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A massive HIV test-and-treat study is underway in Kenya and Uganda. Migratory men in the fishing industry there have been hit especially hard, and researchers are trying creative ways to encourage them to get tested. William Brangham reports from Mfangano Island with support from the Pulitzer Center on Crisis Reporting for our series “The End of AIDS?”
Finally, as the International AIDS Conference convenes in Durban, South Africa, this week, we continue our "End of AIDS" series.
As we have been reporting, public health officials believe that getting the overwhelming majority of HIV-positive people tested and consistently treated is a crucial step to ending the epidemic. But that's proven a difficult goal.
But in Western Kenya, on the border with Uganda, there's a small island where researchers are finding remarkable success with even the hardest-to-reach groups.
Correspondent William Brangham and producer Jason Kane continue our series, with support from the Pulitzer Center on Crisis Reporting.
It's late on a Monday night.
Fisherman Kevin Opiyo and his crew are heading out onto Lake Victoria on the very western edge of Kenya. They throw out their lines and stretch out their nets, hoping the tiny omena fish are schooling below.
Fishing these waters is long, grueling, dangerous work. It's also become one of the main pathways for the growth of the HIV epidemic in this part of Kenya.
Opiyo himself is infected.
KEVIN OPIYO, Fisherman (through translator):
I'm confident that I got it through sexual intercourse and can say it was the time I was working in Remba.
Fishing crews often have to travel long distances to other islands on the lake, and into neighboring Uganda.
DR. MOSES KAMYA, Makerere University/SEARCH Co-Principal Investigator:
I think there's a mentality among fishermen that life is not as important. Therefore, you can enjoy it and have as much sex as you can.
Dr. Moses Kamya is an HIV researcher who's been working with fishermen in the region for years.
DR. MOSES KAMYA:
You know, fishermen tend to have a lot of disposable income, and, you know, they can buy sex very easily. And, of course, where fishermen are, there are, you know, sex workers who hang around them.
The fishermen live on Mfangano Island here on Lake Victoria, near the border with Uganda. The island's 25,000 residents live clustered in homes near the water, and fishing is the main industry.
Largely because of this migratory fishing, it's estimated that nearly one out of every three adults here is infected with HIV.
We traveled to Mfangano Island with Jon Cohen. He's covered the epidemic for "Science" magazine in more than two dozen countries and helped us report this series.
JON COHEN, “Science”:
Here in this region, the HIV prevalence in fishermen is incredibly high. I mean, we're talking on the order of 30, 40 percent. That's something you see in people who inject drugs. It's something you see in sex workers. But people haven't thought about heterosexual men as being a key affected population. And these fishermen, they are!
So, to stem this epidemic, how do you reach this hard-to-reach population? Well, you try something like this.
This is what state-of-the-art HIV care and prevention in Kenya looks like. You set up your testing team, not in a clinic, but right next to the water. You do it at night, because that's when the fishermen are coming home. You get a band to play. You give away prizes.
DR. DIANE HAVLIR, University of California, San Francisco/SEARCH Principal Investigator: What we have done, in order to have a place where people want to go test, is made it accessible to them. We have brought testing to people, as opposed to having people have to go for the test.
Dr. Diane Havlir is one of the world's foremost experts on treating HIV. As we reported earlier, she's helping lead San Francisco's ambitious strategy to end the epidemic there, and she's helping run one of the largest HIV test-and-treat studies in the world here and in Uganda.
The study, sponsored by the U.S., Kenya and Uganda, is called SEARCH.
DR. DIANE HAVLIR:
HIV medicines have been transformative for the individual. So what we're testing in SEARCH is: Can we transform communities with treatment?
Not just individuals.
Not just individuals, the whole community. And in order to do that, one of the first things that we had to do was to figure out how to offer testing to every person. Not just people who were sick. Every single person in that community.
Kenya, like most governments in the developing world, only starts people with HIV on treatment after their immune system becomes compromised.
But the SEARCH study is trying to determine whether treating HIV-positive people immediately, regardless of how sick they are, can have an impact across the entire community.
But the problem still exists that men here, particularly fishermen, have generally been very reluctant to get tested.
DR. JAMES AYIEKO, SEARCH:
We are not able to get to him. So, that's a challenge.
Dr. James Ayieko is one of the doctors with the SEARCH study.
DR. JAMES AYIEKO:
Our system doesn't make health care-seeking a manly thing. So, you have to get something extra that would motivate them, you know, to come to care.
The SEARCH team also makes an economic argument to fishermen: If you don't treat your HIV, you will get sicker, and it's going to cost you because you can't work.
