Country Spotlight: Swaziland

Country Overview

EGPAF began supporting the government of the Kingdom of Swaziland in 2004 to prevent HIV infections and reduce HIV-related morbidity and mortality among women, children, and families.

Jon Hrusa/EPA

Our Work in Swaziland

EGPAF works with the government of the Kingdom of Swaziland and other partners to implement efficient and effective programs that prevent the transmission of HIV from mother to child and provide testing, care, treatment, and psychosocial support services to children and adults living with HIV. EGPAF contributes to these efforts by:

EGPAF’s clinical and operations research efforts are dedicated to improving delivery of the best prevention, care, and treatment services to families affected by HIV and AIDS. Through its research and documentation of PMTCT, prevention, and care and treatment programs in Swaziland, EGPAF is:

Advocacy is critical to ensuring that prevention, care, and treatment services, as well as education and support, are available to all those who stand to benefit. Working with the government of the Kingdom of Swaziland and other partners, EGPAF engages in advocacy efforts including:

As of December 31, 2013, EGPAF-supported programs in Swaziland had:

Key Projects in Swaziland

Combination Prevention Program in Swaziland (USAID/PSI: 2010-2014)

This USAID/PEPFAR-funded project, led by PSI, seeks to implement effective and tested approaches to support a national, coordinated approach to combination prevention programs through three pillars of interventions: structural, behavioral, and biomedical. EGPAF is focusing on the biomedical pillar in order to strengthen the male circumcision (MC) program through the integration of MC messages into existing community activities including community days, male dialogues, male support groups, and community outreach. In addition, EGPAF will work with PSI to develop and finalize neonatal MC training curriculum for nurses, counselors, and outreach workers, and will work with public and NGO partners to ensure linkages between behavior change communications activities and MC service delivery activities.

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Eliminating Pediatric AIDS in Swaziland (EPAS) Program (USAID/PEPFAR: 2010-2015)

The goal of this five-year USAID/PEPFAR-funded project is to assist the Government of the Kingdom of Swaziland in its efforts to eliminate pediatric HIV. This project will expand the availability of comprehensive services for the prevention of mother-to-child transmission (PMTCT) of HIV, reduce missed opportunities for delivery of services, and better address cultural norms that keep some women from obtaining these services. The EPAS program will make the most effective PMTCT services available to mothers in 100 percent of public facilities and selected high-volume private facilities. In addition, missed opportunities to provide services will be reduced through increased primary prevention, family planning, HIV re-testing during pregnancy, and mobilization of pregnant women for early antenatal care and delivery in health facilities.

In addition, the project focuses on sustained quality, comprehensive, and integrated PMTCT services at Ministry of Health-supported facilities. Quality will be improved through clinical mentoring, training, and supervision, and by facility-based, quality improvement techniques that are already in use. To ensure a comprehensive service package, the EGPAF team will accelerate support around HIV counseling and testing for children and couples, referrals and linkages to neonatal male circumcision, and up-to-date HIV care and support.

The project also targets health sector strengthening, a critical component of the Ministry of Health’s national plan, including PMTCT. Through the capacity building aspects of this program, five key areas will be addressed:

  • Human resources
  • Strategic information
  • Logistics management
  • Site support supervision
  • Program and financial management

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A Secondary Analysis of Retention Across the PMTCT Cascade in Selected Countries Implementing the Various Guidelines. Kenya: Option A; Swaziland: Option A; Rwanda: Option B; Malawi: Option B+ (USAID/Population Council: 2011-2014)

This PEPFAR-funded HIVCORE study is a retrospective cohort analysis of mother-infant pair retention in prevention of mother-to-child transmission of HIV (PMTCT) services from antenatal clinic through 18 months postpartum in four selected EGPAF-supported country programs that are implementing Option A, Option B, or Option B+ for PMTCT. The study is being conducted in selected urban, semi-urban, and rural facilities in Malawi, Rwanda, Kenya, and Swaziland. The primary objectives of the study are to determine:

