J.17_HIV_2018_Annual_Program_Report.pdf

MONITORING AND EVALUATION

Monitoring and Evaluation Unit Strategic Information Department

SIY I NQ A B A

KINGDOM OF ESWATINI

MINISTRY OF HEALTH

Annual Program

Report

HIV

Acknowledgements

The report is based on the calendar year Jan 2018 - Dec 2018

The 2018 HIV Program Annual Report has been made possible with the technical direction and support of the Ministry of Health Directorate through a process led by the Monitoring and Evaluation Unit and the Eswatini National AIDS Programme. The Ministry of Health acknowledges the financial and technical support provided by the Institute for Health Measurement for the report writing process.

The effective involvement of the HMIS Unit especially the Data Management Team and other departments in the Ministry of Health as well as all Implementing Partners, UN Agencies, and Civil Society Organizations is highly appreciated. Special recognition also goes to the health care workers in health facilities who deliver services to clients and document health information that is used to track progress for the health sector response to HIV.

Special thanks go to the following individuals who were involved in the 2018 HIV Program Report writing and review process:

Thabo Motsa MoH-M&E Zandile Masangane MoH-SRH

Nompumelelo Dlamini-Mthunzi MoH-M&E Mgcineni Ndlangamandla MoH-SRH

Dr. Simangele Mthethwa MoH-ENAP Mavis Vilane MoH-CMS

Dr. Rudo Kuwengwa MoH-ENAP Dr. Florence Baylor

Dr. Hervé Nzereka Kambale MoH-ENAP Dr. Christopher Makwindi EGPAF

Nompilo Gwebu MoH-ENAP Nondumiso Ncube CHAI

Lenhle Dube MoH-ENAP Tengetile Nhlengethwa CHAI

Gugulethu Madonsela MoH-ENAP Siyabonga Ndwandwe CHAI

Ntombi Ginindza MoH-ENAP Ndumiso Dlamini CHAPS

Nonhlanhla Dlamini MoH-ENAP Setsabile Gulwako FLAS

Ayanda Sikhondze MoH-ENAP Themba Matsebula HC4

Nobuhle Mthethwa MoH-ENAP Nomenzile Mamba ICAP

Mpumelelo Mavimbela MoH-ENAP Patrick Shabangu IHM

Sindy Matse MoH-ENAP Bongani Dube NERCHA

Nhlanhla Magagula MoH-ENAP Nokuthula Mdluli PSI

Bonisile Nhlabatsi MoH-SRH Lawrence Mashimbye UNAIDS

Lindiwe Malaza MoH-SRH Thamary Silindza UNFPA

Nozipho Motsa MoH-SRH Lindiwe Mkhatshwa URC

Ntombikayise Dlamini-Madlopha MoH-SRH

CONTENTS

Acknowledgements ii Executive Summary vi Acronyms viii

1.1 Background 9

1.2 Program description 10

1.3 Strategic directions 10

1.4 Key Performance Targets 11

Chapter 2: Methodology 12

3.1. Service Delivery 13

3.1.1 Condom Promotion and Distribution 13

3.1.2 Key Populations 14

3.1.3 HIV Testing Services (HTS) and Linkages 19

3.1.4 Voluntary Male Medical Circumcision (VMMC) 24

3.1.5 Prevention of Mother To Child Transmission

of HIV (PMTCT) 27

3.1.6 Sexually Transmitted Infections (STIs) 30

3.1.7 HIV Treatment, Care and Support 34

3.1.8 Palliative Care 59

3.2 Health Workforce 60

3.3. Information 62

3.4. Medical Products, Vaccines and Technology 63

3.5. Financing 65

3.6. Leadership and Governance 66

Chapter 4: Summary of major program achievements 67

Chapter 5: Achievements and Challenges 68

Chapter 6: Conclusions and way forward 69

References 70

CHAPTER 1: 9

Introduction

CHAPTER 2: 12

Methodology

CHAPTER 3: 13

Methodology

CHAPTER 4: 67

Summary of major program achievements

CHAPTER 5: 68

Achievements and Challenges

CHAPTER 4: 69

Conclusions and way forward

Figure 1: Number of male and female condoms distributed (HMIS: 2018) 13 Figure 2: Number of FSWs hotspots by region in 2017 and 2018 (Program data) 14 Figure 3: Number of MSM safe spaces by region in 2017 and 2018 (Program data) 15 Figure 4: Number of FSWs accessing HIV services in 2018 (Program data) 16 Figure 5: Number of MSM reached with HIV prevention services in 2018 (Program data) 16 Figure 6: Number of PWID and Transport Operators reached with HIV services in 2018 (Program data) 17 Figure 7: Number of FSWs and MSMs screened and treated for STIs in 2018 (Program data) 18 Figure 8: Number of FSWs and MSMs screened for TB in 2018 (Program data) 18 Figure 9: Number of commodities distributed to Key Populations (Program data: 2018) 19 Figure 10: Number of HIV tests done by sex (HMIS: 2018) 20 Figure 11: Number of HIV tests done and Positivity by sex and region (HMIS: 2018) 20 Figure 12: Number of HIV tests done and Positivity by age, sex and region (HMIS: 2018) 21 Figure 13: Trends for HIV tests done and Positivity by sex from 2013-2018 (HMIS) 23 Figure 14: Number of people diagnosed with HIV successfully linked to treatment and care services in 2018 (HMIS) 24 Figure 15: Number of males circumcised by age in 2018 (Program data/HMIS) 25 Figure 16: Number of male circumcisions performed by region (Program data/HMIS: 2018) 26 Figure 17: Number of post-operative adverse events following a VMMC procedure (Program/HMIS: 2018) 26 Figure 18: PMTCT cascade for pregnant women (HMIS: 2018) 28 Figure 19: Number of HIV exposed infants tested for HIV at 6-8 weeks (HMIS: 2018) 29 Figure 20: Number of women attending FP services who receive HIV testing and ART initiation services (HMIS: 2018) 30 Figure 21: Number of STIs cases seen at OPD (HMIS: 2018) 31 Figure 22: Number of STI cases seen at OPD from 2017 and 2018 (HMIS: 2018) 31 Figure 23: Number of STIs seen at CMIS sites (HMIS: 2018) 32 Figure 24: Number of Urethral Discharge Syndrome cases seen at CMIS sites by age (HMIS: 2018) 33 Figure 25: Number of PLHIV newly initiated on ART by age and sex (HMIS: 2018) 34 Figure 26: Number of PLHIV newly initiated on ART by age, sex, and region (HMIS: 2018) 35 Figure 27: Number of PLHIV initiated on ART through Test and Start (HMIS: 2018) 36 Figure 28: Number of PLHIV currently receiving ART by age and sex (HMIS: 2018) 37 Figure 29: Percentage ART coverage by age and sex (HMIS: 2018) 40 Figure 30: Number of PLHIV currently receiving ART tested for viral load and virally suppressed by sex (HMIS: 2018) 40 Figure 31: Number of PLHIV LTFU, Stopped treatment and deceased by sex (HMIS: 2018) 44 Figure 32: Number of Paediatric PLHIV newly initiated on ART by age and sex (HMIS: 2018) 45 Figure 33: Number of Paediatric PLHIV newly initiated on ART by region (HMIS: 2018) 47 Figure 34: Number of Paediatric PLHIV currently receiving ART by age and sex (HMIS: 2018) 48 Figure 35: Number of Paediatric PLHIV currently receiving ART by region (HMIS: 2018) 48 Figure 36: Number of Paediatric PLHIV currently receiving ART by age, sex and region (HMIS: 2018) 49 Figure 37: Trends for Paediatric PLHIV newly initiated on ART and current on ART from 2014-2018 (HMIS: 2018) 50

