J.19_National_Strategic_Plan_for_Ending_AIDS_and_Syphilis_in_Children_(2018-2022).pdf

SIY I N Q A B A

Elimination of Paediatric HIV and Congenital Syphilis

Policy Leadership

Health Financing

Services Delivery

Human Resources

Community Health System

HMISCommodities

Health Systems Strengthening

MINISTRY OF HEALTH

National Strategic Plan for Ending AIDS and Syphilis in Children (2018 – 2022)

KINGDOM OF ESWATINI

SIY I N Q A B A

MINISTRY OF HEALTH

National Strategic Plan for Ending AIDS and Syphilis in Children (2018 – 2022)

KINGDOM OF ESWATINI

Table of Contents

Foreword iii Acronyms iv Acknowledgements vi

1. Background 7 1.1: Country Profile 8 1.2: Organisation of the Health System 8 1.3: HIV and AIDS in Eswatini 9 1.4: The PMTCT Programme in Eswatini 10

2. Situation Analysis 11 2.1: Availability of Services at Health Facilities 12 2.2: Maternal PMTCT Cascade 12 2.3: Delivery, Postnatal Care and HIV Re-testing 13 2.4: Uptake of Services for HIV Exposed Infants 13 2.5: Management of Syphilis 14 2.6: Progress of Paediatric ART Towards 90-90-90 15 2.7: Cross-cutting Health Systems Strengthening 16

3. Context for the Strategic Plan 19 3.1: Introduction 20 3.2: Policy Framework 20 3.3: Guiding Principles 21 3.4: Conceptual Framework 21

4. The Strategic Framework 24 4.1: Strategic Vision, Mission and Goal 25 4.2: Strategic Objectives 25 4.3: Results Framework 25 4.4: Main Strategic Areas 26

5. The Implementation Framework 27

6. Monitoring and Evaluation Framework 32 6.1: Introduction 33 6.2: Objectives of the M&E Framework 33 6.3: Core Indicators for the M&E Framework 33 6.3.1: Indicators for Measuring Impact and Outcomes 34 6.3.2: Indicators for Monitoring Progress at National Level 34 6.3.3: Regional Level Targets 36 6.4: The Evaluation Framework 36 6.4.1: Mid Term Evaluation of the Strategic Plan 36 6.4.2: End of Term Evaluation of the Strategic Plan 36

7. Bibliography 38

NATIONAL STRATEGIC PLAN FOR ENDING AIDS AND SYPHILIS (2018 – 2022) 3

Foreword

The HIV epidemic has remained a major public health challenge in Eswatini with significant social and economic consequences that the country continues to grapple with. Mother-to-child transmission of HIV constitutes a preventable cause of morbidity and mortality among children in the country, which justifies the prioritisation of its prevention among the high impact interventions. At the global level, Eswatini is among the 22 priority countries for elimination of Mother-to-Child Transmission of HIV.

The Ministry of Health has led the national response for elimination of mother-to-child transmission of HIV with commendable progress since 2003. In the last five years, the transmission rates at 6 weeks declined from 4.1% in 2012 to 2.1% in 2016, while the rates at final diagnosis declined from 14.8% in 2012 to 6.8% in 2016. To fast-track elimination of new infections among children, a “three frees” framework was launched in 2015 globally to guide the strategic focus of countries in line with SDGs. This strategy therefore aligns Eswatini’s response to the ‘Three Frees’ and make a final push towards elimination of mother-to-child transmission of HIV and syphilis as well as end paediatric AIDS.

This Strategic Plan has been designed to ensure that every child is born and remains HIV and syphillis free, whilst every pregnant woman or mother living with HIV should have access to lifelong HIV treatment. In addition, every child and adolescent living with HIV should be linked to quality HIV treatment, care and support to realize their full potential without stigma and discrimination. This will be achieved through collabo-rative interventions with other programs and implementing partners to ensure that every child, adolescent, and women access comprehensive prevention HIV and syphillis services.

The Government of Eswatini remains committed to the fight against HIV and syphillis, and to supporting the implementation of this Strategic Plan, in partnership with key stakeholders in a collective response that is critical to the achievement of elimination targets. This will contribute to the country’s vision of ending AIDS by the year 2022.

