APPROACH AND METHODOLOGY
The approach taken in this commitment will follow three primary activities.
1. Achieve universal access to testing and treatment for those eligible based on current clinical and immunological criteria
This activity will seek to scale up testing and treatment programs to ensure that everyone in Swaziland is tested for HIV and that those found positive and meeting eligibility criteria for ART will be started on treatment. Specific activities will include mobilizing the community to change perspectives on HIV testing and treatment and empowering community members to develop their own solutions to the barriers to testing, care, treatment, and retention; bringing services closer to people in need and increasing access for hard to reach groups including adolescents and men; and developing improved follow-up systems to ensure that HIV-positive individuals are retained in care and treatment.
All of these activities will be done by developing innovative solutions while focusing on strengthening existing systems and partnering with organizations on the ground in Swaziland.
2. Assess impact of reaching universal access to treatment at current threshold on prevention efforts
In this component, the project will assess the impact of activities listed above to ensure they are addressing the most essential services, it will evaluate the experiences of people living with HIV, and it will use models to better understand whether or not increased testing and treatment is reducing new infections in Swaziland. Specific activities will include mathematical and epidemiological modelling to demonstrate the impact of universal access to treatment at current thresholds on prevention; social science research to investigate the quality of services and remaining barriers across the continuum of HIV testing, care, and treatment; and additional research to assess the impact of increased scale-up of HIV services on people living with HIV, including a focus on human rights.
3. Demonstrate treatment as an effective form of prevention in a high prevalence setting
In this final component, the program will initiate a Treatment as Prevention pilot, in which treatment will be initiated at a different threshold for a portion of the population. While activity one, above, will offer treatment to those HIV positive patients meeting the current eligibility criteria as laid out by the Government of Swaziland and the WHO, this pilot will lower this threshold, allowing patients to initiate ART even earlier.
IMPLEMENTATION, TIMELINE, AND DELIVERABLES
The project is scheduled for launch in July 2011 and will run for three years, through June 2014, with a small amount of tail-funding for a year following. The program will cover the entire Kingdom of Swaziland and will be implemented jointly by CHAI and STOP AIDS NOW!, in partnership with the Ministry of Health, as well as partners including Southern Africa HIV and AIDS Information Dissemination Service (SAfAIDS), the University of Amsterdam, Southern African Center for Epidemiological Modelling and Analyses (SACEMA), the Global Network of People Living with HIV (GNP+), and Swaziland National Network of People Living with HIV/AIDS (SWANNEPHA), with the vital support of the Postcode Lottery.
The success of the program will be measured by the number of people tested, alive and on treatment by the end of the program, as well as the long-term reduction in new infections. In year 1, the primary focus of the program will be on activities required to overcome the barriers to testing those individuals who are hard to reach, and enrolling and retaining individuals who are in need of care and treatment. It will also involve establishing baselines for much of the social science research and details of the Treatment as Prevention pilot will be established. Year 2 will involve rolling out some of the most effective interventions established, continuing the strengthening of the health systems, and within this timeframe the Treatment as Prevention pilot will commence. By Year 3, the goal is to have 90% of those individuals in need of treatment based on current guidelines on treatment and the Treatment as Prevention pilot will be well underway.
Dramatic progress has been made in the fight against AIDS over the past decade. As the number of people on anti-retroviral therapy (ART) has jumped from 0.25 million in 2002 to 6.2 million in 2010 (UNAIDS), the number of new infections per year dropped by nearly 20% between 1998 and 2008. Despite this significant progress, more than 10 million people in need of treatment currently do not have access to it, and more than half of those who are positive do not know their status (UNAIDS).
In Swaziland, the situation is dire. Life expectancy has dropped from 56 years in 1997 to 34 years in 2008 (UNDP). In 2011, 200,000 adults and children are estimated to be living with HIV in Swaziland (SPECTRUM, 2010). Amongst the reproductive population (15-49 year-olds), 26% of individuals are HIV positive and a staggering 41.1% of pregnant women are HIV positive in Swaziland (Swaziland Ministry of Health (MOH)). This represents the highest HIV prevalence in the world. Currently, about 65,000 individuals in Swaziland are on anti-retroviral therapy (ART), which represents less than 70% of those who are currently in need of this life-saving treatment (MOH, SPECTRUM HIV Estimates 2010) based on current treatment guidelines. Without an ambitious and aggressive intervention, the future for Swaziland looks bleak.
'Treatment as Prevention' has the potential to be just the intervention needed to break the back of the epidemic in Swaziland. The premise of the program is simple. By providing ART to HIV positive individuals earlier in the progression of their disease, the amount of virus (viral load) in these individuals will drop significantly, thereby decreasing their risk of transmitting the virus to their partners. If early treatment can be provided on a broad enough scale, the infectiousness of an entire population in a high risk area can be reduced significantly, and most new infections can be prevented.
In partnership with the Postcode Lottery, CHAI and STOP AIDS NOW! will provide essential technical assistance, financial, and strategic support to the Ministry of Health of Swaziland to turn the HIV epidemic around by leveraging anti-retroviral treatment (ART) as a form of prevention. The program will build the essential systems for the country to diagnose and treat those HIV positive individuals who are in need of treatment at current thresholds and eventually establish a pilot in which HIV positive individuals will receive treatment at a different eligibility threshold, potentially significantly improving the survival outcomes for those living with HIV with a simultaneous impact on reducing the number of new HIV infections.
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The potential impact of this program could have significant implications for the methods used in HIV care and treatment in all resource-limited countries. Rather than a single project or initiative, the most profound impact of this work will come when shared with other like minded organizations and countries with similar obectives
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