  • What are the levels of retention 30 days after entry into the PMTCT program, at delivery, six weeks, two months (60 days), three months (90 days), six months, and 12 months post-delivery among women and infants on Option A and on Option B/B+?
  • How do the levels of retention vary by facility characteristics such as type of facility, higher versus lower volume PMTCT facility, rural/urban facility, and presence and type of follow-up (active/passive) among women and infants on Option A and on Option B/B+?
  • How do the levels of retention vary by demographic and clinical characteristics among women and infants on Option A and on Option B/B+?
  • What are the most modifiable characteristics associated with retention in Option A and in Option B/B+ sites?

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Strengthening Facility Based HIV Testing and Counseling (HTC) Service in Swaziland (CDC/PEPFAR: 2011-2016)

The goal of this CDC/PEPFAR-funded project is to assist the Government of the Kingdom of Swaziland to achieve its goal of increasing the percentage of the population undergoing HIV testing each year to 50% of women and 40% of men by 2013. EGPAF’s project objectives are as follows:

  • Support the Ministry of Health (MOH) to create an enabling environment to achieve universal access to HTC services in all health facilities in the country;
  • Support implementation of routine HTC services at all points of care within health facilities;
  • Strengthen linkages to ongoing prevention, treatment, care and support services;
  • Build capacity and strengthen health systems.

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An Exploratory Study of the Behaviors and Practices That May Increase HIV Risk among Pregnant and Lactating Women in Communities in Swaziland (2012-2013)

This is an exploratory study to better understand the sexual practices of pregnant women that may affect HIV seroconversion during pregnancy. This is a follow-up study to the Gates study, which identified an increased rate of seroconversion during pregnancy. There are four study aims:

  • To describe beliefs, communication, and behaviors regarding sex and sexuality in Swaziland;
  • To understand how sexual practices change during pregnancy and lactation;
  • To examine knowledge and perceived risk of HIV acquisition during pregnancy and lactation among women and men;
  • To explore HIV prevention practices during pregnancy and lactation.

The study uses a qualitative exploratory study design. This study will interview three study populations: pregnant women, sexually active men, and health care workers. Data will be collected from the three study populations through focus group discussions and in-depth interviews. Focus group discussions will be used to gather more general information about cultural and traditional sexual norms and practices. Individual interviews will provide an opportunity to explore participants’ sexual experiences during pregnancy and lactation. Focus group discuss will be conducted with health care workers to gather an additional perspective and triangulate findings between the study populations. Given the minimal amount of information available regarding this topic, this small exploratory study may encourage additional research.

Swaziland is comprised of rural, urban, and semi-rural areas. In order to ensure that the study is representative of these three types of areas, the study will include one urban, one rural, and one semi-urban site. Currently, the study is in the process of translating the data collection tools and plans to launch data collection in September 2012.

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Advancing Community-Level Action for Improving MCH/PMTCT (ACCLAIM) Program (Department of Foreign Affairs, Trade and Development Canada: 2012-2016)

The goal of this project is to increase community demand for, uptake of, and retention in maternal and child health (MCH)/prevention of mother-to-child transmission of HIV (PMTCT) services to improve country progress toward elimination of pediatric HIV/AIDS. This will be achieved through the following objectives:

  • Improving key HIV, MCH, and gender-related health behaviors through the implementation of community-based interventions that target changes in community norms and attitudes, thereby increasing the number of pregnant women accessing and completing the sequence of PMTCT services;
  • Assessing the behavioral and operational outcomes of selected community-based interventions and determine their relative effectiveness through strategic evaluation and operations research;
  • Documenting and disseminating research results, tools developed, and lessons learned to facilitate widespread expansion of community engagement activities found to be effective.