Honourable Minister of Health Ms. Sibongile Ndlela-Simelane

4 NATIONAL STRATEGIC PLAN FOR ENDING AIDS AND SYPHILIS (2018 – 2022)

Acronyms

AIDS Acquired Immune Deficiency Syndrome ANC Antenatal Care ART Antiretroviral Therapy ARV Antiretroviral Drugs CMIS Client Management Information System DBS Dried Blood Spot DNA Deoxy Ribo-Nucleic Acid EGPAF Elizabeth Glaser Paediatric AIDS Foundation eMTCT Elimination of Mother-to-Child Transmission (of HIV and syphilis) eNSF Extended National Strategic Framework EPI Expanded Program on Immunisation FP Family Planning HEI HIV Exposed Infants HF Health Facility HIV Human Immunodeficiency Virus HMIS Health Management Information System HTS HIV Testing Services ICT Information and Communication Technology m2m mothers2mothers M&E Monitoring and Evaluation MICS Multiple Indicator Cluster Survey MNCH Maternal, Newborn and Child Health NGO Non-Governmental Organisation PCR Polymerase Chain Reaction PEPFAR President’s Emergency Plan for AIDS Relief PHU Public Health Unit PMTCT Prevention of Mother-to-Child Transmission of HIV PNC Post Natal Care POC Point of Care PREP Pre-Exposure Prophylaxis SAM Services Availability Mapping SDG Sustainable Development Goal SHIMS Eswatini HIV Incidence Measurement Survey SOPs Standard Operating Procedures SRH Sexual and Reproductive Health TB Tuberculosis UNAIDS Joint United Nations Programme on HIV/AIDS UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund WHO World Health Organisation

Acknowledgements

This Framework is drawn from contributions of citizens and technical experts from different organizations’ across the country.

The Ministry of Health wish to thank the Prevention of Mother to Child Transmission of HIV technical working group under the leadership of the Sexual Reproductive Health Manager in MoH for steered the consultations that led to the development this framework.

We thank the following institutions for technical support during the development of the framework; Ministry of Health - Sexual Reproductive Health Programme, Eswatini National AIDS Programme and monitoring and evaluation unit and Regional Health Management Team; United Nations - UNICEF, UNFPA, UNAIDS, WHO; US Government Agencies and their implementing partners including EGPAF, URC, ICAP, and M2M. Your input to the framework at greatly valued.

Special thanks to, UNICEF for the financial support and technical assistance through Dr Saul Onyango (the consultant) towards the development of this strategy.

To all individuals who participated in this exercise not mentioned here, your contributions are highly appreciated.

CHAPTER 1

BACKGROUND

1.1: Country Profile

The Kingdom of Eswatini is landlocked with a surface area of 17,364 square kilometres, bordered on the north, south and west by the Republic of South Africa and on the east by the Republic of Mozambique. The Kingdom is administratively divided into four regions namely: Hhohho, Lubombo, Manzini and Shiselweni.

The four regions are further sub-divided into 55 constituencies known as Tinkhundla and 360 chiefdoms and towns.

Description Value

ANC coverage at least 4 visits 76.1%

Skilled A�endance at Delivery 88.3%

Contraceptive Prevalence Rate 66.1%

Unmet Need for Family Planning 15.2%

Total Fertility Rate (15 – 49 years) 3.3

Age-Specific Fertility Rate (15 – 19 years) 87

Neonatal Mortality Rate 20

Infant Mortality Rate 50

Under-5 Mortality Rate 67

Exclusive Breastfeeding Rate (0 – 5 months) 63.8%

Full Immunization Coverage 70.7%

The country’s projected population in 2016 based on the 2007 Population Census is about 1,093,238 people, with slightly more females (51.4%) than males. The population of Eswatini is comparatively young, with 46% under the age of 20 years.

Urbanisation is still limited and more than three-quarters of the people (79%) reside in the rural areas. The literacy rate among women of reproductive age is 91%, with 59% having attained secondary level education, or higher. Selected national socio-demographic indices from the Multi-ple Indicator Cluster Survey (MICS) of 2014 are presented in Table 1.

1.2: Organisation of the Health System

Eswatini has a total of 287 health facilities organized within a five-tier health care system (Figure 1):

• 1 National Referral Hospital

• 5 Regional Referral Hospitals

• 2 Specialised & 6 Private hospitals

• 5 Health Centres & 6 PHUs

• 23 Clinics with Maternity & 192 without

• 6 Specialised Clinics

Table 1: Selected Socio-Demographic Indices

Figure 1: Health Care Delivery Structure

Source: MICS 2014

National Referral Hospital

Regional Hospitals

Sub-regional Hospitals

Health Centres

Community Clinics

¹ Central Statistics Office, Mbabane: Eswatini Population Census 2017.

