- South Africa needs to get more than a million people on antiretrovirals (ARVs) — in addition to the 5.9-million who already are — on HIV treatment before the end of next year to meet the global targets to end Aids by 2030.
- Over half of these have to be men, a group that the country has struggled to get — and keep — on ARVs so far.
- Men don’t get on treatment, for many reasons — from the stigma of HIV and the lifelong nature of the disease to having to queue for a long time at a clinic.
- Can a project that looks at the problem like building an all-male sports team help solve this?
In today’s newsletter, Zano Kunene tells us why the Coach Mpilo project can help men get onto — and stay consistent with — their HIV treatment. Sign up today.
South Africa needs to get about 1.14-million more people with HIV on treatment by the end of next year if the country wants to make good on the goals it signed up to to help end Aids by 2030 — and about half of them need to be men, a health department presentation showed at the International Aids Conference in Germany in July.
To reach the so-called 95-95-95 targets set by the Joint United Nations Programme on HIV and Aids (UNAids), countries need to have 95% of all people with HIV diagnosed, 95% of this group on antiretroviral (ARV) medication and 95% of those on treatment having so little virus in their bodies that they can’t infect someone through unprotected sex (this is called viral suppression).
While South Africa is doing well with diagnosing men who have HIV (about 94%), starting them on treatment lags behind. The Thembisa model, which the health department uses for reporting the country’s HIV figures to UNAids, shows that only around 74% of men with HIV in the country are on ARVs, and of those just 63% are virally suppressed.
This is 16% lower than in women, the Thembisa model shows.
Getting men on treatment and sticking to it is often difficult, because of the stigma around having HIV, like their partners not wanting to have sex with them if they’re open about their status or getting a positive test result being a sign that death was “imminent”. Moreover, long waiting times at clinics put men off and the idea that the facilities are “female social spaces” because most nurses are women, who make some men feel uncomfortable talking about health issues such as those around their sex lives.
But thinking about getting guys on treatment like building a winning sports team could change the game. Here’s how.
‘They just get better at hiding’
Trying to get men on medication often means health workers are “tracking them down [to follow up] and then dragging them into the clinic,” says Shawn Malone, who heads the Mpilo Project, a partnership between Population Services International (PSI), a global network of public health nonprofits, the Bill & Melinda Gates Foundation and organisations funded by the US President’s Emergency Plan for Aids Relief (Pepfar).
But, he says, the problem is that they then “just get better at hiding”.
Instead, the Mpilo model gets men with HIV to help other men with HIV.
It’s not just a peer support group, though; it’s more like a sports team. HIV-positive men who have been on treatment for at least a year work as “coaches” (and are paid roughly the same as a community health worker — about R4 000 a month) to help newly diagnosed guys — the team’s “players” — understand how to talk to their families about their diagnosis, stick to taking their pills and go back to the clinic for check-ups.
By April this year, three years since the Coach Mpilo model was first introduced and started being rolled out by implementation partners, there are now 364 coaches based at 291 clinics, across all nine provinces.
When men test positive for HIV at these clinics, a health worker refers them to a coach, who has been trained to talk to guys — not only about dealing with their diagnosis, how treatment works and why it’s important to stick to it, but also about things like handling their relationship or sex life.
If they agree — in writing — to join the coach’s “team” and stick to the playing rules, they’re added to a list of players. The coaches also follow up with men who’ve not gone back to the clinic to start their treatment.
Muzi Mathebula, a coach at the Chiawelo Clinic in Johannesburg, says he’s seen that many men struggle to come to terms with the diagnosis.
He himself tested positive for HIV in 2008, but didn’t start treatment then. At the time, the government’s policy was that only people in whom the number of a type of white blood cell (called CD4 cells) was under 200 cells per millilitre of blood could get ARVs because at this point the virus would have weakened the body so much that it can’t fight off other infections or diseases.
He felt healthy, says Mathebula, so he didn’t think much of being HIV positive.