List of Figures

Figure 38: ART coverage for Paediatric PLHIV by age and sex (HMIS: 2018) 50 Figure 39: Number of Paediatric PLHIV tested for viral load and virally suppressed by age (HMIS: 2018) 52 Figure 40: Percentage viral load testing coverage and viral suppression by age and sex (HMIS: 2018) 53 Figure 41: Number of Paediatric PLHIV LTFU, Stopped treatment and deceased by age (HMIS: 2018) 54 Figure 42: Number of PLHIV screened for TB at ART initiation (HMIS: 2018) 55 Figure 43: Number of PLHIV currently receiving ART screened for TB (HMIS: 2018) 56 Figure 44: Number of PLHIV newly initiated on ART started on TPT (HMIS: 2018) 56 Figure 45: Number of PLHIV currently receiving ART screened negative for TB and started on TPT (HMIS: 2018) 57 Figure 46: Number of facility-based Expert Clients by region (Program data: 2018) 57 Figure 47: Number of clients receiving pain medication (Program data: 2018) 59 Figure 48: Number of health workers trained on Palliative Care (Program data: 2018) 60 Figure 49: ENAP Organogram 62 Figure 50: Number of views for Eswatini National AIDS Program website (Program data: 2018) 63 Figure 51: Proportion of PLHIV collecting first line ART regimen from health facilities (LMIS: 2018) 64 Figure 52: Percentage stock-out rates for one or more ART tracer products by region (LMIS: 2018) 65

List of Tables Table 1: HIV Program Key Performance Indicators as per HSRP 2014-2018 11 Table 2: Number of HIV Tests and Positivity Rate by Entry Point, 2018 22 Table 3: Number of pregnant women attending ANC tested for HIV by year (HMIS: 2018) 27 Table 4: HIV positivity rate among pregnant women attending ANC by year (HMIS: 2018) 27 Table 5: Number of pregnant women attending ANC tested for Syphilis by year (HMIS: 2018) 33 Table 6: Baseline CD4 count for PLHIV at ART initiation by sex, 2018 38 Table 7: Baseline WHO Staging for PLHIV at ART initiation by sex, 2018 38 Table 8: Number of PLHIV currently receiving ART by age, sex and region 2018 39 Table 9: Number of PLHIV on First Line ART regimen for adults 15 years and older, 2018 41 Table 10: Number of PLHIV on Second Line ART Regimen for adults 15 years and older, 2018 42 Table 11: Cohort Retention Trends for PLHIV on ART by Age, 2012-2018 43 Table 12: Number of Paediatric PLHIV on NNRIT-based ART Regimens by age, 2018 51 Table 13: Number pf Paediatric PLHIV on PI-based ART Regimens by age, 2018 52 Table 14: Number of Nurses cadre available in health facilities by region, 2017 61 Table 15: Number of health facilities reporting for ART consumption by region, 2018 64 Table 16: Number of days for stocked-out ART Tracer products in 2018 (LMIS) 65

EXECUTIVE SUMMARY

The Government of the Kingdom of Eswatini (GoKE), through the Ministry of Health, has continued to support the imple-mentation of HIV program activities to attain its goal of an HIV-free generation. The GoKE is committed to ensure the procurement and availability of antiretroviral medicines (ARVs) and to support personnel in healthcare facilities in the fight against HIV. More focus has been placed on the 90-90-90 UNAIDS global targets for 2020 where it is expected that 90% of PLHIV should be diagnosed for HIV, 90% be put and retained in treatment and 90% be virally suppressed.

The country has aligned itself to the global community and implemented a number of approaches in the fight against HIV from prevention to care and treatment in a decentralized manner for all population groups affected by and infected with HIV. In 2018, 82% (249/304) of health facilities were providing HIV testing services (MoH, 2017), and a total of 391,067 HIV tests were carried out. There were also 2,500,019 male condoms and 420,758 female condoms that were distributed for this reporting period (2018).

In 2018, the country joined the global community making the commitment to eliminate mother to child transmission of HIV and syphilis as a public health priority. The Ministry of Health working through the sexual and reproductive health (SRH) Program has focused on taking a harmonized and integrated approach to improve the health outcomes of women and children in order to achieve the ultimate goal of eliminating mother-to-child transmission of HIV and syphilis. Over the past 3 years, Eswatini has achieved the one percent (1%) target for the proportion of HIV infected infants at 6-8 weeks that are born to HIV positive mothers. Also, in 2018, the proportion of HIV positive and lactating women receiving lifelong antiretroviral therapy (ART) was at 91%.