8 NATIONAL STRATEGIC PLAN FOR ENDING AIDS AND SYPHILIS (2018 – 2022)

Figure 2: Prevalence of HIV in 2016 by Age and Sex (Source: SHIMS 2)

Overall, the health service delivery system consists of both formal and informal sectors. Under the formal sector, the system is constituted by public, private-not-for-profit and the private sectors. Through the public sector, government owns 40.1% of health facilities, 12.2% are owned by faith based institutions, 7.3% by Non-Governmental Organisations (NGO), 10.8% by industrial facilities, whilst 22.7% are privately owned by doctors and 7% by nurses. The informal sector consists mainly of traditional and alternative health care providers (SAM 2013).

Functionally, the public health system is decentralized from the central ministry to the four regional health offices, with the following roles and responsibilities:

• The central Ministry of Health performs executive and administrative functions and provides strate-gic guidance on delivery of the essential health care package at all levels;

• Each regional office is headed by a Regional Health Administrator and supported by the Regional Health Management Team, whose mandate is to provide technical leadership in executing policies developed by the central Ministry of Health;

• At the community level is a network of health workers, including Rural Health Motivators to promote community participation in health activities within the areas. In addition, there are health committees to support the general management of health facilities.

The health sector faces challenges in equitable deployment of human resource cadres at all levels of the health care delivery system. Over 50% of the existing workforce is deployed in hospitals located in the urban areas that serve only about 20% of the population whilst the remaining 50% serve the majority (80%) within the rural areas.

1.3: HIV and AIDS in Eswatini

The second Eswatini HIV Incidence Measurement Survey (SHIMS 2) of 2016/17 reported overall HIV preva-lence of 27%, with gender discrepancy being higher among females than males (32.5% and 20.4%, respectively). In terms of geographical distribution, HIV prevalence is highest in Lubombo region (29.4%) and lowest in Hhohho region (25.7%), with Manzini and Shiselweni regions at 27.3% and 25.9%, respec-tively. The prevalence of HIV in 2016 based on the SHIMS 2, disaggregated by age and sex has been summarised and illustrated in Figure 2.

Age (years)

H

IV

P re va le nc e

5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-640-4 65+

Male

Female

NATIONAL STRATEGIC PLAN FOR ENDING AIDS AND SYPHILIS (2018 – 2022) 9

Figure 3: Prevalence of HIV among Women 18-49 Years (Source: SHIMS 2)

Figure 4: PMTCT Programme Milestones in Eswatini

The weighted annual HIV incidence is 1.4% with relatively higher risk among females (1.7%) than males (1.0%). Its noteworthy that young females age 15 – 24 years carry higher risk of HIV infection (1.9%) when compared to males of the same age (0.8%). Decline in HIV incidence has been observed from 2.5% in 2011 to 1.4% in 2016/17, which constituted a reduction of 50% among males (1.8% to 0.9%) and 38% among females (3.2% to 2.0%).

Comparison of the HIV prevalence from SHIMS 1 and SHIMS 2 reveals a decline from 32.1% in 2011 to 30.5% in 2016/17, more notable among males (24.1% to 21.2%) than among the females (38.8% to 38.1%).

The decline is not statistically significant and hence constitutes evidence of stabilisation in the HIV preva-lence rather than decline. Nevertheless, over the 10-year period between 2006/07 and 2016/17 (Figure 3) there is a significant declining trend in prevalence among the young women and men.

Age (years)

H

IV

P re va le nc e

18-19 20-24 25-29 30-34 35-39 40-44 45-49

16.0

31.5

38.4

49.2 46.7

37.5

45.2

53.8 50.7

37.7

49.1

27.9

39.7

51.954.2

21.4

31.6

42.3

20.9

9.1

14.3

HIV Prevalence among women

SHIMS 2 (2016-7)SHIMS 1 (2011)DHS (2006-7)

1.4: The PMTCT Programme in Eswatini

The PMTCT programme was officially launched in 2003 at three pilot sites, with primary support from UNICEF. The lessons from these pilots formed the basis for the national expansion from 3 sites in 2003 to an impressive 150 in 2010. In 2011, the framework for Elimination of New HIV Infections among Children by 2015 and Keeping their Mothers Alive (Elimination Framework) was developed to guide PMTCT imple-mentation in the country. It reflected the national priorities for a comprehensive response to the epidemic and provided the unified platform for a strengthened and accelerated effort. The key PMTCT programme milestones are highlighted in Figure 4.

