pregnant with her fifth child. It took her two weeks to tell her husband. “He left four months later. Now he is married again.”

Grace remarried in 2011, to a man who was also HIV positive. She said: “There is a lot more awareness of the importance of anti-retroviral drugs. There would be a different reaction now.”

Her optimism is encouraging. But less than half the clinics in the south east have expert mother support, and coverage is lower elsewhere.

The key to reducing stigma is to normalise HIV testing so that everyone knows their status and checks it on a regular basis. Malawi is pioneering a second innovation. It is the first country in Africa to introduce HIV self-testing at home. The scheme has been piloted among 16,000 people in Blantyre with an 84 per cent acceptance rate after a year and a three-fold increase in those reporting they have HIV and starting on treatment.

Professor Liz Corbett, leader of the study at the Malawi-Wellcome-Liverpool Research Centre in Blantyre, said there were fears that home testing would lead to marital disputes and even violence. “Nothing has been reported that is alarming in discovering this information in this way – it is very reassuring. The commonest complaint is from those in the control arm who want the test. There would be no problem getting people to test annually based on what we found. To maximise prevention we need people to test annually in areas of high HIV prevalence”

Day Four: Lusaka, Zambia

David Mvula was waiting alone at the New Start Male Circumcision clinic in Lusaka when I visited at noon on a Tuesday. He was twiddling a red baseball cap belonging to his friend with the logo “Legoland California” on it.

“I did mine last May. Now I have brought him. I told him he had to do it,” he said.

Four more men arrived in the next hour – looking apprehensive – and Mildred, the manager, pronounced it a good day with 12 operations carried out at this walk-in centre (no appointment needed) before lunch.

When I first visited the clinic five years ago, it had performed just 1,000 circumcisions and was pioneering the procedure in Zambia. Today more than 500,000 Zambians have sacrificed their foreskins at this and other clinics to gain protection from HIV – and millions more have followed across sub-Saharan Africa.

But it is not enough. Zambia is still 75 per cent short of its target of two million circumcisions by 2015. So is Uganda, having completed 1.5 million towards its 4.1 million target. Kenya has achieved its target in numbers – but not among the “right” men.

The donors who are pouring cash into male circumcision following the landmark 2006 study which showed that it reduced the risk of HIV infection by 60 per cent, have neglected a crucial factor – the attitude of women.

Why would a man seek circumcision, unless he had plans to sleep around? For single men, there may be no barrier other than their fear of the surgery. But for men with partners, whether married or otherwise, there are two people whose views must be taken into account.

As with condoms, it is the issue of trust that is holding back progress with circumcision across the continent. The message about its protective power is now widely understood. Parents bring their children – in Nyanza province, western Kenya they have had to ban them after the demand proved overwhelming – and teenage boys flock to the clinics. But the key age group - men aged 20 to 40 who are chiefly responsible for spreading HIV – do not come. David and his friend, both in their 30s, are the exception.

Namwinga Chintu, director of the Society for Family Health, which runs the New Start clinic and has carried out four fifths of Zambia’s circumcisions, said: “All countries are grappling with the same problem. We have scores of kids – parents don’t have a problem with it – but the real challenge is to get the older men.”

In Uganda they are going to extraordinary lengths to drum up business. On a dusty field in the village of Kakuuto, 200km south west of the capital Kampala, a crowd of 600 was gathered, seated on benches and chairs under marquees, around a bus belting out deafening music carrying the legend “Muleme Mambe” – Stylish Man.

In the centre of the arena dancers and comedians performed, and men were urged to compete for prizes – a power generator, a bicycle and the star prize of 10 corrugated iron sheets worth $100 – but only if they agreed to undergo circumcision.

The DJ hosting the proceedings called out “Who will be the most Stylish Man?” to roars from the crowd, while glamorous young female dancers gyrated on stage and then mingled with the crowd looking for recruits. Behind the arena, a long red carpet led to the registration and counselling tent, where a dozen young men sat nervously waiting their turn.

Carol Musimami, one of 30 “technical advisers” who counsel the men, said: “You will see the older ones come after dark. They don’t want to be with the youth. We are targeting the 25 to 35-year-olds –they are the ones with the money, they buy the women, they are exposing themselves [to infection]. But they are hard to get. They don’t want others to know,” she says.

Leadership is key. In Kenya, the circumcision programme in Nyanza province in the west – one of the three centres in the landmark 2006 trial that proved its effectiveness – was faltering when Raila Odinga, the Prime Minister and a member of the non-circumcising Luo tribe, responded to protests from tribal elders fearing the loss of their identity by declaring: “We don’t lead with our foreskins, we lead with other faculties. This is a medical issue.”