You know, if you're infected, you can stay out there. The disease will progress, you will get worse, and then you might be brought in, in a stretcher to the hospital, which is not a good option. So, the idea, this study is trying to bring the idea of: We can keep you healthy as you are.
Fisherman Kevin Opiyo thought he might have gotten HIV. But even when he started to feel sick and weak and found it hard to work, he still didn't want to get tested.
KEVIN OPIYO (through translator):
It was fear of my past life. Fear of the ladies that I used to move around with. It was that fear that kept me away from testing.
It was likely during this period that Opiyo brought the virus home to the island and infected his wife as well.
One of the things which, sadly, still exists in HIV, it remains a highly stigmatized disease. And people may suspect they're at risk for HIV disease. They may deny to themselves they're at risk for HIV disease. So, it takes a lot of energy, often, for a person to go to seek testing.
At SEARCH's community health events, they know the stigma of HIV and AIDS will keep people away, so they don't call this an HIV event. And it isn't just that. They offer testing and care for all sorts of health issues — diabetes, family planning, hypertension, as well as HIV.
On this day, they even ran a boat race to attract more fishermen to the event. Six teams of young men competed in a race. The prize? Brand-new cell phones. But, of course, you couldn't compete until you got tested.
Dr. Craig Cohen is part of the SEARCH team, and he says this broader health approach is more appealing for men.
DR. CRAIG COHEN, SEARCH:
I'm going there to make sure that I'm healthy, that my family's healthy, my children are healthy.
It provides cover, in a sense.
DR. CRAIG COHEN:
It's not just cover. I mean, these other conditions — malaria is super endemic here, depending on the season. It also helps to build up a sense of camaraderie around health, so that people are understanding that the clinic here is here for everyone, whether you're 70 years old, or 50 years old living with diabetes, whether you're 40 years old and living with HIV.
Making the tent bigger.
Making the tent much bigger, and understanding that health is about everyone. HIV is part — is under that tent. It's not an HIV tent. It's a health tent.
But even after people are diagnosed with HIV and get started right away on daily treatment, the next challenge becomes keeping them in treatment.
And for those who fall out of care, the SEARCH team will come find you. Today, the team is out looking for another HIV-positive fisherman who'd missed his last appointment.
If someone stops taking their HIV meds, the virus will surge back, making the person sicker. But a resurgent virus means you're also much more likely to pass the virus to others. A person who's on regular treatment almost never does that.
But they found the missing fisherman, persuaded him to come back to the clinic on the spot, and made sure he stayed on his meds. One more success in a long campaign.
Two years ago, the U.N. set an ambitious HIV/AIDS goal called 90-90-90. It said that, by the year 2020, 90 percent of people who have HIV should know their status, that 90 percent of those people should be taking antiretroviral treatment, and that 90 percent of them should be treated consistently enough that the virus is suppressed — undetectable in their blood. All that by 2020.
But here on this Kenyan island, thanks in large part to the SEARCH study, they have already hit that goal, four years early. There are few other places in the world with similar success.
Of course, replicating what's happening here across an entire nation, or the rest of the world, will require enormous funding and effort. But the SEARCH team hopes that by proving what works, they can set an example.
I think a study like the SEARCH trial is giving out evidence to show that what was hypothesized is really — is really going to be the direction that HIV treatment and care should go.
Having hit this 90-90-90 goal, the SEARCH team is monitoring their broader aim of creating community-wide change. The study has found that, by treating people with HIV immediately, those individuals have been working an entire week more per month, compared to those who waited to start treatment.
A large percentage of the community is, of course, still living with HIV from before this study began. But far fewer people are dying from it, and the virus is much less likely to spread.
When people are taking a treatment that is changing a uniformly fatal disease to a chronic disease, they think about investments differently. They think about investing, for example, in their farming, maybe in their fishing. And they think about investing more and having their children go to school.
But Jon Cohen says this still may come up short on the broader goal of ending AIDS.
The whole idea of test and treat, it may or may not be enough to break the back of an epidemic. We really don't know. You know, it could be that you get to 90-90-90, and transmissions are still occurring at too high of a rate to really stop the epidemic from being an epidemic.
The SEARCH study here will be wrapping up by 2020. It's hoped that, if it's successful enough, these practices will be embedded into HIV care more permanently throughout Kenya and Uganda, and perhaps the rest of the world.
For the "PBS NewsHour," I'm William Brangham on Mfangano Island, Kenya.
You can explore our entire series "The End of AIDS," and meet the people behind the stories, on our website.
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William Brangham is a correspondent and producer for PBS NewsHour in Washington, D.C. He joined the flagship PBS program in 2015, after spending two years with PBS NewsHour Weekend in New York City.
Jason Kane is a PBS NewsHour producer, focusing on health care and national affairs.
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