Key Milestones in the PMTCT Program

• 2002: PMTCT Guidelines 1st Edition

• 2002: PMTCT Program piloted at 3 facilities

• 2003: PMTCT Strategic Plan (2003 – 2005)

• 2006: PMTCT Guidelines 2nd Edition

• 2007: PMTCT Operational Plan (2007 – 2011)

• 2009: Early Infant Diagnosis of HIV using DNA PCR fully established in the country

• 2010: PMTCT Guidelines 3rd Edition

• 2011: Operational Plan (2011 – 2015)

• 2011: National Strategic Framework for Accelerated Action (2011 – 2015)

• 2015: Integrated HIV Management Guidelines

• 2017: Joint review of the national HIV and PMTCT programs

10 NATIONAL STRATEGIC PLAN FOR ENDING AIDS AND SYPHILIS (2018 – 2022)

CHAPTER 2

SITUATION

ANALYSIS

12 NATIONAL STRATEGIC PLAN FOR ENDING AIDS AND SYPHILIS (2018 – 2022)

Table 2: Availability of Selected Services at Health Facilities by Region

2.1: Availability of Services at Health Facilities

On basis of the Service Availability Mapping Report of 2013, there are 287 health facilities in the country.

The majority (42%) are located in Manzini region whilst Shiselweni region (13%) has the lowest with Hhohho and Lubombo regions registering 29% and 17%, respectively. Table 2 shows that 79% of all the health facilities specifically provide family health services, of which 81% and 69% offer antenatal care and PMTCT services, respectively. Family Planning is provided at different service delivery points and imple-mentation is done using different models. A key observation is that some nurses have not been trained on the new FP guidelines. In 2016 overall 92% of the eligible 45,211 women at FP clinics were offered HTS and of those tested, 1,054 (3%) were found to be HIV positive of whom 792 (75%) were linked to HIV care and treatment services.

Region (N) Family Health Services Offering HTS Offering ART Offering ANC Offering

PMTCT

Hhohho (82) 64 59 34 52 46

Lubombo (48) 42 44 28 38 35

Manzini (121) 87 94 44 63 53

Shiselweni (36) 34 35 27 30 28

Total (287) 227 221 133 183 162

Source: Service Availability Mapping (SAM) 2013 Report

2.2: Maternal PMTCT Cascade

Figure 5 illustrates the maternal cascade for PMTCT in 2016 including the gap to be bridged before reaching the estimated 33,000 pregnancies in the country. Out of the 11,000 pregnant women estimated to be in need from the Spectrum Projections in 2016, about 86% were initiated on ART. In line with the global elimi-nation targets, the gap relates to reaching 95% of HIV positive pregnant women in the country knowing their HIV status and initiating 95% of pregnant women living with HIV on lifelong ART. It is noteworthy that some clients served through the private sector facilities may have been omitted from the cascade.

Figure 5: Maternal PMTCT Cascade in 2016 (Source: 2016 Annual Report)

The 2016 Maternal PMTCT Cascade

35,000

30,000

25,000

20,000

15,000

10,000

5,000

Estimated

Pregnancies 1st ANC

Attendance Tested for

HIV

Know their HIV Status

Estimated Positives

HIV Positive Initiated on

ART

33,000

11,000

30,515

[92%]

28,978

[88%]

28,710

[87%]

9,909 [90%]

9,435

[86%]

95%

95%

NATIONAL STRATEGIC PLAN FOR ENDING AIDS AND SYPHILIS (2018 – 2022) 13

Figure 6: Deliveries and Postnatal Care from 2014 to 2016 (Source: 2016 SRH Program Annual Report)

Estimated Deliveries

Reported Deliveries

PNC

7-14 Days

[80%] 33,000 87%

78%

2,329

26,490

20,696

[63%]

35,000

30,000

25,000

20,000

15,000

10,000

5,000

Delivery and Postnatal Care

Home

Facility

2.3: Delivery, Postnatal Care and HIV Re-testing

The reported deliveries through the HMIS in 2016 constitute 80% of the estimated deliveries for the year (Figure 6) and the adolescents account for about 17% of all the reported deliveries at health facilities. The women who attended postnatal care (PNC) only constitute 63% out of all the estimated deliveries in the country. The greatest strategic gap relates to increasing uptake of PNC which is an important platform for PMTCT service delivery. In terms of regional variation, home deliveries is highest in Lubombo region (17%), but lowest in Manzini region (4%) whilst Shiselweni registered 11% and Hhohho region 8%. The critical gap will relate to improvement in the deliveries under skilled service providers, especially in Lubombo region.