Progress has been made in increasing ART coverage and retaining PLHIV on ART; 87% of adults 15 years and above and 67% of children less than 15 years were receiving ART by the end of 2018. Seventy-seven percent of adults 15 years and above years and 73% of children less than 15 years were retained on treatment at 36 months after ART initiation.

Concentrated efforts have to be made in order to achieve the 90-90-90 UNAIDS global targets among PLHIV.

Regarding the management of HIV/TB coinfection among PLHIV, the country has made great strides through the imple-mentation of TB and HIV collaborative activities. A 95% TB screening rate for PLHIV receiving ART and those newly initiated on ART was achieved in 2018. There is need to increase the TB preventive therapy (TPT) coverage for PLHIV on ART who have screened negative for TB from 5% for those initiating ART and 18% for those already on ART to reach a 100% coverage.

Improving the health sector response to HIV will help the country to achieve the Ministry of Health’s goal of providing Universal Health Coverage to its citizens as enshrined in the 2007 National Health Policy and NHSSP II, and make Eswatini better placed to achieve the Sustainable Development Goals. Broad partnerships and strong linkages must be emphasized at all levels of care and a Health Systems Strengthening approach must be implemented to attain an HIV-free generation.

67% children less than 15 years were receiving Art by the end of 2018. Seventy-seven percent and seventy-three percent of adults 15+ years and children less than 15 years were retained into treatment at 36 months after ART initiation, respectively. Concentrated efforts have to be made in order to achieve the 90-90-90 UNAIDS global targets and improve on the ART coverage and viral suppression among PLHIV receiving ART.

vi HIV Program_2018 Annual Report

EXECUTIVE SUMMARY

On another note, great work has been achieved in managing HIV/TB coinfections among PLHIV receiving ART through the implementation of TB and HIV collaborative activities. A ninety-five percent TB screening rate for PLHIV receiving ART and those newly initiated on ART has been achieved in 2018. There is a need to improve on the TPT coverage for PLHIV on ART who have screened negative for TB from 5% at ART initiation and 18% for those PLHIV already on ART to reach 100% TPT coverage.

Improving of the health sector response to HIV will help the country to achieve the ministry of Health goal of providing Universal Health Coverage to its citizens as enshrined in the 2007 National Health Policy and NHSSP II and be better placed in achievement of the Sustainable Development Goals. Broad partnerships and strong linkages must be empha-sized at all levels as well as focus on Health Systems Strengthening to attain an HIV-free generation.

HIV Program_2018 Annual Report vii

ACRONYMS

ANC - Antenatal Care

ART - Antiretroviral Therapy

BCC - Behaviour Change Communication

DNA - Deoxyribonucleic acid eNSF - Extended National Strategic Framework

HMIS - Health Management Information Systems

HSRP - Health Sector Response to HIV/AIDS Plan

IEC - Information Education & Communication

IHM - Institute of Health Management

INH - Isoniazid

LGBTI - Lesbian, Gay, Bisexual, Transgender and Intersex

LLAPLa - Life Long ART for Pregnant and Lactating women

M&E - Monitoring and Evaluation

NERCHA - National Emergency Response Council on HIV and AIDS

PCR - Polymerase chain reaction

PEP - Post Exposure Prophylaxis

PLHIV - People (person) Living with HIV

PNC - Post Natal Care

POC - Point of Care

SHIMS - Swaziland Incidence Measurement Survey

SID - Strategic Information Department

TPT - TB Preventive Therapy

UNAIDS - Joined United Nations Program on HIV & AIDS

WHO - World Health Organization viii HIV Program_2018 Annual Report

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INTRODUCTION

1.1 Background

The Human Immuno-Deficiency Virus (HIV)/Acquired immune deficiency syndrome (AIDS) is a major public health prob-lem, which over the years has culminated in scores of lives being lost globally. The World Health Organization (WHO) states that in 2017, 36.9 million people were living with HIV/AIDS; of these 4.87% accounted for new infections (WHO, 2018). Key populations are at a higher risk of acquiring HIV as they accounted for about 50% of global new infections in 2017. Socio-legal issues relating to key populations’ behaviors increase their vulnerability to HIV and reduce their access to HIV testing and treatment programmes (WHO, 2018).

By 2018 HIV/AIDS had killed over 35 million people; with 940 000 lives claimed in 2017 alone (WHO 2018). In 2017, the African Region had the highest number of people living with HIV (PLHIV) as it contributed two thirds of the 36.9 million people living with HIV globally (WHO,2018). According the second Swaziland HIV Incidence Measurement Survey (SHIMS 2), HIV prevalence was 27% for people aged 15-49 years, and the incidence was 1.4% (1.37% in women vs 0.93% in men).

An overall reduction of 44% in the incidence was observed from 2010 (2.70%) to 2017 (1.4%).

Regarding people knowing their status, about 75% PLHIV knew their status globally while in the Eastern and Southern Africa region 76% PLHIV knew their status (WHO, 2018). In Eswatini, 84.7% PLHIV knew their HIV status in 2017. Howev-er, the coverage of those knowing their status was not the same among the different sub-populations. More women (88.6%) knew their status compared to their male counterparts (77.6%); 12.6% of men who have sex with men (MSM) knew their status; and 60.5% of female sex workers knew their status (eNSF, 2018). The Kingdom of Eswatini has made great strides towards fighting HIV/AIDS in line with sustainable development goal 3.3 through decentralization of HIV Testing Services (HTS). There are new testing modalities (HTS optimization, targeted testing, index and self-testing) that Eswatini has adopted to increase the proportion of PLHIV who know their status. In 2018, testing among children was reported to be at 66.1% (NSF, 2018).

