Over the past decade, with support from PEPFAR, the Government of the Kingdom of Swaziland has led a highly effective national HIV/AIDS response resulting in historic gains in HIV prevention, care and treatment coverage throughout the country. As a result, Swaziland has surpassed the 80 percent benchmark for universal antiretroviral therapy (ART) coverage based on World Health Organization guidelines. ICAP, which began partnering with Swaziland’s Ministry of Health (MOH) and the Centers for Disease Control and Prevention (CDC) in 2005, has been instrumental to this expansion.

Under the Rapid Scale-Up project, which began in 2009, ICAP and the MOH worked hand-in-hand with health authorities, community representatives, and local NGOs to scale-up HIV care and treatment services, decentralize HIV services, and increase access in three of the country’s four regions (Hhohho, Lubombo, and Manzini). Five years ago, only 47 facilities nationwide provided antiretroviral therapy (ART) for 40,000 HIV patients; today, there are over 140 facilities providing ART and the number of people receiving treatment has tripled.

As Swaziland’s lead technical assistance partner, ICAP supports ART for more than 73 percent of the 125,000 patients enrolled in HIV treatment. ICAP worked with Swaziland’s National AIDS Program to shift HIV services from central hospitals to local health facilities. Multidisciplinary teams of health providers strengthened community linkages, and ICAP built capacity at all levels of the health system, pursuing aggressive quality improvement well beyond central health facilities.

“Innovative implementation strategies have made Swaziland one of the successful countries in ensuring access to and retention on ART,” said Dr. Velephi Okello, deputy director of clinical services, Swaziland Ministry of Health.

Task-shifting in Swaziland has been an influential factor to increased HIV testing and treatment numbers. Training nurses to administer HIV treatment was central to expanding care, especially at local and regional facilities in low-resource communities, where today, over 64 percent of patients initiate ART with support from nurses. In addition, ICAP supported over 27,000 training opportunities for health care administrators, faculty, physicians, and other health practitioners over the five-year project.

ICAP and the MOH also championed the use of trained lay providers as “expert clients,” responsible for counseling, linking, and supporting patient ART adherence, ultimately freeing nurses to focus on clinical services. Expert clients working at the community level, locate patients who miss appointments and support their return to care.

“People in this community know that even if you have HIV, kuyaphileka, life goes on,” said Mr. Jabulani Maseko, expert client at Sigangeni Clinic. “That is what they say they have learned from us expert clients. It’s not easy to face HIV, but people feel better when they are counseled by someone who knows what they are going through and they ask for us by name at the clinic.”

There are currently 165 expert clients working in Swaziland. Through ICAP’s partnership with the correctional services, over 70 were “trained in prisons”:https://icap.columbia.edu/news-events/detail/icap-expands-hiv-care-and-treatment-in-swazilands-correctional-facilities where they helped initiate more than 400 inmates on ART and connected over 3,500 to voluntary HIV testing and counseling.

Similar support systems were also fostered among professionals, creating accountability among health care facilities and between providers. ICAP worked closely with the MOH and partners to forge a culture where teams routinely analyze data, identify weaknesses and bottlenecks in services, adjust activities, and review progress. Building on early achievements in HIV care and treatment and adherence has required rigorous monitoring and evaluation and unceasing focus on quality. “National and regional ART data reviews”:https://icap.columbia.edu/news-events/detail/icap-and-swaziland-national-aids-program-convenes-10th-national-hiv-semi-an encourage the development and use of a wide-range of monitoring and evaluation, assessment tools, and databases.

“When ART retention figures for Swaziland are presented internationally, people even question whether they are too good to be true,” said Nosipho Storer, adherence and psychosocial support and linkages advisor at ICAP. “Everybody works towards the same goal of retaining patients on ART, and the whole community benefits.”

This quality improvement resulted in improved ART initiation times—increasing eligible patients initiating ART by over 20 percent in just one year. And among new patients at ICAP-supported facilities, 91 percent remained in care one year after they were initiated on ART.

“We’ve been aggressively attacking the HIV epidemic in Swaziland from all angles,” said Ruben Sahabo, ICAP country director in Swaziland. “Many of our initiatives from the “Health Research Training Program”:https://icap.columbia.edu/news-events/detail/icap-welcomes-second-round-of-fellows-and-mentors-in-swazilands-health-rese to the HIV incidence measurement survey will enable long-term, sustainable solutions and a remodeling of the of the health system as we know it.”

Advancing research in Swaziland has been an important component of the +Rapid Scale-Up+ project, and the “Swaziland HIV Incidence Measurement Survey (SHIMS)”:http://shims.icap.columbia.edu/, a landmark achievement, was the first national measurement to directly observe HIV incidence, in Swaziland and in the world. More than 18,000 adults from nearly 14,000 households were visited across the country and key measures were collected on prevalence, incidence, viral load, and CD4 count.

“SHIMS has established an unequivocal baseline incidence rate against which to judge the effectiveness of such strategies for an entire national population,” said Jason Reed, co-Principal Investigator of SHIMS, formerly of CDC Division of Global HIV/AIDS.

As “ICAP and partners move forward”:https://icap.columbia.edu/news-events/detail/icap-to-continue-supporting-the-scale-up-of-hiv-care-and-treatment-strength, with a continued focus on HIV/TB care and treatment, research, and health systems strengthening, the coming years will provide an unprecedented opportunity to reverse the health and economic impacts of the epidemic. For now, the innovations in Swaziland are being felt far beyond its borders. As ICAP readies for more population-based HIV impact assessments across Africa, it has the last five years of achievements in Swaziland to guide the way.

For more on the impact and innovations of ICAP’s _Rapid-Scale Up_ project, read the <a href=”{filedir_2}ICAP_Swaziland_28June_LowRes_FINAL.pdf”>full project report</a>.

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