The national HIV Guidelines promote conducting of repeat HIV tests for HIV negative women in all facilities at 8 week intervals. In addition, targeted services are provided for adolescents to prevent new HIV infec-tions. The prevalence of HIV among those re-tested in 2016 was 1.5% at ANC, 1.3% at labour and delivery and 1.9% at PNC. The strategic gap relates to consolidation of the HIV prevention package for negative pregnant and lactating women, to sustain low levels of sero-conversion.

2.4: Uptake of Services for HIV Exposed Infants

All postnatal women and their infants are seen together regardless of their HIV status at MNCH settings, which provide daily services including ART refills and immunization. Integration of services for HIV exposed infants varies in different institutions with some having synchronized PNC, POC or DBS/PCR and EPI services. As illustrated in Figure 7, out of all the estimated births in 2016, only 79% of the infants were seen during the scheduled 6 to 8 weeks’ visit. The figure further shows the gap in reaching the estimated children in need of HIV related services derived from the Spectrum Projections in 2016. The critical strategic gap relates to increase in uptake of postnatal care for infants in general, uptake of ARV prophylaxis among the HIV exposed infants and the other interventions to at least 90%. Out of the HIV exposed infants tested by PCR, 220 (2.5%) were found to be HIV positive, corresponding to 79% of the estimated number of those in need. Out of those identified through the PCR test, 150 (68%) were linked to antiretroviral treatment, implying the program initiated only about 54% of all infected children in need of ART. The strategic gaps relate to increasing proportion of HIV exposed infants who get tested by PCR and the proportion of HIV positive children who get initiated on ART.

14 NATIONAL STRATEGIC PLAN FOR ENDING AIDS AND SYPHILIS (2018 – 2022)

Figure 7: The Care Cascade for HIV Exposed Infants in 2016 (Source: 2016 HIV Program Annual Report)

Figure 8: Syphilis Screening and Treatment in 2016 (Source: 2016 SRH Program Annual Report)

Syphilis Screening and Treatment

33,000 30,515

27,228 [83%]

89%

92%

(2.3%)

85%

Estimated Pregnancies

1st ANC Tested for Syphilis

Estimated Syphilis

Zero-postive Treated for Syphilis

35000

30000

25000

20000

15000

10000

2.5: Management of Syphilis

Figure 8 summarises the uptake of syphilis screening and treatment for pregnant women in 2016. It shows that 83% of all the estimated pregnant women (33,000) were screened and 70% (765)* of those in need were treated. It implies that about 765 would have been identified if all those in need had been screened and only 70% has been treated. Elimination of congenital syphilis in the country will among others require sustaining 95% level of screening and 95% level of effective treatment for the seropositive mothers and their partners.

*calculated based on the syphillis in ANC against estimated pregnancies

35000

30000

25000

20000

15000

10000

Estimated

Births Infants Seen

6-8 Wk Estimated

HEI

Given NVP

Prophylaxis HEI Seen

6-8 Wk HEI Given

CTX

HEI Tested by PCR

33,000

79%

26,172

11,000 72% 82% 80% 79%

7,917 9,019 8,787 8,677

Infant Care Cascade

More specifically out of 1,417 children initiated in 2016, there are more girls (56%) compared to the boys.

In terms of geographical variation, more children are initiated from Manzini region (36%) and Hhohho region (28%) while similar proportions (18% each) are from Lubombo and Shiselweni regions. The main strategic gap relates to increase in the coverage of ART services for children age 0 – 14 years. This will involve increase the proportion tested, initiated on treatment and virologically suppressed in line with the 90-90-90 targets. There were 9,501 children living with HIV age 0 – 14 years actively on antiretroviral therapy in 2016, with slightly more girls (53%) compared to the boys (Figure 10).