Availability of anti-retroviral therapy (ART) has reduced HIV related deaths by 38%; with 11.4 million deaths averted globally (WHO, 2018). The global population of PLHIV on ART was 21.7 million in 2017. Fifty nine percent of adults who knew their HIV status were on ART compared to 52% of children (WHO, 2018). Sixty five percent of adult females aged 15 years and older had access to ART, while 53% of their male counterparts had access to ART. Linkages to ART for PLHIV need to be scaled up to reach the second 90 by 2020. In the Eastern and Southern region about 60% of PLHIV were initiated on ART (UNAIDS, 2017). In Eswatini 87.4% of adults aged 15 years and older were on ART in 2017 (SHIMS 2, 2017). However, ART initiation was not the same among the different sub-populations. More males (88.6%) were on ART compared 86.9% of women; 33% of MSM were on ART; and 41.5% of female sex workers were on ART (NSF, 2017). To scale up ART initiation of PLHIV to 95% by 2023, the MoH has adopted the test and start model, linkages case manage-ment, treatment optimization, and differentiated service delivery (DSD).

Over 70,000 AIDS-related deaths have been averted since the introduction of antiretroviral therapy in 2003 in Eswatini.

The model adopted in 2003 was the use of eligibility thresholds to initiate ART. However, in 2016, test and treat was adopted in an effort to scale up initiation to 95% by 2023.

HIV Program_2018 Annual Report 09

This indicates that the country is on the trajectory to end AIDS as a public health threat. However, if this target is to be fulfilled, the current incidence rate of 1.4% among those aged 15-49 is not sufficient to achieve epidemic control as younger people bear higher new infections, and some (15%) of PLHIV have not been tested nor initiated on ART.

Availability and accessibility of ART has increased the number of people who are virally suppressed. In 2017, 83% of PLHIV on ART in the Eastern and Southern Africa region were virally suppressed. Eswatini is exceeding regional trends as 92% of PLHIV aged 15 and above were reported to be virally suppressed (SHIMS 2, 2017). Though the proportion of virally suppressed PLHIV in Eswatini is high, children and men living with HIV are still lagging behind, hence activities geared towards increasing adherence and retention on ART need to be strengthened for these populations.

1.2 Program description

The Ministry of Health (MoH) in the Kingdom of Eswatini is responsible for the formulation of health policies, develop-ment of guidelines and standard operating procedures (SOPs), and the monitoring and evaluation of the progress there-

of. The MoH leads the health sector response to HIV and AIDS in the country through the Eswatini National AIDS Program (ENAP) which was established in 1987 to provide technical leadership and a coordination role within the health sector. The core mandate of the ENAP is to coordinate Health sector interventions.

The core mandate of ENAP is to coordinate and oversee the health sector response to HIV. Responsibilities for ENAP include, and are not limited to, advocating for resources and collaboration with all HIV stakeholders at national and regional levels in planning and implementing HIV services; development of guidelines and SOPs for HIV service delivery;

facilitation of the integration of HIV services in other health settings; promotion of quality improvement for HIV services;

and facilitation of HIV commodity procurement and distribution.

With HIV services delivered at the health facility and community level, the thematic area leads within ENAP coordinate delivery of services, and facilitate capacity building for health care workers. The thematic area leads also chair the different technical working groups under each component of HIV response which comprise of members from the differ-ent HIV stakeholders at national and regional levels.

1.3 Strategic Directions

The HSRP (2014-2018) provided strategic directions and targets for the provision of HIV services as part of the country’s vision to eliminate new HIV infections and prevent AIDS-related morbidity and mortality. The delivery of HIV services was focused on providing both prevention and treatment services for HIV/AIDS that are guided by principles of accessibility;

affordability; human rights; prevention; stigma and discrimination; gender sensitivity; family approach; and community involvement.

The activities implemented as part of the HIV service delivery were informed by the following priority commitments:

1. Strengthening and decentralizing quality HIV service delivery to improve coverage for all people including children, young people, pregnant and lactating women, and Key populations;

2. Integration of HIV services with other health care services including TB, Sexual and Reproductive Health services, nutrition, and Non Communicable Diseases;

3. Strengthening policy and legal frameworks for HIV service delivery for all population groups pertaining to gender based violence issues as well as stigma and discrimination;

4. Strengthening referral and linkages systems for HIV services including active tracking mechanisms for PLHIV on ART within and between health facilities and communities;

5. Strengthening the procurement and supply management systems for medicines and related commodities including the laboratory;

6. Strengthening M&E systems for HIV programming;

7. Accelerating task shifting and capacity development for all health care workers;

8. Strengthening the coordination of psychological care and support for health care workers.

CHAPTER ONE: INTRODUCTION

10 HIV Program_2018 Annual Report

CHAPTER ONE: INTRODUCTION

These commitments were aligned to the priority strategies of the National Health Sector Strategic Plan II (2014-2018), the National Development Strategy, the 90-0-90 UNAIDS global target, and Target 3.3 of the Health Goal in the Sustain-able Development Goals.

Within the NHSSP II (2014-2018), the health sector response was to contribute to the achievement of targets such as Promoting health through the life course; Prevention and control of communicable and non-communicable diseases;

Managing medical and related conditions; and Rehabilitation following health events.

1.4 Key Performance Indicator (KPI) Targets

The performance of the national AIDS programme is guided by the following KPIs (Table 1):

Table 1: HIV Program Key Performance Indicators as per HSRP 2014-2018

Program Area Indicator Baseline 2011 2015 Target 2018 Achievement Target

Progress status

HTS

1. Increased proportion of Sites providing HTS 83% (201/242) 85% 82% (249/304) 95%

2. Number of people who have tested for HIV in the last 12 months and know their HIV status*

178,823 500,000 391,067 700,000

VMMC

1. Percentage of males aged 10-49 who are circumcised

19.10% 45% (13,548) (40140)

2. Percentage of new born male infants circumcised within 2 months

(1,149) 30% 4% (632) (5403)

Condom Promotion and Distribution

1. Number of condoms distributed per year

6.5 million – Male Condoms

10 million Male condoms 2,500,019 14 million

202,100 – Female

Condoms

350,000 Female condoms 420,758 500,000

PMTCT

1. Percentage of HIV infected infants aged 6-8 weeks who are born to HIV positive mothers

2% 1% 1% 1%

2. Percentage of HIV positive pregnant and lactating women receiving lifelong

ART

50% 80% 91% 95%

ART

1. Percentage of eligible adults aged 15 and older currently receiving ART.

84% 90% 87% 90%

2. Percentage of eligible children aged 0-14 currently receiving ART.

63% 80% 67% 90%

3. Percentage of adults and children with HIV alive and known to be on treatment 36 months after initiation of

ART.

