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GlobalPost's John Donnelly and a team of reporters investigate what experts are calling a 'turning point' in the global fight to reduce HIV infection rates. Successes in southern African countries have produced valuable lessons on effective approaches to fight AIDS, lessons that need to be learned in US cities where infection rates remain persistently high — particularly among African-Americans. Meanwhile a political confrontation looms in Washington over critical funding which could threaten gains already made.

In Tanzania, HIV at a crossroads

The US will launch a series of HIV prevention strategies to test whether an AIDS-free generation really is possible. Will this be a breakthrough moment?

Withholding sex

In some villages, women are telling men if they aren’t circumcised, they will withhold sex.

In the village of Masita, Maria Komba, 32, said that’s what she and her girlfriends did. It worked, she said.

“We women have talked,” she said smiling in her shop at the center of the southern Tanzania village of 1500 people, one truck, 20 motorcycles, 200 cows, 5000 goats, and corn stalks 10 feet tall. “We have taken a stand that men should go and have it done and if they don’t, that’s it. We’re going back to our mothers and leaving them.”

Standing next to her was her husband, Yohanna Mwinuka, 31, who followed his wife’s suggestion and was circumcised, along with their 10-year-old son Alpha, a week before. He grinned, shyly, and pulled his baseball cap down over his face. 

When he looked up, he acknowledged she was truthful. “We had discussed it,” he said. “And my wife told me, ‘I will escort you there to be circumcised.’ It was showing that this is all about doing it together. It was a show of love.”

Sex workers become farmers

Penina Muyili, 36, a former brewer of local beer, stands in her vegetable garden in her backyard in Makambako, Tanzania. The project, which was funded by the US government, helped her learn to save money and to make money from growing crops. She has stopped making beer as well as sex work.

(John Donnelly/GlobalPost)

In other communities, other prevention tactics were in motion. A three-hour drive north, in the crossroads town of Makambako, Penina Mnyili, 36, a mother of five, said a series of lessons supported by the PEPFAR-funded The ROADS project helped her make the transition from a local brew seller and sometimes sex worker to a small-scale farmer growing vegetables and raising a pig. One of the key lessons from the FHI 360-run program, she said, was how to save money.

“Before, I didn’t know how to save money,” she said in her small backyard with several plots full of spinach, beans, potatoes and a natural herb that kept pests away. One large plastic sack, full of soil and manure, sprouted lettuce and spinach on top and all around the sides, from holes cut out of the fabric.

Mnyili stood beaming next to her crops. “It’s been such a big change for me. For one thing, I’m no longer dependent on my husband to buy our food,” she said. “Now I am growing our greens, or I can sell them and buy meat. I am earning enough money to pay the school fees for all my children. This has given me confidence and much more independence.”

At a nearby truck stop, where workers for The ROADS stop by daily to spread HIV prevention messages and to make sure a condoms dispenser is full, Mohamad Ameeri, 57, nursed a Castle beer and said it’s hard for truckers to avoid HIV messages now.

HIV tests at Congo’s mines

“If you go in and out of the mines in Congo” – where he was headed – “they always ask you if you have taken an HIV test,” he said. “They also will give you a pack of condoms when you go through the gates.”

The way to fight AIDS, he said, is “education, education, education. Condoms are helpful, but you need to be educated about the dangers. You could be drinking like me and then you need to be constantly reminded with cautionary messages.”

Behind him at Mama Kaduma Restaurant, a woman served beer to another man. “She’s a sex worker,” Zayane Ng’umbi, who works on The ROADS project, said softly, nodding in the direction of the woman. “Her mother is the coordinator of all the sex workers here. There are about 30 sex workers, and they are very cooperative with us. We hold what we call Moonlight Tests during the night, and all of them agree to be tested for HIV. Always.”

This effort with truck drivers and sex workers is one piece to the future of fighting AIDS, say experts. But these pieces of the fight have often operated in their own orbits, disconnected from any other prevention efforts. Groups working with truck drivers, for instance, may never have connected the men to circumcision services; or groups providing help to pregnant teens may have been powerless to try to keep those young women in school.