NATIONAL STRATEGIC PLAN FOR ENDING AIDS AND SYPHILIS (2018 – 2022) 15

MINISTRY OF HEALTH

Figure 9: Achievements of 90-90-90 Targets in 2016 Source: MTR Report

2.6: Progress of Paediatric ART Towards 90-90-90

As illustrated in Figure 9, coverage of services based on the 90-90-90 targets among young people age 0 to 14 years shows a strategic gap of 17%, 24% and 74% respectively, to attain the 90-90-90 targets for this age group. Uptake of services in the 2016 HIV Program Annual Report shows ART coverage of 58% and viral load coverage at only 22%.

The trend in antiretroviral therapy coverage shows a more consistent and sharper increase among adults (49% in 2013 to 77% in 2016) when compared to children age 0 – 14 years (43% in 2013 to 58% in 2016).

Gap 90% Target

Number Reached

14,000

16,000

12,000

10,000

8,000

6,000

4,000

2,000

15,413

17%

90% 13,872

2,348

11,524 24%

90%: 12,485 2,984

9,501

90%: 11,236

8,290

100%

74%

2,946

Estimated PLHIV Known HIV+ Status

Currently on ART Virologically Suppressed

Cascade For Children Age 0 - 14 Years, Dec 2016

Figure 10: Distribution of Children 0-14 Years Active on ART in 2016 (Source: 2016 HIV Program Annual Report)

Children Active on Art (2016) by Region

Male

Female

30% 30%

23%

1,455

1,392

1,197

1,513

1,327

17%

47%

4,473

53%

5,028

Hhohho Lubombo Manzini Shiselweni Total Male

Total Female

5,000

4,500

4,000

3,500

3,000

2,500

2,000

1,500

1,000

0 47%

2.7: Cross-cutting Health Systems Strengthening

The findings in this section are predominantly from the Joint Review of the HIV and PMTCT Programs conducted in April 2017.

I. Leadership and Governance Functionally, the regional level administration and finance is headed by the Regional Health Administrator;

clinical services by the Senior Medical Officer, whilst the Senior Matron heads the nursing and public health services. Specific coordinators have been assigned at the regional level for HIV, Tuberculosis and PMTCT with clear roles and responsibilities. Strategic and operational plans were developed to guide implementa-tion of prioritized interventions. Among the key challenges are the following:

• Irregular technical supervision from the regional and central levels, with undocumented feedback to the health facilities;

• National and regional targets are not clearly defined to managers at the health facility level.

II. Policy Leverage The national policy guidelines have been used to influence implementation at the service delivery points. In general, most guidelines and Standard Operating Procedures (SOPs) are largely available to ensure quality service delivery. The managers displayed good knowledge of the key interventions. The following were among the major challenges highlighted:

• Whereas available, key policy documents tend to be in offices of senior management but not readi-ly accessible to the service providers;

MINISTRY OF HEALTH

16 NATIONAL STRATEGIC PLAN FOR ENDING AIDS AND SYPHILIS (2018 – 2022)

• Health facilities not adequately equipped with policies, guidelines and SOPs and where available, tend to keep several versions of the same guideline;

• Private health facilities not adequately equipped with policies, guidelines and SOPs.

III. Health Financing Government resources for HIV interventions, including PMTCT are centralised and hence budgets that include the detailed activity plans, are developed by the regional coordinators in close collaboration with central level officers. In addition, implementing partners are assigned to specific regions to support interventions in a manner that limit duplication and optimally utilise the available resources. The following are among the key challenges:

• Declining funding levels for HIV-related interventions over the preceding three years;

• Central funding of activities causes delays in implementation and leads to a sense of partial owner-ship by the regions;

• Inadequate investment on the infrastructure to maintain delivery of quality services;

• Low economic capacity especially in the rural areas for clients to cover the out-of-pocket health-re-lated expenses.

IV. Services Delivery In general, the health infrastructure is relatively good with access for persons with disability at some facilities. Adoption of the ‘test and treat’ approach has improved initiation of women on treatment and decreased the prevalence of opportunistic infections. Integration in service delivery has been promoted with good practices such as cervical cancer screening as part of the PMTCT package, tuberculosis (TB) and HIV integrated services as well as HIV testing services for children in child welfare. Some of the main challenges include:

• Sub-optimal linkage of HIV negative clients to the available HIV prevention services;

• Few children living with HIV are being initiated on ART at the health facilities, especially those under age of 5 years;

• Limited evidence of quality improvement activities at the health facilities such as plans, journals and programme performance charts;

• Inadequate documentation for the laboratory transport system at the health facility level, including for monitoring the turn-around-time.