68%: Adults 75% 77% 90%

66%: Children 70% 73% 90%

HIV/TB

co-infection

1. Percentage PLHIV enrolled in care screened for TB

N/A 70% 95% 100%

2. Percentage of HIV+ patients screened negative for TB given INH (at ART Initiation)

N/A 50% 5% 60%

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METHODOLOGY

The Monitoring and Evaluation Unit of the Ministry of Health led the development process for this 2018 Annual HIV Program Report. The 2018 HIV Program Annual Report demonstrates the performance of the HIV programming. The methodology employed for the report writing followed a retrospective longitudinal review of health patient data.

The data used for the analysis of this report is sourced from the Health Management Information System, both electron-ic and paper-based system, as well as program data. Paper-based data is reported monthly using monthly summary tools and submitted to the Regional SID for capturing in the HMIS portal. Electronic data were extracted collated, sorted and cleaned (deduplicated) by the Data Management Team.

A data analysis plan was developed through the M&E Unit according to HIV performance indicators for the HIV Program report. Data analysis was performed by the Regional and National SID Officers (HMIS and M&E units) as well as supporting Implementing Partners in a data analysis workshop supported by IHM. From the analysis of the health data, simple descriptive statistics were run using STATA and MS Excel to produce frequencies for the different performance indicators for HIV programming. The program results were presented in frequency tables and graphs disaggregated according to age, sex, and location.

A follow-up report writing workshop was organized by the M&E Unit through IHM and involved ENAP thematic area leads and HIV program stakeholders at regional and national level. The program results from the frequency tables and graphs were interpreted and discussed according to the performance of the indicators.

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PROGRAM RESULTS

3.1. Service Delivery

Good service delivery is a vital element of every health system which is inclusive of HIV programming. Service delivery is a fundamental input to population health status, among other factors, including social determinants of health.

Strengthening service delivery is critical to the achievement of all health related Sustainable Development Goals and targets.

This section of the 2018 HIV Program Annual Report demonstrates the progress made towards the relevant service delivery through the different thematic areas of HIV programming.

3.1.1 Condom Promotion and Distribution

Condoms are a critical component in a comprehensive and sustainable approach to the prevention of sexual transmit-ted infections (STIs) including HIV and are effective for preventing unwanted or unplanned pregnancies. Therefore, they are highly recommended as part of the dual protection package (FP commodity plus condom). Over the years condom issuing has increased but there’s still challenges in tracking condoms distributed on routine data. Figure 1 shows the number of male and female condoms distributed in 2018.

Figure 1: Number of male and female condoms distributed (HMIS: 2018)

2,107,439

3,842,011

2,266,032

1,377,423

2,500,019

75,131 206,269 127,498 99,516 420,758

500000

1000000

1500000

2000000

2500000

3000000

3500000

4000000

4500000

2014 2015 2016 2017 2018

Male condoms Female condoms

HIV Program_2018 Annual Report 13

There were 2,500,019 male condoms and 420,758 female condoms that were distributed in 2018. This shows an increase from the condoms distributed in 2017 for both the male and female condoms.

3.1.2 Key Populations

Key populations are groups where high risk and vulnerability converge. Unique biological, behavioral, and structural risk factors put these groups at heightened risk for HIV infection and of transmission to members of their sexual networks3 and therefore their involvement is vital for an effective and sustainable HIV response. Evidence further reveals that additional to high HIV risk, key populations have higher levels of mortality and/or morbidity, and yet their access and uptake of relevant health and HIV services is significantly lower than the rest of the population.

The vulnerability of key affected populations is compounded by various factors which include among others; personal attributes, social mobility, diverse sexual orientation and gender identity, risky behaviors such as alcohol and drug abuse, unprotected sex, exchange of sex for gain. In addition, the environment (poverty, stigma and discrimination, inaccessibility to services, and criminalization of their activities) in which key affected groups are exposed to increase their vulnerability.

The country has identified female sex workers (FSWs), men who have sex with other men (MSM), transgender and the entire LGBTI community, people who are incarcerated and people who inject drugs as groups at elevated risk of HIV infection. Figure 2 shows the number of FSWs’ hotspots by region.

Figure 2: Number of FSWs hotspots by region in 2017 and 2018 (Program data)

65 66 61

Hhohho Lubombo Manzini Shiselweni TOTAL

2017 2018

There has been an increase in the number of mapped FSWs’ hotspots from 218 in 2017 up to 278 in 2018. The highest increase has been observed in the Manzini region with 61 hotspots mapped in 2017 to 113 hotspots in 2018. A decrease in FSWs’ hotspots is observed in the Lubombo region where 66 hotspots were mapped in 2017 down to 54 in 2018.

There was also a mapping of MSM safe spaces where the location is captured and not the virtual networks. Figure 3 shows the number of MSM safe spaces by region.

CHAPTER THREE: PROGRAM RESULTS

14 HIV Program_2018 Annual Report

Figure 3: Number of MSM safe spaces by region in 2017 and 2018 (Program data)

7 9

Hhohho Lubombo Manzini Shiselweni TOTAL

2017 2018

A total of 78 MSM safe spaces were mapped in 2018 increasing from 28 safe spaces in 2017. The Hhohho region had the highest increase in the number of MSM safe spaces from 10 safe spaces to 27. The most prominent increase was observed in the Lubombo region where the number of MSM safe spaces increased from 2 up to 15.

There 163 nursing students that were sensitized on Key Populations through pre-service training. There were 63 students from the University of Eswatini, 41 from Good Shepherd and 59 from Southern Africa Nazarene University.

There were 19 health workers from the Shiselweni region that were sensitized on Key Population issues. A total of 36 Police Officers from the Domestic and Violence Unit were trained on violence prevention and response.

3.1.2.1 Key Populations HIV Prevention Services

To improve the knowledge on HIV prevention and other health services, Key Populations were reached through outreach workers who conduct one on one sessions and small to medium group sessions on sharing HIV information and offer HIV services. Figure 4 shows the number of FSWs accessing HIV services in 2018.

