The Philandoda clinic run by medical humanitarian organisation Doctors Without Borders (MSF) is tucked away in a discreet corner of Eshowe’s busy taxi rank.

Every week, about 20 men walk through the doors of a container-cum-health centre. Many are taxi drivers and travellers, including men in transit to far-flung places such as Durban and Johannesburg. But it wasn’t always like this when the clinic first opened in July. In those first days, community health workers Bongani Thethwayo and Nkosinathi Mpungose were lucky if one man a week walked in through the doors.

That’s when the duo took matters into their own hands. They began walking up and down the rank, popping their heads into the white Siyaya taxis. As drivers and passengers alike waited for each minibus to fill up before it could depart, Thethwayo and Mpungose spoke to the men inside about the services on offer at their clinic — testing and treatment for sexually transmitted infections (STIs), including HIV and referrals for medical male circumcisions (MMC).

MMC has been shown to reduce a man’s risk of contracting HIV through vaginal sex by about 60% and the World Health Organisation now recommends the procedure as an HIV prevention method.

Thethwayo and Mpungose then set out to canvass the area’s traditional leaders in the rolling green hills outside Eshowe, about 150km north of Durban. Because both men are from the area, they were able to develop close personal and working relationships with chiefs.

The duo’s networking paid off.

“In July we saw 138 clients. Eighty-four were tested and only four were HIV-positive. In August we had 209 clients, 159 were tested and 13 were positive. In September the headcount was 215 and we conducted 120 HIV tests and eight were positive. In October we saw 230 men and 149 were tested, nine were positive. So far we have initiated 29 people on treatment from July to October,” says Thethwayo.

An increasing number of men now walk into the clinic each month to talk about issues such as condom use, STIs and erectile dysfunction, he says, which the health facility doesn’t treat but refers men to other clinics for help. And sometimes the men just come to chat about their relationships, something that is a bit of a rarity in these parts.

Mpungose explains that here the notion of “Zulu pride”, or the concept that strength is a defining characteristic of being a “real man”, makes even sickness a sign of weakness. This means men are often reluctant to seek out medical care and this includes HIV testing. Factor in fears of gossip in a small town where your clinic nurse could be your neighbour and the reluctance of men to test for HIV only doubles, he says.

No one knows this better than Thethwayo and Mpungose, who grew up here.

In South Africa, as in many other countries, men test for HIV at lower rates than women. The country’s latest national HIV survey found that about 72% of women 15 years and older said they had tested for HIV, according to 2012 data from the Human Sciences Research Council (HSRC). Only six out of 10 men canvassed could say the same, the research found.

And men who do test are also less likely to stay on treatment. About half of women living with HIV in South Africa are on antiretrovirals compared with about a third of HIV-positive men, research presented at the 2016 International Aids Conference reveals.

Consequently, men are more likely than women to die of Aids-related illnesses, even in sub-Saharan Africa, a region where new HIV infections in women far outpace those in men, according to 2013 research published in the journal Aids.

By offering services for men by men, Thethwayo and Mpungose are hoping to change this and help men to feel more comfortable about seeking out care. If they do, they could help to curb new HIV infections more widely within their community in this hard-hit area, where up to a quarter of people live with the virus, data from the 2012 HSRC survey shows.

And South Africa won’t achieve the latest round of international HIV goals without finding its missing men.

UNAids’s 90-90-90 goals aim to ensure that 90% of people know their HIV status, that 90% of these are on treatment and that 90% of those on antiretrovirals adhere so well to treatment that they have very low levels of HIV in their blood. When people adhere to HIV treatment, the medication can bring the amount of virus in their blood to almost undectable levels. This is known as viral suppression.

Almost two decades of research published in journals such as the New England Journal of Medicine has found that people who are virally suppressed can’t transmit the virus.

So if more people in areas like Eshowe test for HIV and more start treatment, science posits there will be fewer new HIV infections.

MSF has been trying to achieve the 90-90-90 targets since beginning to work in Eshowe in 2013 and says that about three in every four people living with HIV know their status. Of these, about 85% are on treatment and an equal proportion are virally suppressed, according to a 2016 MSF report.

Musa Ndlovu, MSF deputy field co-ordinator in Eshowe says: “We will only know if new HIV infections are falling after conducting a second population survey in 2018, but we do already know that our community testing and treatment support initiatives have apparently contributed, since 2012, to 86% of patients on treatment in the project area having a suppressed viral load one year after being on treatment — very close to achieving the so-called ‘third 90’.