Community-based interventions designed to complement facility-based services hold tremendous promise for improving PMTCT program outcomes by addressing entrance, adherence, and retention to the range of PMTCT services along the cascade. The three main interventions for implementation and evaluation in this proposal, which address communities on three different levels, include:

  • Engagement of Community Leaders: Through training and capacity building for community leaders, this project will begin by facilitating the development of Community Action Plans (CAP) in order to generate increased demand for MCH and PMTCT services;
  • Community Days: Semi-annual Community Days will bring entire communities together for a day of communication, information, and activities to improve awareness among key target populations of important MCH and PMTCT services;
  • Community Peer Groups: Working at the individual level, MCH classes and men’s groups will provide comprehensive MCH/PMTCT information and skills development to crucial community sub-groups focused on increasing and improving MCH and PMTCT health behaviors.

EGPAF has chosen three countries for these interventions – Uganda, Swaziland, and Zimbabwe – countries that, in collaboration with their respective Ministries of Health (MOH), are all making great strides in expanding facility-based services and strengthening health systems, but that have recognized barriers and gaps in demand and follow-up. This project provides a community-based approach that will influence harmful gender norms, attitudes, and behaviors through engagement at the grassroots level to enhance the potential impact. The addition of complementary community-based services will help move these countries towards the elimination of pediatric HIV/AIDS, and the demonstration of the effect of these interventions will provide other countries with evidence to inform replication and scale-up.

Building upon EGPAF’s successfully supported PMTCT programs, this project focuses on breaking down community-level barriers to uptake of and retention in PMTCT services. The activities are designed to be locally relevant, addressing multiple gaps simultaneously across a variety of settings. The proposed project is being conducted over four years in 45 community clusters across the three selected countries in a stepped approach that will allow for comparison of the effectiveness of single and combination interventions. All clusters will benefit from the “Leadership Engagement” component of the intervention package. In 15 community clusters, “Community Days” will be added on; and in the final 15 of the community clusters, the full combination intervention package comprising “Leadership Engagement,” “Community Days,” and “Community Peer Groups” will be implemented. Through routine monitoring and evaluation and focused operations research, EGPAF will be able to provide in-depth analysis of the implementation and outcomes of the interventions and the added value of each intervention. A comprehensive dissemination plan will allow for adaptation and use of these innovations in additional settings, which will contribute to the overall learning from the experience gained through implementation.

The strategic design of this project will provide the evidence base needed for communities and program managers to make an informed choice of community activities to support. The experience and evidence gained through the proposed interventions will be important not only for the three countries in which they will occur, but also across EGPAF’s other country programs and the broader global health community.

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Call to Action (USAID/PEPFAR: 2002-2010)

With funding from the United States Agency for International Development (USAID) and the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), EGPAF implemented the eight-year Call to Action (CTA) project in 12 countries, including Swaziland (from 2004 through 2010). This service-based program aimed at scaling up prevention of mother-to-child transmission of HIV (PMTCT) services, and preventing pediatric HIV infection through research, advocacy, and prevention and treatment programs.

CTA’s work was conducted in accordance with national health policies and within national AIDS response frameworks. EGPAF-supported programs integrate HIV counseling and testing and antiretroviral (ARV) prophylaxis regimens into existing maternal and child health (MCH) services. Patient flow, HIV counseling techniques, testing algorithms, drug distribution, and other aspects of program delivery differ among countries. CTA funds have supported basic clinic improvements, essential commodities, community mobilization, training of health care workers, education to mothers on infant feeding, technical assistance for program implementation, evaluation and monitoring, and psychosocial support.

