The United States President’s Emergency Plan for AIDS Relief
Since 2007, the United States Government (USG), through the United States President’s Emergency Fund for AIDS Relief (PEPFAR), has partnered the Government of the Kingdom of Eswatini (GOKE) to address the impact of HIV. The PEPFAR/Eswatini (PEPFAR/E) program is coordinated through the Department of State PEPFAR Coordination Office and delivered through five USG agencies: Centre for Disease Control (CDC), Department of Defense (DOD), Department of State (DOS), Peace Corps, and United States Agency for International Development (USAID). Eswatini has one of the highest burdens of HIV globally – 1 of every 4 individuals over the age of 15 lives with HIV; women are disproportionately affected (32.5% prevalence among women versus 20.4% among men; SHIMS2 2011). With the support of PEPFAR over the past 15 years, over 90% of Emaswati living with HIV are now receiving life-saving antiretroviral treatment resulting in a nearly 20-year increase in life expectancy from 42.5 years in 2005 to 60.7 years in 2020. Mother-to-child transmission has dropped to fewer than 500 cases per year, from a peak of an estimated 3300 in 2005. The partnership has moved Eswatini from one of the countries most ravaged by HIV to among the leaders in reaching global HIV epidemic control goals.
The recently completed 2021 Eswatini Population-based HIV Impact Assessment survey, locally known as “SHIMS3”, demonstrated sustained progress towards the ambitious UNAIDS 95-95-95 targets set for 2025. SHIMS3 revealed that in Eswatini, 94 percent of adults 15 years and older living with HIV are aware of their status, 97 percent of those aware of their status are on antiretroviral therapy (ART), and 96 percent of those on ART have achieved viral suppression. This is compared to the SHIMS2 (2016-2017) results of 87-89-91, reflecting laudable progress despite the threats presented by the COVID-19 pandemic. Women achieved the 95-95-95 targets at 95–98–96 in SHIMS3, while men reached 92-96-97. Although marked improvement was seen across the cascade among youth 15-24 years, gaps still remain in case finding and viral suppression.
The country continues to face a dual epidemic of HIV and tuberculosis (TB), although dramatic improvement has been made. According to the 2021 WHO Global TB Report, approximately 3700 new cases of TB (319 per 100,000) occur in Eswatini every year, a 75% reduction since 2012 when Eswatini was experiencing 1,380 new cases annually per 100,000 population. Men 15 years and older are disproportionately affected, constituting 59% of the annual cases. Two-thirds of TB cases are among PLHIV. Although case finding remains a challenge as only 58% of TB cases are identified each year, the treatment success rate is 86%, approaching the 90% treatment success rate global target.
The GoKE has established clear national priorities and strategies to maintain the gains made and address these remaining gaps through its National Strategic Framework (NSF) (2018-2023). Through PEPFAR, the USG and its partners are supporting Eswatini to implement its NSF by providing technical expertise and financial support. This partnership has been further strengthened by the joint planning for PEPFAR annual Country Operational Plans (COP) which detail GOKE and PEPFAR activities in the fight against the HIV pandemic and emphasize the principles of building sustainable, person-centered, and gender sensitive country-led programs.
PEPFAR Eswatini leverages Eswatini’s National Response by providing resources, technical assistance, and capacity-building to ensure that interventions complement and build on existing programs and provide high quality HIV and TB related services while strengthening capacity of organizations and quality of programs. PEPFAR partners with the GOKE and assists in implementing strategic projects through government entities, community-based organizations, faith-based and non-governmental organizations as well as the private sector. Furthermore, PEPFAR coordinates and collaborates with other donors and development partners to strengthen linkages and ensure a holistic and complementary approach to tackling HIV in Eswatini.
Case identification and linkage to treatment – HIV testing efforts focus on early identification and treatment of at-risk populations, men and youth where gaps remain in case identification. Innovative and effective approaches such as HIV-self testing, offering testing in workplaces and schools, and scaling contact tracing are being scaled. The Linkage Case Manager (LCM) model actively pairs all newly diagnosed individuals with peers who link them to treatment and support them through the early stages of the ART initiation process.