Researchers conducting a study in KwaZulu-Natal’s uThukela district, where one in every four adults has HIV, heard similar things: men with HIV said they hadn’t started treatment because they felt uneasy with the diagnosis or didn’t feel sick.
Says Mathebula: “Being a man, I took it as it is and in my mind I was healthy. But over the years I got sick, I lost weight, my skin changed and I lost energy.”
‘Living a normal life with HIV’
South Africa now has a universal test-and-treat strategy, which means that anybody who tests positive for HIV can start treatment immediately, regardless of their CD4 count.
Starting treatment too late is bad news, for two reasons: it can lead to the infection spreading when people have unprotected sex and because the infected person can develop other health problems such as tuberculosis or some types of cancer easily. This happens because when someone is not taking anti-HIV pills, the virus can multiply uncontrollably and weaken their immune system.
PSI’s own research among a group of more than 2 000 men, who were either HIV positive or negative, showed that although they knew they could get tested and treated at clinics, they didn’t because speaking to a nurse seemed “scripted and like being lectured,” Malone explains.
The challenge lies in actually getting men to agree to take the medication, says Mathebula.
That’s why he and the other Mpilo coaches use their own stories and experiences to give their players proof that you “can carry on living a normal life with HIV”, just as he has.
Over the last three years (since the launch), Malone says that figures from three of their implementation partners (Wits RHI, Health Systems Trust and TB HIV Care) show that among 41 671 men supported by 117 coaches, 97% have started treatment — and 97% of those who are on ARVs have stuck to it.
“After two to three months of intensive support from the coaches, most men are doing much better and coach support begins to taper off, although the coach is still available,” says Malone.
Coaches were also good at getting people who had stopped taking their medication back on track, a pilot study showed. Out of the 563 men who had stopped taking their pills in the six months of the study, 82% were back on treatment within two months with their coach’s support.
The model also works because coaches don’t speak to their players only about HIV and treatment, like a health worker would, but they also chat about things like relationship troubles.
Mathebula explains: “It’s easy for them [the players] to come up to me and say, ‘I’m having this issue [for example, sexual dysfunction]. How do we solve it?’ Even if it’s outside of HIV.”
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Giving people options
Experts say the more ways there are to get people their medicine, the better — whether it’s setting up smart lockers from where people can collect their pills, having home deliveries, non-clinic based pick-up points or being part of an adherence club.
In fact, at the Aids 2024 conference in July, the health department said using different ways to help people stay on their pills is “critical” and that we need to “move away from a one-size-fits-all approach for returning patients”.
One of these could be to set up peer support groups in which ordinary people (read: non-health workers) are trained to help others in their communities stay on treatment — which is exactly what Coach Mpilo does.
For example, a project running in Eswatini, Mozambique, Tanzania and Zimbabwe trained 353 young people (between 17 and 23 years old) to be treatment supporters to over 18 000 of their peers with HIV.
In Zimbabwe, the project compared a group of 50 young boys and girls on ARVs who went to a clinic to get their pills to another group of the same size who did that and also had meetings with the treatment supporters.
Those who had a peer group cheering them on were close to four times more likely to stay on their treatment than the group who had only clinic visits.
By using men who aren’t health workers to give peer support to other men, the Coach Mpilo model gives another way to help men stay on their treatment that doesn’t look like the standard methods they’re already hesitant to use.
Says Malone about why they’re behind the Coach Mpilo model: “It helps when it’s another man who’s been on the same journey, [one] who can say ‘I have been in your shoes. I know the fear and how you are feeling.’ So men can open up more easily.”
The Bill & Melinda Gates Foundation is mentioned in this story. Bhekisisa receives funding from the foundation, but is editorially independent. Read more about the nature of our donor relationships.
[Update: 27 September 2024, 09:30] An earlier version of this story mistakenly stated that there were 1.8-million people on ARVs in South Africa but this is only for men. The figure has been changed to 5.9-million, which is the total number of people on ARVs.]
