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How the world’s highest HIV-prevalence country turned around, and in record time

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Because her government aggressively pursued treatment as prevention for people living with HIV, Thembi Dlamini and several women in her support group have been able to counsel each other, give family advice and run an artisanal business. In other words, their government gave them a life together.

Without the availability of the drugs for free, “we would have died,” she says.

It is that pivotal decision and several other critical supporting moves that have enabled Eswatini to become the first country in Africa to achieve the United Nations HIV target: 95% of people living with HIV know their status, 95% of them are on life-saving antiretroviral treatment, and 95% of those on treatment have a suppressed viral load. The country that once had the world’s highest HIV prevalence did so 10 years ahead of the 2030 goal.

After detecting the first case of HIV in 1986, the country experienced an explosion of HIV cases. Following several waves of new HIV infections and deaths, the government declared HIV a national emergency in 1997 and committed that by 2022 it must no longer be a public health threat.

Propelling concerted action

The government’s decision galvanized a multisector response, considered the foundational success factor. The National Emergency Response Council on HIV/AIDS (NERCHA) was established in 2001 to coordinate activities from government to communities, including training for traditional leaders. Housed within the Prime Minister’s Office and funded by the government, NERCHA steered the agenda and programmes towards the goal.

The government’s commitment meant providing free antiretroviral (ART) drugs for HIV patients “We were the first country to say we need to look closely at treatment,” says NERCHA Director Khanya Mabuza. In 2016, the commitment expanded to cover the provision of drugs as soon as someone tested positive.

To ensure uninterrupted treatment programmes, the government procured 80% of antiretroviral drugs, whilst international partners covered the gap, says Dr Vusi Magagula, Director of Health Services.

The government also provided laboratory technologies for CD4 and viral load monitoring. Another critical part of the strategy has been improving patients access to these monitoring and treatment services. Access improved for HIV clients through the implementation of game-changing nurse-led ART policy, where nurses were trained to initiate treatment under the mentorship of doctors from nearby hospitals, with regular oversight provided by PEPFAR partners.

The HIV services at the community primary health care clinics were linked with HIV prevention activities as well as prevention of mother to child transmission of HIV, tuberculosis and non-communicable disease services. HIV testing services are routinely provided at all health facilities, and the age of consent for HIV testing was reduced to 12 years.

Early on, in 2009, the government opted to give patients with a stable record of high adherence to their treatment three months’ refill of their medication. Recently and due to the COVID-19 pandemic, the government accelerated the plan to dispense six months’ refill supplies.

In response to the impact of COVID-19 pandemic on continuity of services, the government expanded its community service delivery to take HIV testing, prevention and treatment services (including ART drug distribution) to people through outreach programmes that rely on rural health motivators and HIV treatment adherence support initiatives.  The effect of all these initiatives helped to maintain uninterrupted regimes and to connect with key and vulnerable populations.

Other innovative community approaches common across Eswatini are peer-to-peer support for people living with HIV, mentor-mothers and community adherence treatment supporters for adolescents and young people.

Thembi Dlamini helped start one of the peer-support groups in her Mayiwane community in the northern Hhohho region, which she says includes HIV-negative members. “We do this so that those who have not tested yet can see we all live normal lives. There’s no need for discrimination,” she explains, after describing how she was shunned when she first started living with HIV. “Many people thought I had been bewitched.”

“The community mobilization and HIV communication programmes have influenced change in behaviours on stigma and discrimination and improved HIV service uptake in communities,” says Dr Nomthandazo Lukhele, the World Health Organization (WHO) HIV/TB Officer in Eswatini.

Protecting the success in the pandemic

A critical part of the drug-adherence monitoring has been keeping a close eye on drug resistance. In 2016, the Ministry of Health and PEPFAR carried out two HIV drug resistance surveys, which led to a shift to a new drug in the ART regimen, in line with WHO guidelines.

The combined gravitas of all the interventions led to a 66% decline in new HIV infections between 2010 and 2019, with AIDS-related deaths declining by 49%.

“Eswatini is a small country with a population of just over a million people. Hence, its achievement of the 95-95-95 should be an inspiration to many other countries, as we have shown that it can be done,” says Minister of Health Lizzie Nkosi in an interview.

The country is also showing how to overcome the threat to success that the COVID-19 pandemic has presented. When the lockdown led to declines in immunization, HIV and TB services, the government went into catch-up mode and continues to invest in the capacity, availability and well-being of the health workforce at all levels of the health system.

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