Maintaining HIV viral suppression and reducing HIV-related mortality – PEPFAR supports the Ministry of Health (MOH) and implementing partners in building the capacity to maintain coverage and the quality of HIV and TB care and treatment services. This includes provision of optimal treatment regimens, clinical and community-based services, clinical mentorship, and laboratory support. In order to ensure access and support treatment continuity, PEPFAR supports differentiated and person-centered HIV service delivery including multi-month dispensing, fast track and after-hours prescription pick up through medication lockers, and community commodity distribution. In addition to treatment, decentralization of diagnostic and treatment services for HIV-associated illnesses such as tuberculosis (TB), cryptococcal meningitis, and cervical cancer is contributing to further reductions in HIV-related mortality.
Eliminating mother to child transmission of HIV – Working with the Government of Eswatini towards the elimination of mother to child transmission of HIV by ensuring universal access to the Prevention of Mother to Child Transmission (PMTCT) services. This includes assuring sustained quality, comprehensive, integrated PMTCT services at GKOE health facilities; training and mentoring service providers, promoting services through community outreach; and providing psycho-social support to HIV pregnant women and mothers.
Reducing new HIV infections – In addition to universal access to antiretroviral treatment, PEPFAR Eswatini implements effective and tested interventions that support national efforts through:
- Structural interventions that create an enabling policy environment and strengthen leadership for HIV prevention.
- Social and behavior change interventions that reduce the risk of HIV infection, promote health seeking behaviors, and enhance protective social and gender norms, including Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe (DREAMS) programming addressing the unique vulnerabilities of adolescent girls and young women (AGYW). The Eswatini DREAMS fact sheet is available at https://www.state.gov/wp-content/uploads/2020/06/ESWATINI_DREAMS-Fact-Sheet-2020.pdf; and
- Biomedical interventions that expand access to and uptake of voluntary medical male circumcision (VMMC), pre-exposure prophylaxis (PrEP), post-exposure prophylaxis (PEP) and condoms.
Addressing the needs of key populations – PEPFAR Eswatini supports the provision of comprehensive services for key populations (KP) — female sex workers, men having sex with men, people who inject drugs and transgender people — to reduce both vulnerability and the heighted to HIV infection. The goal of the support is to improve access and uptake of HIV services for key population through differentiated service delivery models. This includes working with health providers, law enforcement, community gatekeepers and policy makers to address structural barriers for key populations ensuring stigma free and KP responsive services.
Fostering resiliency among orphans and vulnerable children – PEPFAR Eswatini supports strengthening of government and community systems to mitigate the impact of HIV on children and their caregivers, and funds community-based organizations to deliver quality child-focused services in the areas of economic strengthening, education, health, and protection. Systems strengthening focus on the social welfare workforce, and enhanced monitoring and evaluation for impact mitigation.
Preventing and responding to gender-based violence – In addition to programs that directly target women and girls, PEPFAR supports activities that increase male involvement in family-centered programs and address norms around behaviors that make women and girls vulnerable to HIV and gender-based violence (GBV).
Using data for decision making – PEPFAR Eswatini has supported the development and scale-up of Eswatini’s national Client Management Information System (CMIS) which serves as the digital medical record for all public health facilities. Partners support quarterly data reviews to guide quality improvement interventions. Robust surveillance of recent infections, HIV drug resistance, and comorbidities are providing critical information to refine and target program interventions. The recently completed population-based HIV impact assessment (SHIMS3) will guide both strategy and investment to maintain gains made and address remaining gaps.
Strengthening laboratory diagnostic capability and quality – PEPFAR Eswatini collaborates with the Eswatini Health Laboratory System (EHLS) to ensure access to high quality diagnostic testing and monitoring of HIV, TB and other HIV-related illnesses. Two laboratories have achieved international accreditation and PEPFAR is actively supporting others toward this goal. The sample transport and laboratory quality management systems established for HIV have served as a foundation for expanding national laboratory capacity to diagnose and respond to TB, COVID and other public health threats.
Safeguarding commodity security – PEPFAR Eswatini continues to support the GOKE to maintain its TB/HIV commodity security with a blended mix of technical support and selected commodity procurements. This support is through technical advice for strategic supply chain policy development and process improvements. PEPFAR Eswatini and GoKE further fortify this with joint collaboration and coordination of co-funding for procurements, product selection, quantification and forecasting, procurement, and warehousing, optimizing in-country logistics and supply chain data management.