The speech, in 2008, proved a pivotal moment and more than 500,000 Luos have since been circumcised.

But persistent concerns remain and, as elsewhere, older men are reluctant to come. Last month, governors of the provincial capital Kisumu invited one of the most famous advocates of circumcision in Africa, Chief Mumena from Zambia, to tour the province to persuade the elders that circumcision is not just for infants but for adults, too. Wearing jeans, a polo shirt and his signature bowler hat – made by Lock &Co of St James’s – his royal highness met me in the Imperial Hotel in Kisumu on a break from his busy schedule of conferences and speaking engagements.

A former telephone engineer who inherited his title as head of the non-circumcising Kaonde tribe in north-western Zambia more than a decade ago, he risked impeachment by undergoing circumcision in 2011 at the age of 47.

“I was a convert of my own son. At 18, Benjamin said he wanted to go for circumcision, for medical reasons. I did research, talked to my wife and realised what a wonderful way it was of reducing new infections. I was worried how the elders would react to my doing something contrary to our culture. But when I explained the benefits they were excited.”

His bravery won him accolades across the continent, an audience with Bill Gates and an invitation to last year’s International Aids Conference in Washington, turning this courteous, undemonstrative former technician into an articulate and effective global campaigner on HIV prevention.

His success underlines the importance of recruiting peer educators at every level in the battle against the epidemic – sex workers to distribute condoms in the brothels, and chiefs to spread the word among tribal elders.

But confidence in circumcision in western Kenya has been damaged by a new development. Latest figures from the Kenyan Aids Commission show that while HIV prevalence has been cut in half in Nairobi and on the coast in Mombasa to less than 5 per cent since 2007, in Nyanza, which already had the highest rate at 15 per cent, there has been no change.

In his sweltering office in a dusty suburb of Kisumu, Dr Ohage Spala, the director of Impact, a sex worker and behaviour change project, said: “People are asking, ‘Why are you promoting circumcision when it has made no difference?’ It is difficult to answer. Of course the figures are disappointing. How come all this effort is being made and all this money is going in and prevalence is not going down?”

The figures worry Peter Cherutich, Kenya’s conscientious head of HIV prevention at the Ministry of Health who is waiting for the incidence figures – the key measure.

“I hope to have a definitive answer to the Nyanza question. We need to know what is driving the epidemic. It is politically necessary or people will question why we exist. We may be prescribing the wrong medicine,” he said.

But he is not about to abandon circumcision. “We are convinced it is a key preventive measure.”

Yet doubts remain. Research last year suggested four out of 10 men were resuming sex before the recommended six week healing period – when the risk of transmission is increased.

“Men come without telling their wives. It may be they feel under pressure to resume sex after a long period pretending they are not interested. That could be the problem,” said Dr Elijah Odoyo-June, who led the research at the Nyanza Reproductive Health Society in Kisumu.

There were also signs that men were having more sex after circumcision. “There is a subjective belief that they perform better – it is common among men and women. It is a good myth for encouraging men to come – but it is not good if it leads to more unprotected sex,” he added.

Day Five: Kwa Zulu Natal, South Africa

The Phakama Tavern stands isolated in a cinder car park on a hillside, a grimy beacon to the pleasures of alcohol. Around it, concrete shacks, each with its own fenced compound, stretch across the scrub-covered hills to the horizon.

There is no furniture of any kind inside. Half-a-dozen figures stand or sit on the bare concrete floor in the gloom, bottles of Castle beer around them. Behind the counter, the bartender is imprisoned by a heavy iron grille.

As I enter, a man with silver earrings levers himself unsteadily to his feet, grasps my hand and shakes it vigorously. “Can you get me a job?” he asks, thickly.

The coastal province of Kwa Zulu Natal (KZN), where 60 per cent of the population depend on government hand-outs, has the highest rate of HIV in South Africa, itself the country with the highest HIV rate in the world. More than five and a half million people are infected – and in KZN the virus has spread to more than one in four (29 per cent).

But the province now has a new, more optimistic, claim to fame – it is also the first place in the world to demonstrate that by rolling out treatment with anti-retroviral drugs (ARVs) to those infected, it is possible to cut the rate at which the virus spreads through the population.

The drinkers at the Phakama Tavern in Hlabisa, a mainly rural area with a 90,000 population, have a 38 per cent reduced risk of contracting HIV if they live in a community where treatment coverage is high (at least four out of 10 people with HIV on ARV drugs) compared with those communities where coverage is low (fewer than one in 10 of those infected on drugs).

