Faced with the highest HIV prevalence of any country in the world – where one in three adults is infected with HIV – the early days of HIV in Swaziland were devastating. Countless lives were lost, and the average life expectancy plummeted from 57 years to 31 years at the most critical point in the epidemic. Today, there are an estimated 130,000 orphaned children in the country, the majority as a result of AIDS, and more than 200,000 people are living with HIV.
Yet Swaziland, a country of just over a million people in Southern Africa, plays an important role in the global HIV response, far greater than its size might suggest. Despite seemingly insurmountable challenges, the country has made incredible progress in its response to HIV, and is ready to take the lead in the region by launching an ambitious new project that will provide immediate access to treatment to all people living with HIV.
Much of the progress in the HIV response in Swaziland so far is the result of the Ministry of Health’s comprehensive and innovative approaches, which bring services closer to people, involve communities, and ensure access to treatment for all in need. Over the past decade, the country has significantly expanded access to lifesaving anti-retroviral therapy (ART). Today, more than 90,000 people are alive and on treatment — about 90 percent of people living with HIV who are currently eligible — and life expectancy is on the rise again. By the end of the year, health service providers will have performed more than 300,000 HIV tests over 12 months, a rare feat in a country of just over one million people. These are hugely successful outcomes resulting from the tireless work of many different stakeholders, and they offer lessons from which many other countries can learn.
Advances in HIV research have shown that earlier and expanded access to HIV treatment could transform the HIV response globally. Providing earlier treatment to people living with HIV not only improves their health and well-being, it also dramatically reduces the number of new HIV infections. For HIV, treatment is also prevention. In the countries hardest hit by HIV, dramatically scaling up ART also has the potential to improve economic growth as it enables people with HIV to live healthier and more productive lives. Now, the global community needs a developing country to provide the evidence around what it will take to put earlier treatment into practice within a government-managed health setting. Consequently, Swaziland has launched a number of ambitious new programs to further strengthen the HIV response, culminating in a pilot program – Immediate Access to ART for All – to demonstrate that treatment can turn around the AIDS epidemic globally.
To prepare the country to provide access to treatment for everyone living with HIV, the Ministry of Health is committed and working hard to bring HIV services closer to the people it serves. Treatment services are now provided in the most rural areas of the country in primary health clinics and, in most cases, by skilled nurses. In the past, only a few large hospitals provided ART and treatment was the domain of doctors. New and innovative laboratory equipment also allows health workers to immediately determine whether it is time for a client to begin HIV medication, without sending tests to external laboratories. This reduces the number of trips a client has to make to the clinic and improves the likelihood they will remain in care. An Expert Client program, in which people living with HIV provide supportive counseling to their peers, and innovative use of technology for patient reminders and follow-up, contribute to Swaziland’s success at keeping people alive and in care. Now more than 90 percent of patients are still on treatment 6 months after they begin – a rarity in the region.
In addition, the Ministry is working directly with people living with HIV not only to understand their needs on the ground, but also to ensure services are provided in a way which maintains human rights. It has established community-owned solutions by working with religious leaders, traditional leaders, and community based volunteers to mobilize individuals for HIV testing and treatment and to strengthen care and support. This is particularly important in the context of groups such as men and adolescents, who are extremely hard to reach and to encourage to access health services. Targeted services for the people most in need and missed by earlier HIV scale up programs will continue to ready the country to reach all people living with HIV.
Now, Swaziland will continue to advance its HIV program in line with new World Health Organization guidance and will consequently increase access to treatment for many more people, including all HIV positive pregnant women and all children below 5 years of age. Yet, the country will not stop there. The Clinton Health Access Initiative is proud to be partnering with the Ministry of Health and its MaxART Consortium partners to take the country an additional step by launching the ambitious Immediate Access to ART for All demonstration project. This initiative will provide immediate access to treatment to all people living with HIV in one area of the country to improve the health of those living with HIV, prevent new HIV infections, and demonstrate that treatment for all is feasible, acceptable, affordable and scalable.
Swaziland is ready to transform the global community’s approach to finding an end to AIDS. Both Swaziland’s leadership and this initiative offer a critical opportunity not only to catalyze a huge change in Swaziland, but also to provide essential lessons to other countries working to get in front of the pandemic across the African region. Swaziland may be a small country – but it’s also an important one, poised to open brand new frontiers and ready to turn the tide on HIV.
If you would like to learn more about CHAI's work in Swaziland, please contact the CHAI Swaziland team at [email protected]