“We estimate that we are also close to reaching the first two 90s. The proportions of people in care, receiving timely viral load tests and succeeding on treatment are higher than the national average.”

A similar set of services is available at Umfolozi College’s Eshowe campus: STI screening, pregnancy tests and HIV testing and counselling (HCT) for its students. Silindile Mtshali the nurse on duty is assisted by lay counsellor, Mduduzi Dlamini. By making her office a one-stop shop for counselling and treatment, those affected by HIV are less likely to default on their medication and easier to track in the event they need more support.

Umfolozi College is one of nine public Further Education & Training Colleges in the province of KwaZulu-Natal and one of only 50 in the country. The College has 5 main campuses: Chief Albert Luthuli, Eshowe, Esikhawini, Mandeni and Richards Bay.

The Department of Health and MSF have collaborated with the Eshowe campus to offer STI screening, pregnancy tests and HIV testing and counselling (HCT) to students who attend the college. In 2013, the TVET clinic only offered HIV testing and counselling but expanded the scope of their work to provide primary healthcare services in 2015.

Mtshali notes with a mischievous smile that women here are aware of HIV messaging and openly collect condoms from her office, but their main concern is not HIV but unplanned pregnancies. For those who test positive for HIV, she is able to initiate anti-retroviral treatment (ART) and link them to King Dinizulu Clinic, a provincial primary health care facility providing HIV and TB-related treatment, care and support services, situated in Eshowe. Students have the option of collecting their ARVs from her office until such a time as they leave the college. By making her office a one-stop shop for counselling and treatment, those affected by HIV are less likely to default on their medication and easier to track in the event they need more support.

The MSF model is relatively simple in theory. Healthcare is provided in a manner that is cost-effective, efficient, self-reliant and easily replicable. From 2016, MSF lay counsellors had begun to mentor and support their DoH colleagues with the implementation of the National Adherence Guidelines, but there are already questions about whether the KwaZulu-Natal department of health has the resources to take the ‘Bending the Curves’ program forward.

The hills of Eshowe and Mbongolwane are carpeted in sugar cane for most of the year: the region is known for its sugar production, dominated by farms and mills. Sugar cane is cut manually, using a panga. The hours are long, beginning before dawn and the labour is unforgiving and intense. Cane-cutters are usually paid per metre of cane that they cut, and a sizeable portion of the money they earn is sent home to support their families across South Africa, Mozambique and Swaziland.

Hercules Maritz is a farm manager at Hohl’s Farming in Eshowe. A few years ago, he noticed farm labourers were falling ill and dying at an exponential rate, from diseases such as TB and HIV. Sugar cane is a labour intensive crop which doesn’t really allow for rest even for minor ailments. Working such long hours – and only being paid for the cane that you cut means labourers are usually unable to get to their local clinics during opening hours.

If you don’t work, you don’t get paid.  Most farm workers live in remote ‘compounds’ and designated reserves where living conditions can exacerbate illness. These living areas are situated several hours over hills and dirt roads on foot from their nearest clinic. Many labourers don’t have easy access to transport, and if there is transport available they don’t necessarily have the money to pay for it. Access, to healthcare, if any, is limited.

To further aggravate the situation, stigma and discrimination is high amongst sugar-cane workers.  There’s a fear of job loss if the farm owner learns they are HIV positive or not in peak physical condition for the gruelling work. Others do not want to disclose their HIV status to those around them out of fear of being discriminated against. The cramped and often unhygienic quarters in compounds makes it near-impossible to receive and store medication or live there without facing discrimination.

The Department of Health and MSF’s clinic at Hohl’s farm began as an exercise of winking in the dark. The clinic wasn’t an instant hit as stigma and discrimination is pervasive amongst farm labourers. A few years ago, an MSF branded vehicle or tent was synonymous with HIV treatment only, so to be seen going anywhere near them was asking for trouble.

Nurse Lindi Dlamini has been coming to the farms since 2015. In that year, she would go to eight farms. That number has grown to include an additional 10 farms. She visits one farm a day, or four a week providing HIV testing and counselling, ART initiation and follow up, TB screening, treatment of STI’s and other minor ailments from Monday through Friday. Depending on the farm, she may see on average no less than 20 people. Most of her clients are women and they often come in for family planning concerns as well as other minor ailments.

