Despite a concerted international effort in recent decades that has yielded significant progress in the fight against HIV/AIDS, the disease continues to kill large numbers of people, especially in certain regions like rural Ndhiwa district in Homa Bay County, Kenya. Although there is still no definitive cure or vaccine, UNAIDS has set an ambitious goal of ending the epidemic by 2030, specifically via its 90-90-90 (treatment cascade) strategy – namely that 90 per cent of those with HIV will know their status; 90 per cent of those who know their status will be on antiretroviral therapy and 90 per cent of those on antiretroviral therapy will have an undetectable viral load. These bold assumptions were put to the test in a five-year pilot project launched in June 2014 by Médecins Sans Frontières (MSF) and Kenya’s Ministry of Health in Ndhiwa district, where an initial NHIPS 1 study by Epicentre (MSF’s epidemiology centre) in 2012 revealed some of the world’s highest HIV incidence and prevalence, and a poor “treatment cascade”. Six years later a new Epicentre study, NHIPS 2, showed that the 90-90-90 target had been more than met. What explains this ‘success’? And given the still-high incidence, is it truly a success? What follows is an interview on the political, scientific, and operational challenges of the Ndhiwa project with MSF Deputy Director of Operations Pierre Mendiharat and physician Léon Salumu, Head of MSF France Kenya programs, conducted by Elba Rahmouni.
President’s Emergency Plan for AIDS Relief.
Since the decentralisation of governance required by the new constitution (adopted in 2010), Kenya has been made up of 47 counties, themselves divided into districts. Thus, the former Nyanza Province, located in southwestern Kenya on the shores of Lake Victoria, includes Homa Bay County, which itself contains eight districts, of which Ndhiwa is one.
A population-based approach aims to improve the health status of a population in a given territory via collaboration among different health actors in that territory.
In a serodiscordant couple one partner is HIV-infected and the other is not.
Up to that point, prevention programmes had recommended only condom use or abstinence, two behaviours that failed to control the epidemic. In the absence of biomedical tools, public health policies called for behaviour changes; these required a lot of discipline and gave an unreliable result.
UNAIDS (2015), ‘Understanding Fast-Track: Accelerating Action to End the Aids Epidemic by 2030’ (Geneva: UNAIDS), www.unaids.org/sites/default/files/media_asset/201506_JC2743_Understanding_FastTrack_en.pdf (accessed 24 November 2021).
MSF (2020), ‘VIH : l’amélioration de la prise en charge a fait chuter la proportion des personnes infectés dans l’un des foyers les plus touchés au monde’, press release, 24 November, www.msf.fr/communiques-presse/vih-l-amelioration-de-la-prise-en-charge-a-fait-chuter-la-proportion-des-personnes-infectees-dans-l-un-des-foyers-les-plus (accessed 24 November 2021).
Xavier Plaisancie’s MD thesis, Representations of HIV and Impact on Care Seeking among the Men of Homa Bay, Kenya’, 9 June 2020, https://msf-crash.org/en/publications/medicine-and-public-health/representations-hiv-and-impact-care-seeking-among-men-homa (accessed 24 November 2021) was the subject of a Cahier du CRASH. That process was the subject of a regular dialogue between Xavier Plaisancie and MSF-CRASH research centre members Jean-Hervé Bradol and Marc Le Pape. The survey described, in particular, the wide range of institutional actors (doctors, politicians, religious leaders, etc.) responsible for the abstinence directive.
Rose Burns et al. (2019), ‘“I saw it as a second chance”: A qualitative exploration of experiences of treatment failure and regimen change among people living with HIV on second- and third-line antiretroviral therapy in Kenya, Malawi and Mozambique’, Global Public Health, 14:8, 1112–24, doi: 10.1080/17441692.2018.1561921.
Patients who fail the second-line treatment are put under third line following the resistance genotype result.