The discovery by Frank Tanser and colleagues from the Africa Centre, a couple of kilometres from the Phakama Tavern, published in Science last March, created ripples around the world. It followed the landmark 2011 trial in The New England Journal of Medicine (NEJM) showing that treating couples where only one sexual partner had HIV reduced transmission to the other by 96 per cent. The question the NEJM trial raised was: could a similar effect be achieved across a whole population? Dr Tanser’s work proved that it could.

That in turn raised an extraordinary prospect – the possibility of halting the Aids epidemic.

“We were so excited when we saw the results. The response has been overwhelmingly positive,” Dr Tanser said, sitting in the Africa Centre’s airy building, where sparrows pick crumbs from the tables and an owl has taken up residence in the ceiling – to the consternation of the more superstitious African staff. “It’s the first time that anyone has shown in the real world in sub-Saharan Africa that treatment reduces the risk of acquiring HIV infection.”

Now other groups are racing to confirm the findings. On these studies global hopes of an end to the Aids epidemic rest.

In a dusty, windblown field, bordered by a sugar cane plantation and a copse of eucalyptus trees, the first attempt is under way a few kilometres from the Africa Centre. Launched in March 2012, the Treatment as Prevention (TasP) trial has begun to enrol 10,000 patients at mobile clinics such as this one at Egedeni (with a further 12,000 to follow next year, subject to funding) who will be offered testing and immediate treatment with anti-retroviral drugs.

Typically, this will mean that patients start treatment while they are still in their 20s and at their most sexually active, (sooner than in the Tanser trial), with a potentially greater effect in halting the spread of the virus.

But there are huge challenges. It is one thing to prescribe a pill that could end Aids. It is another to identify those who are infected and persuade them to take it. Stigma, long queues at clinics, and travel distances all act as barriers

Nonhlanhla Okesola, standing beside the vehicles that serve as consulting rooms for the Egedeni mobile clinic which she manages, said: “It could be we will have a problem with adherence. It is a challenge for any treatment. When patients feel well they stop taking it.”

Five patients were sitting on plastic chairs under a canvas that flapped in the hot wind as she spoke. In the Tanser study, one in five defaulted during its seven-year course. More recent figures from the Africa Centre suggest that as the numbers on treatment have grown, adherence has declined – possibly as a result of growing pressure on the clinics.

Collins Iwuji, project co-ordinator for the TasP trial, said that early indications were good, with 80 per cent of patients accepting an HIV test.

“We have an opportunity now to bring down new infections so they are less than the numbers going on treatment. We have to try. Otherwise you are constantly chasing something you can’t catch.”

An even bigger test of the treatment-as-prevention approach began last month. The $133m study at 21 sites across South Africa and Zambia involves almost one million people who will be offered testing at home and immediate treatment with ARVs.

Helen Ayles, director of the research group Zambart, in Lusaka, who leads the trial called PopART (Population Effect of Antiretroviral Therapy) in Zambia, has made meticulous preparations. But she is steeled for failure.

“I am mildly sceptical, which I think is appropriate for a researcher in my position. The crucial factor is the level of coverage – can we persuade enough people to buy into this?”

The trial is being run from existing government clinics (unlike that in Kwa Zulu Natal) so that if it works it can be easily adopted. But at the Chipata Health centre in Lusaka on a Monday morning – already treating 19,000 patients with ARVs – the scale of the challenge is apparent. Patients jammed every clinic, every bench, every corridor; exhausted mothers clutching their babies, sickly children, hollow-eyed youths.

I joined community workers going from house to house to explain what was to happen. The prospect of home testing for HIV was welcomed – but people were sceptical whether the service would last. They have seen too many come and go. At the Chipata community centre, two dozen neighbourhood representatives, mopping their brows in the heat, said that, with proper explanation, the scheme could succeed.

But when I asked what would happen if, during a home visit, a woman tested positive and her husband negative, doubts surfaced. Many men would be angered by such an outcome.

“There is a loss of trust. Counsellors need to be there,” said a woman wearing a yellow “Stop TB” T-shirt.

Sitting beside me, Dr Kwame Shanaube, study manager, whispered: “How do you sensitise a whole population? We have a limited number of people we can hire. But we believe this is definitely the way to go.”

Dr Clement Chela, director general of Zambia’s National Aids Council, backed the trial. New infections have come down but are still running too high. “We have to switch this off,” he said.

But he has personal experience of the difficulties. “My own niece died of Aids after she stopped taking the drugs. She was still in her 30s, she had a child, she had money and family support. She was a treatment advocate – unfortunately she was not able to apply those things to herself.”

“To keep people on treatment, we have to involve everyone. The community must come in, the chiefs must come in, the neighbours must come in, to try to sustain this.”