Though HIV naivety has diminished since she began nursing, Lindi finds that a lot of her clients are still very unaware of how to manage their reproductive health especially where family planning is concerned. “What they do, they’ve got this thing of telling each other wrong myths. For now, with the whole department of health, we’ve got a problem of them taking about their [contraceptive] implants – the three year prevention. They believe it’s Satanism. They believe it makes them bleed. They believe they get pregnant with it. So there’s a lot of myths. We’ve got more removals than insertions. We are removing more than inserting.”

Dlamini is hopeful that the DoH can take over the clinics after MSF pulls out. Knowing the sorry state of the province’s healthcare department, that may be a tough one. Farmers may have to fund the clinics, Maritz says. Maritz admits the clinics in the area have improved the general health for workers, in turn, boosting productivity for farms.

For Sipho Gumede, a mask is the necessary barrier between him and the world. At 19, he has had to drop out of school and stays in his room where he hardly receives visitors. The slender young man moves slowly and deliberately with the speed of a person navigating through pain. The constellation of pimples on his face give away his youth, belying his weary eyes.

Gumede was diagnosed five months ago and began his treatment for TB the day after he was screened. He has another four months to go before his treatment ends. Of all his friends, only he contracted the disease. The girl he was dating stuck by him but he says would have understood had she bolted. She was at first hesitant but she knows the mask is necessary. Gumede can’t wait to get his life back. Having your own cutlery and crockery and basically living in quarantine warps the mind a little.

With or without TB, the rolling hills of Mbongolwane are a nightmare on foot, plus there’s a long-distance taxi ride into town. On the occasions that he has had to visit the clinic, Gumede’s grandmother, Gogo Sakhephi Nduli had to borrow money from neighbours for the R36 round trip. Of the nine people living at his grandmother’s homestead, only one person is employed.

In 2012, MSF initiated community models of care in ten facilities in Eshowe and Mbongolwane in order to ease the burden of treatment collection for patients and streamlining the workload from the health care providers. Gumede’s medication is delivered to him by MSF lay cadres.

Gumede’s mother was in a car accident and during her hospital stay found out she had contracted TB. Her body gave out not long afterwards. Sipho’s father died too and within the space of months, Gogo took in her daughter’s 3 children, including Sipho.

Sipho’s siblings who are older than him are nowhere to be found. Gogo says they are in the area and receives news about their welfare and whereabouts intermittently. “I was unable to control them. I’m old and alone,” she says as tears begin to fall. Gogo is house proud. She does the best she can to keep a tidy home because she wants people to know that it wasn’t due to uncleanliness that Sipho became ill. Her grandson is a good boy who made bad choices because of alcohol and drugs, his grandmother insists, but he is taking his medication and will return to school as soon as he is well. More than anything, Gogo wants to do right by Sipho in ways she couldn’t for her own daughter and other grandchildren.

One of the more striking aspects of Eshowe is the number of funeral homes in the town. As Babongile Luhlangowe counsellor commented, “We used to bury so many people here. Every Saturday there was a funeral. Saturdays. Old people, young people, it didn’t matter.”

Lay cadres or Community Health Agents (CHAPS) as they’re also known, work in the communities, providing a door-to-door service with the same package of services as the mobile and fixed sites. They also ensure linkage of patients who test positive to clinics and trace defaulters for the counsellors who are based at facilities.

Luhlangowe has been a CHAP since 2012. She walks long distances in the Mbongolwane area.

The hardest part of her work is not the diagnoses nor the long arduous walks or being turned away.

Luhlangowe has been a CHAP since 2012. She walks long distances in the Mbongolwane area. Her home has a backroom where she also receives clients, usually her immediate neighbours, who would like to be tested and get counselled away from their own homes.

The hardest part of her work is not the diagnoses nor the long arduous walks or being turned away. Her eyes moisten and her gaze remains fixed to the floor as she describes when she has to deal with children who test positive for HIV. She has met resistance from parents who sometimes understandably, react to the news badly.

One family she says refuses to accept their 14-year-old daughter’s positive status and will not allow their child to begin ARV treatment. Abantu bazothini – what will people say is one of the main barriers to her work. Luhlongwane is afraid the child will not get treatment but she refuses to give up on the family. “She won’t die. I won’t let it happen. I can’t let it happen.”