V. Human Resources for Health The mandate for recruitment and management of health staff lies with the Civil Service Commission and significant investment has been made to strengthen capacity for HIV related service delivery. Contributions from implementing partners has facilitated focus on specific programmes and priorities through comple-mentary staff recruitment at the health facility and community levels. There has been regular training of health workers to improve capacity for service provision. The following are among the key challenges:

• Inadequate numbers and skill mix of staff, especially in the rural-based facilities;

• Various positions are funded by implementing partners with risk of service interruption when partner funding gets constrained;

• Inadequate technical staff to manage medicines and commodities/ supplies with task-shifting being done to nurses despite the relatively busy clinics;

• Limited human resource capacity for data analysis and use at the health facility level.

NATIONAL STRATEGIC PLAN FOR ENDING AIDS AND SYPHILIS (2018 – 2022) 17

VI. Equipment and Commodity Security The procurement and supply chain management system has been functional with limited or no stock-outs of HIV-related medicines, including of the ARVs being reported from the service delivery points. Routine viral load tests are also regularly conducted at the health facilities. Stock cards are routinely utilised at the health facility level to monitor distribution of medicines and related commodities. The following are among the key challenges cited:

• Limited storage space for medicines at some health facilities;

• Inefficient communication with Central Medical Stores that results in relatively long tur-around time for orders placed;

• The servicing and repair of medical equipment at the health facilities not well streamlined.

VII. Health Information Management System Health facilities have been equipped with necessary tools for monitoring PMTCT reporting, including HTS, ART, Pre-ART, ANC, PNC, FP, Child welfare registers and of recent, are linked to the CMIS. Monitoring programme performance has been regularly conducted through review meetings involving managers, stakeholders and health facility staff. Regional and cluster level meetings are conducted to discuss data quality, identify gaps and develop action plans for rectification. Some of the key challenges include:

• Too many registers that affect data completion, quality as well as service delivery;

• Possibility of double counting such as recording of clients already on ART at the time of conception as being newly initiated on ART;

• Collected data does not fully segregate age-groups in order to capture the adolescents;

• Limited or no data quality assurance initiatives at the health facility level;

• Limited analysis and use of data at health facility level.

VIII. Community Health System Community Health Workers are constituted by various cadres such as the Rural Health Motivators, Commu-nity Expert Clients, Facility Expert Clients, mentor mothers etc. who provide health promotion, psycho-so-cial care and support to clients and their families. The health facility cadres link up with their community counterparts to trace and follow up mothers and infants who have missed appointments. Among the key challenges are:

• Various cadres implement community level activities with possible overlap and duplication of effort;

• Difficulty in motivation of the community cadres and maintenance of the equipment supplied such as bicycles when broken down;

• Stigma and discrimination at community level still fuel provision of wrong information including addresses, by the clients;

• Inadequate documentation of the community activities and limited use of data to inform planning;

• Inadequate support groups for the pregnant and lactating women living with HIV.

18 NATIONAL STRATEGIC PLAN FOR ENDING AIDS AND SYPHILIS (2018 – 2022)

CHAPTER 3

CONTEXT FOR

THE STRATEGIC PLAN

20 NATIONAL STRATEGIC PLAN FOR ENDING AIDS AND SYPHILIS (2018 – 2022)

3.1: Introduction

Eswatini is one of the 22 priority countries of focus for elimination of mother-to-child transmission of HIV.

The United Nations developed the standardised protocol and set of impact criteria towards path to elimina-tion of both paediatric HIV infections and congenital syphilis . The Global AIDS Community also developed the framework in 2016 to enable countries to super-fast-track ending of AIDS among children, adolescents and young women, while ensuring that children are born free of HIV and their mothers have access to lifelong antiretroviral therapy.

The National Strategic Plan for Ending AIDS and Syphilis in Children and Adolescents (2018 – 2022) is the response from Kingdom of Eswatini to the global call to give a final push towards elimination of MTCT of HIV and Syphilis. It also provides the framework to end paediatric AIDS and reduce new infections among adolescent girls and young women in the country. This will contribute to the country’s vision of ending AIDS by 2022.

3.2: Policy Framework

The development process for the Strategic Plan drew heavily from the extensive consultations conducted during mid-term review of the HIV, PMTCT and TB programes in 2017. It involved support from the imple-menting partners and consultations with key stakeholders from national and regional levels. It has been designed to consolidate the achievements under the Framework for Elimination of New HIV Infections among Children by 2015 and Keeping their Mothers Alive.