Trials: $60 million price tag

The three upcoming HIV combination prevention trials will start this fall and are expected to run a minimum of four years, at an initial cost of $60 million. They are designed to each have multiple approaches that will reach truck drivers, sex workers, migrant farmers, injectable drug users, and men and women who have multiple partners. 

Each trial will have a similar base: A control group that will receive the current level of AIDS prevention, and a randomized group will receive a larger package of prevention services. 

The ramped up package will start HIV-positive people on treatment earlier, expand male circumcision programs, and increase community education on risky behaviors.

Then each trial will add a wild-card element, designed to see which of these other efforts works most effectively. 

In Iringa, a region with 1.6 million people, that means teen-aged girls and young women in their early 20s will be offered small cash payments to stay in school.

In Botswana, it means starting treatment much earlier than the other sites – at the level of a 500 CD4 count, instead of the 350 level now recommended by the World Health Organization. CD4 cells are a type of white blood cell that fights infections, and a CD4 count gives a good sense of the strength of a person’s immune system and its ability to fight diseases. The higher the count, the stronger the immune system.

In Zambia and South Africa, it means ramping up counseling and testing of people and linking more people into AIDS treatment.

Iringa was chosen as a trial site because of its relatively low level of services and its extremely high HIV prevalence, 15.6 percent of all adults aged 15 to 49, compared to the national rate of 5.6 percent. 

HIV and the road

A tea plantation in Iringa province

(Charles Wanga/GlobalPost)

Here, HIV follows the road. Large numbers of truckers stop in Iringa, helping fuel a highly risky sex trade. Migrant workers harvesting tea leaves, coffee beans, cocoa, potatoes and bananas are away from home for months. Infections easily skip into the general population, as high-risk groups pass the virus on to their regular sex partners.

“It’s a recipe for HIV transmission,” said Daniel Moore, deputy country director for the US Agency for International Development.

The details around the trial in Iringa were still being finalized this month. But by all accounts, the scope of the work will be huge, involving 12,000 participants and adding “thousands” of health workers, Rettmann said. Still unknown is how the trial site will secure that many workers. Also not settled is the amount of cash payments to girls, or how the money will be transferred to potentially thousands of them.

“With this cash transfer, we want to see whether the behavior is different in young women,” said David Stanton, USAID’s division chief of Technical Leadership and Research in the Office of HIV/AIDS, and a chief architect of the trials. “We want to see if they reduce the number of sex partners.” Earlier studies done by the World Bank in Africa have shown some reductions in infections.

Questions about trials’ approach

Some HIV prevention experts have questioned parts of the approach, including the cash transfer as well as whether increasing treatment will significantly prevent infections. The doubts on treatment-as-prevention have come about because the clinical trial looked at HIV passed in a relationship in which one was infected and the other not; skeptics note that roughly one third of all infections happen in sex outside of those central relationships.

Mitchell Warren, executive director of AVAC, a global non-profit advocating for HIV prevention initiatives, said people shouldn’t have too high or too low expectations from the scientific trials.

“We have to be realistic that treatment in and of itself is not going to end the epidemic,” he said. “The best method is to provide the most options to the most people. Each of these methods has real-world challenges. The challenge is how do you put it all together? How do you recognize that each of these has deficiencies?”

Outside trials, what’s next?

The results from combination prevention trials may not be fully available for several years, which raises another pressing issue: What should be happening in the meantime? Can the United States, other donors, and developing countries afford to start scaling up prevention tactics in other high-risk populations?

Or, can they afford not to?

“In the fight against AIDS, we’ve always had turning points and critical moments,” Warren said. “This is a major turning point now. If we don’t do the right things now, doing them in five years time is going to be a lot harder, with many more people infected. The mountain becomes that much higher, and the cost that much greater.”

Video: John Donnelly in Tanzania

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