HIV Program_2018 Annual Report 15

Figure 4: Number of FSWs accessing HIV services in 2018 (Program data)

373 20149% 78% 16% 54%

FSWs Reached Eligible for HIV Test

FSWs tested for

HIV

FSWs tested HIV Positive

FSWs linked to HIV Treatment

There were 7,335 FSWs targeted with HIV prevention services and 6,228 were reached with health education. From the total FSWs reached, 49% (3,072/6,228) were eligible for HIV testing and 78% (2,381/3,072) were tested for HIV. Sixteen percent (373/2,381) tested HIV positive and of these 54% (201/373) were successfully linked to HIV treatment services.

There were 3,432 MSM that were targeted with prevention services in 2018 where 2,386 MSM were reached. Figure 5 shows the number of MSM reached with HIV prevention services in 2018.

Figure 5: Number of MSM reached with HIV prevention services in 2018 (Program data)

67 2861% 81% 6% 42%

MSM Reached Eligible for HIV Test

MSM tested for

HIV

MSM tested HIV Positive

MSM linked to HIV Treatment

16 HIV Program_2018 Annual Report

There were 61% (1,460/2,386) MSM who were eligible for HIV testing and 81% (1,188/1,460) were tested for HIV with 6% (67/1,188) testing HIV positive. Forty-two percent were successfully linked to treatment services.

Worth noting in Key Population programming is that targeting people who inject drugs (PWID) and other vulnerable populations (transport operators) has commenced. These groups have been reached with HIV prevention services and distribution of commodities through peer educators in the past year. Figure 6 shows the number of PWID and transport operators who were reached with HIV services in 2018.

Figure 6: Number of PWID and Transport Operators reached with HIV services in 2018 (Program data)

Target Reached Target Reached

PWID Transport Operators

Prevention services Tested for HIV

There were 106 PWID reached with prevention services and 26 tested for HIV out of the 338 and 173 targeted for preven-tion and HIV testing services, respectively. A total of 1,185 transport operators were reached with prevention services and 45 were tested for HIV out of the 2,097 and 1,363 who were targeted for prevention and HIV testing services, respec-tively.

3.1.2.2 STI and TB Screening services for Key Populations

STI and TB screening is one of the key services offered to Key Population groups in the HIV continuum of care. STI infec-tion increases one’s chances of getting HIV and co-infection with TB increase mortality and morbidity among Key Popu-lations. Figure 7 shows the number of Key Populations screened for STIs in 2018.

HIV Program_2018 Annual Report 17

Figure 7: Number of FSWs and MSMs screened and treated for STIs in 2018 (Program data)

FSWs MSM

Screened for STIs Tested Positive and Treated

A total of 5,780 Key populations were screened for STIs with 4,589 FSWs and 1,191 MSM. There were 955 FSWs and 2018 MSM who screened positive for STIs and were treated.

There were 5,178 Key Populations were screened for TB in 2018 through a mobile unit for Key Populations. Figure 8 shows the number of Key Populations screened for TB in 2018.

Figure 8: Number of FSWs and MSMs screened for TB in 2018 (Program data)

3 633

1 545

3 33 3

FSWs MSM

Screened for TB Presumptive for TB Referred for TB Treatment

There were 3,633 FSWs and 1,545 MSM who were screened for TB with 3 FSWs and 3 MSM presumptive for TB. All those presumptive for TB were referred for TB treatment to nearby health facilities.

18 HIV Program_2018 Annual Report

3.1.2.3 Commodity Distribution for Key Populations

It is essential to include condom and lubricant distribution as part of HIV services for Key Populations. HIV programming relating to condom and lubricant distribution requires addressing both the demand and supply for this commodities to increase their use among Key populations.

During the outreach visits, there are commodities that are distributed to Key Populations through the mobile unit.

Figure 9 shows the number of commodities distributed in 2018.

Figure 9: Number of commodities distributed to Key Populations (Program data: 2018)

775,396

79,728

423,946

100,000

200,000

300,000

400,000

500,000

600,000

700,000

800,000

900,000

Male Condoms Female Condoms Lubricants

There were 775,396 male condoms and 79,728 female condoms that were distributed to Key populations in 2018 through the mobile unit. There was also 423,946 lubricants that were distributed.

3.1.3 HIV Testing Services (HTS) and Linkages

Over the years, the MoH through ENAP has recognized the need to develop and offer a variety of service delivery models for HIV Testing Services to effectively meet the needs of the country’s HIV epidemic context, while maintaining the core values of informed consent, confidentiality and counselling, and ensuring accurate HIV test results – the WHO 5 Cs:

Consent, Confidentiality, Counselling, Correct test results and Connection (linkage to prevention, treatment and care services).

According to SHIMS2 2016/2017 results, with regards to the first 90%, the country is at 84.7% and the positivity rate dropped from 8% in 2012 to 6% in 2017. With the aim of successfully achieving the first 95 and increase the yield, this results prompted the MOH of Eswatini to introduce targeted testing through index testing, HIVST and HTS eligibility assessment. Effective implementation of these targeted testing modalities aims at reaching the underserved population namely children, adolescents, men and key populations.

During this reporting period, the country has implemented a number of strategies aimed at identifying HIV positive individuals and engaging males in HTS, including index case testing, self-testing and outreach HTS as part of achieving the first 90(95) of the 90(95)-90(95)-90(95) UNAIDS global targets.

3.1.3.1 HTS for the General Population

HIV testing services is the gateway to prevention, care, treatment and other support services for HIV. Knowledge of HIV status through HIV testing among the population is a key factor in success of the HIV response. It is also the starting point in the achievement of the 90(95)-90(95)-90(95) UNAIDS global targets and Sustainable Development agenda. There were 391,067 HIV tests that were done in 2018 showing a 6.7% positivity rate. Figure 10 shows HIV testing done in 2018 by sex.

