ESHOWE, South Africa — The landscape outside Eshowe, a town about two hours northwest of Durban, is an undulating green sea of sugar cane plants. Houses appear intermittently, sprinkling across the hills. Monkeys crouch at the side of the road, near speed bumps, where they snatch up crops that fall off passing trucks.
Four days a week, Babongile Luhlongwane, 40, and Busisiwe Luthuli, 32, trek up and down the rolling terrain, their backpacks stuffed with medical equipment. Though they get paid only 2,500 rand a month — about $174 — the women have an important job: testing their community for HIV.
The region comprising Eshowe and the neighboring town of Mbongolwane has been hit hard by the HIV epidemic. HIV prevalence is 25.2% among people ages 15 to 59, according to a survey by Doctors Without Borders, or MSF. Among women ages 30 to 39, the prevalence is a staggering 56.6%. KwaZulu-Natal, the province where Eshowe and Mbongolwane are located, has a higher HIV prevalence than any other South African province.
Getting tested is crucial to preventing the spread of HIV. When people know they're HIV negative, they can take steps to protect themselves from infection; when they know they're HIV positive, they can begin antiretroviral therapy, or ART, and stop the virus from spreading to others.
According to the same MSF survey, 88.4% of women and 69.8% of men in the region knew their status — short of UNAID's goal to have 90% of all people living with HIV aware of their status by 2020. Various barriers prevent residents from going to the clinic for testing as often as they should — or at all.
"It might be distance; it might be money for transport; it might be fear of the associated stigma of going to a clinic and having people potentially discover that you're testing for HIV; it might be that the clinics are overcrowded already, and you're having to wait all day in a queue to test," MSF project medical manager Dr. Vivian Cox said in an interview. "Not many people want to do that."
So, instead, Luhlongwane and Luthuli go to the people.
They set out late morning on a sunny July day. Both wear skirts, comfortable shoes and white T-shirts emblazoned with the name of their initiative: Community Health Agents Program, or CHAP, founded a few years ago by MSF. Luhlongwane and Luthuli are two of 86 community health agents charged with conducting HIV tests, TB and STI screening, condom distribution and other health-related duties in their neighborhoods.
"I like to help people," Luthuli said. "Sometimes people, they [don't know their] status, and they don't understand HIV."
Luhlongwane and Luthuli enter the residence of 27-year-old Hlanganani Thugi, who says he was last tested for HIV a year ago. Before Thugi agrees to be tested that day, the duo presented a booklet of education information about HIV — what it is, how it's transmitted and how it's treated. When they finish, Thugi consents to an HIV test.
They prick Thugi's finger and siphon the blood onto a small strip of paper. No more than 20 minutes later, Thugi is happily waving his results in the air: He is negative.
It isn't always this easy. When people find out they're HIV positive, "sometimes they cry, because the results have changed," Luhlongwane said after Thugi's appointment. "Because last time you were negative, and now it's positive. You cry and say, 'Oh, what's happened?'"
When that happens, Luthuli reminds patients, "It's not you only [who's] HIV positive." Then she explains how ART works.
Sometimes, people refuse to be tested. Perhaps they've had unprotected sex in the past few weeks, and are worried they've been infected.
"They're afraid to know that they are positive," Luhlongwane said.
In a household of five people, "maybe two or three" are comfortable talking to Luhlongwane, she said. The others might run away, "especially boys." They'll say they're going outside to use the bathroom, and they never return.
"There can be very traditional strong male role model pressures, such that men don't want to be thought of as sick, or be told that they're sick," Cox said. "That might translate into weakness."
Community health agents like Luhlongwane and Luthuli help fight that stigma. When folks can see their own lifelong community members conducting health screenings and sharing facts about HIV, "they're not as afraid of it and not as judgmental," Cox said. "That has a cascading effect of more people testing, and more people that are on treatment being supported by friends and family in their community."
On days she only manages to test one or two people, Luhlongwane sometimes feels downtrodden. "I would say, 'Oh, look at my time, I wasted so much time going to this household, then people there refuse to test, then what's the use of doing this thing? Maybe I [should] just give up.'" For Luthuli, walking up and down hills gets tiring — and she'd also like to be earning more money.
But above it all is the contribution they're making to the fight against HIV.
"For me, I'm loving to work with my community and helping them to know their status," Luhlongwane said. "That's what keeping me doing this work."
Jordyn Taylor reported from South Africa on a fellowship with the International Reporting Project.