Since its inception in 2004, EGPAF’s strategy in Swaziland has been to support the PMTCT program of the Swaziland Ministry of Health (MOH) through design, development, management, monitoring, and technical support activities. Under CTA, EGPAF supported the Swaziland national PMTCT program to prevent HIV infection among infants and utilized the PMTCT program as a point of identification of HIV-positive individuals to provide care and support and access to HIV treatment services. EGPAF directly supported facilities to provide HIV testing and counseling (HTC), ARV prophylaxis for PMTCT, early infant diagnosis and treatment, psychosocial support, training of service providers, adequate counselor and laboratory technician staff, confidential counseling spaces, monitoring and evaluation systems, and strengthened MCH/family planning services. Swaziland-specific highlights include:

  • Increased coverage of comprehensive PMTCT, HIV care and treatment services: By the end of project, EGPAF support reached over 80% of pregnant women who gave birth in all facilities, and reached 100% coverage in MOH facilities;
  • Improved Early Infant Diagnosis: Early infant diagnosis in Swaziland has resulted in 83% of HIV-exposed infants receiving CTX prophylaxis at six weeks at the 47 EGPAF-supported sites;
  • HIV testing of pregnant women increased from 15% to 67%, and maternal and infant uptake of prophylaxis increased from 87% to 90%.

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Swaziland Implementation Plan for Prevention of Mother-to-Child Transmission of HIV (SWIPP) (Johnson & Johnson: 2010-2012)

In September 2010, the EGPAF partnered with Swaziland’s Ministry of Health, Johnson & Johnson (J&J), the University of California, Los Angeles Anderson School of Management, and the African Medical and Research Foundation (AMREF) to strengthen the management skills of government and civil society leaders responsible for scaling up high-quality prevention of mother-to-child transmission of HIV (PMTCT) services in accordance with new 2010 World Health Organization guidelines. EGPAF worked with J&J to host the Management Development Institute, which resulted in the creation of regional and national teams that developed plans for PMTCT implementation (SWIPP). The J&J-supported training and SWIPP team mentorship filled a key gap in Swaziland, enabling those responsible for designing, managing, and monitoring health programs to build and strengthen critical management skills, develop action plans, and to be accountable for plan results.

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Increasing Access to Pediatric Care and Treatment Services (ViiV Healthcare: 2010-2012)

In June 2010, ViiV Healthcare and EGPAF joined together to improve early detection of HIV and treatment access for HIV-positive infants and young children (IYC) in three countries. The EGPAF-ViiV partnership focused on expediting access to testing, care and antiretroviral treatment for IYC, and enabled EGPAF to fill critical gaps that limit access by focusing on three key objectives:

  • Increasing early detection and initiation of antiretroviral therapy for HIV-positive infants and young children;
  • Strengthening government leadership;
  • Using strategic information to understand what works, and to apply this understanding to improve programs.

By project end, there were significant improvements in key indicators, including more HIV-exposed infants tested within eight weeks of birth; more HIV-exposed infants who tested positive receiving their results within eight weeks of testing; and more HIV-exposed IYC who tested positive initiated on antiretroviral therapy (ART). In addition, linkages between health facilities and communities were strengthened via new partnerships with community-based organizations and the engagement of village health workers, technical advocacy aimed at addressing barriers to testing and treating IYC was successful in a number of areas, including the ability for nurses to prescribe ART and the development of a new national pediatric counseling and testing curriculum in Swaziland, and 40 HIV/AIDS Technical Leaders from 16 countries were provided critical training on how to implement the new WHO Guidelines on Pediatric ART.

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Publications

Country adaptation of the 2010 World Health Organization recommendations for the prevention of mother-to-child transmission of HIV (2012): Download PDF download

Swaziland Program Brief: Addressing the Social and Behavioral Barriers to Prevention of Mother-to-Child Transmission of HIV Through Community Dialogue - An Implementer's Guide Based on the Elizabeth Glaser Pediatric AIDS Foundation's Swaziland Experience (2012): Download PDF download

Program Brief: Using Data to Understand and Address Gaps in the Treatment Cascade for HIV-Positive Infants and Young Children: Experiences from Lesotho, Malawi, and Swaziland: Download PDF download

Our Program: Swaziland: Working with Women, Children, and Families to Eliminate Pediatric AIDS: Download PDF download