HIV Program_2018 Annual Report 19

Figure 10: Number of HIV tests done by sex (HMIS: 2018)

241 516

149 551

238 527

147 052

15 899 10 232 13 662 8 975 6.8%6.6%

50000

100000

150000

200000

250000

300000

Female Male Female Male Female Male Female Male Female Male

Number Tested Number Received Results

Number Tested HIV Positive

Number Referred for HIV Care

Positivity Rate

There were 241,516 HIV test done for females as compared to 149,551 test for males out of the 391,067 HIV test done in 2018. This translates to an HIV positivity rate of 6.6% among the females who took an HIV test during the reporting period.

To better understand the epidemic and to respond effectively, there is need to show service delivery at national and sub-national levels which is central to the success of the health sector response to HIV. Collecting service data by all levels helps in revealing prioritizing the response to where it can have the greatest impact. Figure 11 shows HIV testing services performance by region for 2018.

Figure 11: Number of HIV tests done and Positivity by sex and region (HMIS: 2018)

Female Male Female Male Female Male Female Male

HHOHHO LUBOMBO MANZINI SHISELWENI

Number Tested 64896 45053 48084 29570 79214 46719 49322 28209 Number Tested HIV+ 3557 2507 2826 2028 6885 4093 2631 1604 Positivity Rate 5.5% 5.6% 5.9% 6.9% 8.7% 8.8% 5.3% 5.7%

5.5% 5.6% 5.9%

6.9%

8.7% 8.8%

5.3% 5.7%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

9.0%

10.0%

10000

20000

30000

40000

50000

60000

70000

80000

90000

20 HIV Program_2018 Annual Report

The Manzini region shows highest HIV positivity rate for both males and females compared to all regions at 8.8% and 8.7%, respectively. There is a slight difference in positivity rate between males and females across all regions except for Lubombo region where we see a significant difference in positivity rate between males (6.9%) and females (5.9%).

Monitoring the delivery of HIV services requires a range of disaggregations by certain population characteristics to assist targeting services to the population groups that need them. Age and sex offer greater utility of HIV information obtained from routine program data or surveys. These are key in understanding the changes in HIV prevalence and incidence, characterizing HIV is evolving, monitoring equity of access to services, and supporting HIV programming for specific age groups. Figure 12 shows HIV testing services done in 2018 disaggregated by age and sex.

Figure 12: Number of HIV tests done and Positivity by age, sex and region (HMIS: 2018)

<1 yrs 1-4 yrs 5-9 yrs 10-14 yrs 15-19 yrs 20-24 yrs 25-49 yrs 50+ yrs

Tested Female 11446 16026 5052 8623 32306 48324 100158 19581

Tested Male 11665 15737 4948 10371 10552 18938 63048 14292

HIV Positive Female 90 102 71 149 1270 3424 10098 695

HIV Positive Male 102 115 82 152 143 568 8156 914

% Positivity Male 0.9% 0.7% 1.7% 1.5% 1.4% 3.0% 12.9% 6.4%

% Positivity Female 0.8% 0.6% 1.4% 1.7% 3.9% 7.1% 10.1% 3.5%

0.8% 0.6% 1.4% 1.7%

3.9%

7.1%

10.1%

3.5%

0.9% 0.7%

1.7% 1.5%

1.4%

3.0% 6.4%

0.0%

5.0%

10.0%

15.0%

20000

40000

60000

80000

100000

120000

The HIV positivity rate ranges from 0.6% to 1.7% among those below 15 years for both females and males. There is a gradual increase in positivity rate from the age group 15-19 years (3.2%), with a peak in the age group 25-49 years (11.2%). Interestingly, the ages over 50 years is giving a yield of 4.8% (females: 3.5%; males: 6.4%) compared to 4.1% (females: 3.1%: males: 5.5%) in 2017 and this requires focussed interventions and reach.

3.1.3.2 HTS by Entry Point

The expansion and integration of routine HTS needs to be expanded to cover a range of other health services at health facilities and community settings. The expansion is not merely done to achieve high testing uptake or to meet HIV testing targets, and it is done primarily to provide access for all people in need of appropriate quality HIV testing services linked to the whole HIV continuum of care. Table 2 shows HIV testing services done through the different entry points by sex.

HIV Program_2018 Annual Report 21

Table 2: Number of HIV Tests and Positivity Rate by Entry Point, 2018

Entry Point Number Tested Number Received Results

Number Tested HIV Positive Positivity Rate

OPD 128 870 128 796 10 646 8.3%

Outreach 57 176 57 142 4 799 8.4%

CWC 51 297 49 989 336 0.7%

CIHTC/VCT 49 619 49 548 5 081 10.2%

ANC 33 511 33 482 2 962 8.8%

FP 29 884 29 870 553 1.9%

MC 8 654 8 654 83 1.0%

Inpatient 8 585 8 580 511 6%

PNC 8 297 8 287 135 1.6%

Maternity 3 606 3 596 138 3.8%

TB 2 782 2 777 434 15.6%

Campaigns 2 371 2 337 119 5.0%

STI 1 072 1 072 95 8.9%

HBHTC 396 391 8 2%

PEP 351 351 13 3.7%

Partner Testing 234 232 42 17.9% Dental Department 95 95 3 3.2% Laboratory 38 38 0 0% Dermatology 17 17 4 23.5%

TOTAL 386 855 385 254 25 962 6.7%

The data shows that the OPD, Outreach, Child Welfare, CIHTC/VCT, ANC and FP have the highest volume for the number of tests done that are above 29,000 with the Dental Department, Laboratory and Dermatology Department had less than 100 HIV tests done. Dermatology and TB recorded the highest HIV positivity rates (23.5% and 15.6%, respectively) among all the entry points yet they had the lowest volume of HIV tests done. The Laboratory recorded no positives for the reporting period.

22 HIV Program_2018 Annual Report

Figure 13: Trends for HIV tests done and Positivity by sex from 2013-2018 (HMIS)

214 942

249 904 268 282 270 816

311 321

241 516

120 816 139 185 153 542 148 131 166 238 149 551

9.6%

7.4%

6.0% 6.2% 5.3%

6.6%

9.9%

7.6%

6.3% 7.2%

5.9% 6.8%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

50000

100000

150000

200000

250000

300000

350000

2013 2014 2015 2016 2017 2018

Number Tested Number Tested % Positivity Rate % Positivity Rate

3.1.3.3 HTS Trends

Figure 13 shows the HIV testing trends from 2013 to 2018 which demonstrates that there was a general increase in the number of HIV tests done and a declining positivity rate.