Almost 500 community health workers have been trained to roll out the message across Zambia. The trial is due to run for five years but Dr Ayles said she would know in as little as six months whether the approach would work. It will be a critical moment for the fight against HIV.

“When we go out into the community in the first sweep we will see what happens. We will have some big answers to whether we can do it or not.”

The writer’s trip was funded by a no-strings grant from the European Journalism Centre

Day Six: Love is the drug putting couples at risk of Aids in Africa

Sex is no longer the main driver of Aids in Africa. It is love, and trust.

This autumn I spent five weeks travelling through the most captivating continent on Earth, examining the epidemic that has laid waste to it. As I journeyed through bars and brothels, schools and hospitals, clinics and research centres, one phrase echoed in my head. I talked to scores of doctors, sex workers, tribal leaders, patients, civil servants, mothers, social workers and campaigners, assisted by a no-strings grant from the European Journalism Centre.

But it was the words of Jane Thiomi, manager with a Kenyan HIV organisation called LVCT in Nairobi, which kept coming back to me.

She was explaining how, among sex workers, it was not their clients who infected them, but their boyfriends. “It is love that makes them vulnerable,” she said.

In its fourth decade, the epidemic, which has claimed over 20 million lives so far, has changed. Unlike other diseases which wreak devastation across the continent such as malaria and tuberculosis, Aids is wholly avoidable. People know better than they did what they need to do to protect themselves. They know the importance of abstinence, faithfulness and condoms.

What they have not learnt to deal with is love. Long-term relationships between men and women involve commitment and trust and it is fear of undermining that trust that prevents many from seeking the protection – whether condoms, male circumcision, or treatment with antiretroviral drugs – that they need.

While Western leaders proclaim the end of Aids, bolstered by research showing antiretroviral drugs reduce HIV transmission by 96 per cent, few in Africa share their optimism. Huge advances have been achieved in rolling out the drugs – taken by 10 million people –and new infections have fallen by a third since 2001.

But no one knows how much of that is due to behaviour change, drug treatment or to the natural course of the epidemic – newly emerging viruses always cull the most susceptible first. The fall has slowed in recent years and in Uganda new infections have begun to rise again. The drivers of the epidemic in Africa are strengthening, not weakening. As economies grow and men become better-off they can afford to keep mistresses or use sex workers. Continuing gender inequality keeps women dependent on men, forcing many who lack a male breadwinner into sex work.

The major donors are losing faith in efforts to change sexual behaviour. In Uganda, the US Centres for Disease Control organisation has closed its behaviour change research centre in Entebbe. In Kisumu, Kenya, a well-regarded youth project called Tungaane shut its doors after donors switched to biomedical interventions such as male circumcision.

Biomedical interventions require behaviour change too. As with condoms, men must be persuaded to volunteer for circumcision and HIV-positive pregnant women must be persuaded to accept antenatal testing and drug treatment. In each case what prevents them doing so is love.

Condoms, the single most effective preventive measure against HIV infection, were once uncommon in Africa. Today they are widely used in casual affairs and with sex workers. But their use in long-term relationships is close to zero – it signals mistrust.

“If a man uses a condom, the woman will ask him, ‘Are you sick?’ If a woman uses one, he will ask her ‘Are you having other men?’ Most people have negative attitudes to condoms. There is very little use by couples,” said Molly Businge, chief nurse at the Kawaala Health Centre in Kampala.

With male circumcision, the message about its protective effect has got through. Parents bring their children and teenage boys to queue up for the surgery. But the over 25-year-olds stay away. They have wives and girlfriends – how do they explain why they need circumcision? Fear of undermining their relationships holds them back.

A pregnant woman who discovers she is HIV positive must start drug treatment immediately, and continue for life. She must bring her child back for testing after birth and may have to give it drugs, too. And she must break the news to her husband who may reject her. Many fear this so much they throw the drugs away.

Among the lessons I learnt on my journey are that there is not one HIV epidemic in Africa but hundreds, each with its own drivers. That nothing can be achieved without involving specially trained “peer educators” – members of the community being targeted to help spread the message – a strategy that is now being adopted across the continent. And while starting people on drugs is a huge achievement, keeping them on them is an even tougher challenge.

But one area of research has been neglected – trust. If we understood it better we might understand how to help couples protect themselves more effectively from the holocaust that has swept Africa. In Kenya, almost half (44 per cent) of the 100,000 new infections a year occur in stable relationships while just a third are linked to high-risk groups such as sex workers.

Nduku Kilonzo, head of the Kenyan HIV organisation LVCT, said: “We are not investigating the nature of trust. What leads a couple to abandon condoms for example? It’s a key thing we avoid. We need to start thinking about it.”

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