Developing Human Resources for Health (HRH) capacity – Within Health Systems Strengthening, PEPFAR has supported the Ministry of Health, Human Resources Department (HRD) in 4 strategic pillars: 1. Improving HRH data quality and use in planning, 2. Training to build HIV technical skills, 3. Strengthening the MOH HRH leadership, including development of strategic documents to guide the operations of the HRD, and 4. Utilizing the Human Resource Information System (HRIS) to align donor HR support with the Ministry of Public Service Establishment Register. Several assessments have been conducted that have informed HRH interventions and identified best practices across the strategic pillars.
PEPFAR DOD SUPPORT TO THE UMBUTFO ESWATINI DEFENCE FORCE (UEDF)
The Department of Defense (DOD) provides comprehensive support to the Eswatini Military Health Service. DOD has a Health System Strengthening approach to the support, with an emphasis on sustainability. Over the last couple of years, we have assisted with:
Policy Development – The UEDF has been assisted in developing their HIV and Wellness Policy. This was a rigorous process which involved multiple stakeholders from various departments of the MOH. The policy serves to guide expected levels of service delivery, and processes and governance within the Military Health System. The policy is reviewed every 2 years.
Collation of Baseline Epidemiology Data – The UEDF was assisted in completing their SABERS (Seroprevalence and Behavior Epidemiology Survey). The survey covered HIV, STIs, NCD, and Behaviors. The survey results have been disseminated, program priorities have been developed and a concert effort is in place to address the issues identified in the survey.
Development of Management Systems (ISO 9001:2015/ISO 15189) – The development of management systems, as well as adequate management capacity, is critical for efficiency, continuity and sustainability. The UEDF is being assisted to develop management systems based on international standards; the ISO 9001:2015 which is quality based, and the ISO 15189 for laboratory standards. The military hospital at Phocweni has been awarded ISO 9001:2015 from SWASA (Swaziland Standards Authority) and there is ongoing collaboration with ICAP to implement the WHO SLIPTA program.
HIV Service Delivery – The UEDF is supported to provide a comprehensive HIV, TB, Cervical Cancer, VMMC service. The HIV services include HIV testing, clinical care, prevention services, advanced disease management and recency testing. There is extensive mentoring in all service delivery areas to build long term capacity in the respective areas. A sustainability dashboard MILSID (Military Sustainability Dashboard) is developed and reviewed every 2 years to monitor progress.
Infrastructure Development and Maintenance – A multi-year development plan has been implemented to upgrade all the military Health facilities in the base camps. These are being developed to the level where they can offer comprehensive MOH approved ART services; this allows for the services to be decentralized, which in turn improves retention in care. In addition, through the Pretoria office, there are community projects that help in the establishment of community projects such as the building of schools and refurbishment of clinics.
Environmental Awareness – A waste management program for hazardous and non-hazardous waste has been institutionalized. An incinerator bought by DOD has been refurbished and commissioned. The incinerator provides an effective way to deal with all the hazardous and non-hazardous waste from all the clinics.
COVID-19 Support – The COVID pandemic strained the already burdened health system. DOD provided COVID support directly to military facilities, and also provided support to the MOH through the Pretoria DOD office. The Pretoria office provided the essential PPE and Oxygen Concentrators needed for clinical care.
For any questions or comments about PEPFAR programs, please contact the Country Coordinator at Tel: +268 2417-9000 or write to:
The PEPFAR COORDINATOR
P.O. Box D202,
The Gables, Eswatini.
Tel: +268 2417 9000
Fax: +268 2416 3344
The Country Coordination Office of the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) in Swaziland disseminates stories of hope about men, women, and children who are infected and affected by HIV/AIDS across the country. For any questions or comments about PEPFAR programs, please contact the Country Coordinator at Tel: +268 2417-9000 or write to:
The PEPFAR COORDINATOR
P.O. Box D202,
The Gables, Eswatini.
Tel: +268 2417 9000
Fax: +268 2416 3344
For the latest story, please click on the link below:
- Success Stories (PDF 842KB)