With the introduction and implementation of new Integrated HIV management guidelines in 2018 which emphasizes on targeted testing, resulted in a significant reduction in number tested as shown in Figure 13 (females: 311,321; males:

166,238) with a slight increase in positivity rate among both sexes (males: 5.9%; females: 5.3%).

3.1.3.4 Index Testing

The country started full scale roll-out of index testing in December 2018 with M&E systems strengthened in February 2018. Eswatini Ministry of Health has adopted the WHO recommended partner notification and testing options, namely contract referral, provider referral and dual referral. To operationalize these options, the country has developed a standardized Index testing register that includes recording of mapping and outcomes of index testing efforts. Training of healthcare workers has been conducted in all the 4 regions, including nurses, HTS counsellors and Expert Clients.

The graph below stipulates the country’s performance in relation to index case testing. Noticeable, eliciting of partners and children is done, however, there’s a need to strengthen contacting and reaching index contacts with testing servic-es.

3.1.3.5 Community (Outreach) HTS

The country has engaged in intensified male involvement through targeted campaigns in Correctional Services and outreach HTS activities to reach males working in Manzini industrial areas and Hhohho region with HIV testing services.

This was done through approaching Industries to provide the HTS to their workers. During the evenings the Mobile service is taken to the dwelling sites for the farm workers and community setups to encourage members to access the service. On weekends, community Dialogues are held to discuss HIV and AIDS and other health related issues and also to encourage individuals to test for HIV. In another strategy, one clinic partnered with Matsapha municipal Council and

HIV Program_2018 Annual Report 23

HC4 to conduct outreach HTS to male dominated industrial workplaces in Matsapha. A total of 257 males were reached with information package; of these 96 tested were tested and screened for TB. Eleven percent (11%) were diagnosed HIV positive and none screened positive for TB. All eleven clients were referred for ART initiation with only 27% successfully linked to initiation. The remaining 8 clients were followed up by Mathangeni clinic.

3.1.3.6 Linkages and Referrals

The quality of HIV testing services depends on accurate diagnosis and effective linkage to HIV prevention, treatment and care services. It has been noted that linkages to HIV care is still a challenge for people tested for HIV especially those diagnosed to be HIV positive. The WHO (2015) estimated that as much as 40% of people diagnosed with HIV are not successfully linked into ART and late ART initiation continues to be common especially in sub-Saharan Africa.

The kingdom of Eswatini is also facing the same predicament as other sub –Saharan African countries with regards to linkages. In 2018 the country adopted the linkages case management (LCM) strategy which is recommended by World Health organization. This strategy is peer delivered and aims to achieve 90(95) % for PLHIV either diagnosed at facility or community. To operationalize LCM the country has developed standard operational procedures to guide health care workers. Health care workers including HTS counsellors and expert clients have been trained on LCM.

Figure 14 shows the number of linkages for people diagnosed with HIV who were successfully linked to treatment and care services in 2018.

Figure 14: Number of people diagnosed with HIV successfully linked to treatment and care services in 2018 (HMIS)

241 516

149 551

15 899 10 232 13 662 8 975 10 732 6 023 68% 59%

50000

100000

150000

200000

250000

300000

Female Male Female Male Female Male Female Male Female Male

Tested HIV Positive Referred for HIV Care

Initiated on ART % Initiated on ART

Data shows that there were 64% people diagnosed with HIV that were initiated on ART. There were 68% females and 59% males who were successfully linked and initiated on ART in 2018 out of the 15,899 females and 10,232 males diagnosed HIV positive.

3.1.4 Voluntary Male Medical Circumcision (VMMC)

Voluntary Medical Male Circumcision has been implemented in the country following the MOH’s implementation of the MC policy in 2009 as one of the key strategies to prevent new HIV infections in the country. Evidence has shown that male circumcision reduces the risk of heterosexually acquired HIV infection in men by approximately 60%. Alone, male circumcision is only partially protective, however, when combined with HIV testing and counselling services, condoms, safer sexual practices and treatment of sexually transmitted infections, it is highly effective.

24 HIV Program_2018 Annual Report

In Eswatini the VMMC program has primarily been implemented by the MOH with large support from multiple interna-tional and national partners (NGOs) in a vertical approach. Integration with the other prevention packages, including risk reduction education, condoms, HTS and PrEP, and linkage of HIV positive clients to care and treatment will be promoted.

The 2017 Swaziland HIV Incidence Measurement Survey (SHIMS) 2 Report shows that among males 15 years and older, prevalence of medical male circumcision is 26.7%, the prevalence further decreases with age from 38.2% among 15-19 year olds to approximately 28% in males 25-29 years old and 7.5% among males 65 years and older. Figure 15 shows the number of medical male circumcisions performed by age and region for the period January – December 2018.

Figure 15: Number of males circumcised by age (Program data/HMIS: 2018)

0%

10%

20%

30%

50%

60%

70%

<1yrs 1-4yrs 5-9yrs 10-14yrs 15-19yrs 20-24yrs 25-49yrs 50+ yrs

1 000

2 000

3 000

4 000

5 000

6 000

7 000

8 000

9 000

10 000

4% 0% 0%

17%

65%

7% 6% 1%

9 264

2 457

0 0

40%

The data shows that 65% (9264/14316) of the medical male circumcisions were received by clients in the 10-14 year old age group, followed by clients aged 15-19 years old which contributed 17% of total circumcisions done in the period. The health facilities providing medical male circumcision services include public health facilities, private health facilities and NGO health facilities.

HIV Program_2018 Annual Report 25

Figure 16: Number of male circumcisions performed by region (Program data/HMIS: 2018)

31%

17%

33%

20%

0%

5%

10%

15%

20%

25%

30%

35%

HHOHHO LUBOMBO MANZINI SHISELWENI

Figure 16 shows total number of circumcisions conducted by region during the period. The Manzini Region had the highest number of circumcisions performed during the period contributing 33% of the total circumcisions conducted.

Hhohho, Shiselweni and…