At the international and regional levels, the Strategic Plan builds upon the previous strategies and has been aligned to the following commitments, policies and standards among others:

• Attainment of Sustainable Development Goal 3 to ensure healthy lives and promote well-being at all ages, in particular Goal 3.3: By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases

• Start Free, Stay Free, AIDS Free: A super-fast-track framework for ending AIDS among children, adolescents and young women by 2020

• Guidance on global processes and criteria for validation of elimination of mother-to-child transmis-sion of HIV and syphilis as well as related documents on pre-elimination and validation

At the national level, the Strategic Plan builds upon, and has been aligned to the following:

• The Extended National Multi-Sectoral HIV and AIDS Framework (eNSF) 2014 – 2018

• National Health Sector Strategic Plan II (NHSSP II) 2014 – 2018

• National Sexual Reproductive Health and Rights Strategic Plan 2014 – 2018

• Eswatini Male Circumcision Strategic and Operational Plan for HIV Prevention 2014 – 2018

• Eswatini Integrated HIV Management Guidelines (2015)

• National Policy Guidelines for Community-Centred Models of ART Service Delivery (CommART) in

Eswatini (June 2016)

² WHO, 2014. Global Guidance on Criteria and Processes for Validation: Elimination of Mother-to-Child Transmission (EMTCT) of HIV and Syphilis.

³ UNAIDS, PEPFAR, UNICEF, WHO, EGPAF, 2016: Start Free, Stay Free, AIDS Free.

NATIONAL STRATEGIC PLAN FOR ENDING AIDS AND SYPHILIS (2018 – 2022) 21

3.3: Guiding Principles

The Strategic Elimination is consistent with the broader national HIV and AIDS response and is based on the following principles:

i. Result-Based Management: Planning, implementation and monitoring of PMTCT interventions at all levels with a focus on achieving stated measurable results or change;

ii. Family Centred Approach: Provision of a basic package of MNCH services to the pregnant and breastfeeding woman, her partner and children directly and through efficient referral services in collaboration with partner agencies and the community;

iii. Gender Equality and Equity: Enlisting the active participation of men and women to take great-er responsibility in reducing the spread of HIV and encouraging stakeholders to address gender inequalities that fuel the HIV epidemic; as well as incorporating gender dimensions in all aspects of HIV programming to reduce gender vulnerability and improving equal access to HIV prevention, treatment and care services, especially amongst the most vulnerable;

iv. Systems approach and Integration: Applying a health systems’ building approach to strengthen integration and linking of HIV prevention, care and treatment services within maternal, newborn, child health and reproductive health programmes, including community health systems;

v. Promote Greater Involvement and Empowerment of People living with HIV and AIDS (GIEPA): Embracing and operationalising the principle of meaningful involvement and participation of PLHIV in the national HIV response at all levels, particularly mentor mothers working at both the facility and community levels;

vi. Adolescent friendly services: Catering for, and responding to their unique health needs by recognizing that adolescents are not simply old children or young adults;

vii. ‘Three Ones’ Principle: Encouraging all stakeholders to harmonise their operations under a single national (a) coordination authority, (b) strategic framework, and (c) monitoring and evaluation framework;

viii.Community engagement and participation in, and ownership: Supporting and empowering the communities, strengthening their systems and ensuring that interventions are communi-ty-owned and driven; as well as ensuring adequate stakeholder support, use of existing infrastruc-ture and community solutions, equity and sustainability of interventions;

ix. Knowledge Management: Making deliberate efforts for stakeholders to share and learn from each other based on their “hands-on” experiences, the existing and emerging ‘best’ practices;

x. Commitment to address regional and international obligations and adherence to inter-national protocols: Encouraging all stakeholders to take due cognisance of adapted and custom-ised regional and international protocols, ensure compliance and thus contribute towards meeting Eswatini’s regional and international commitments.

3.4: Conceptual Framework

As illustrated in Figure 11, the conceptual framework for ending AIDS and syphilis among children, adoles-cents and young women in Eswatini has been adapted from the “Three-Frees” framework: Start Free, Stay Free and AIDS Free. On the foundation of health systems’ strengthening building blocks, there will be a three areas of focus to ensure that children start their lives free of HIV, are supported to stay free of HIV whilst those that are living with HIV are treated to stay free of AIDS and rendered less capable of further transmission.

4 This section draws on the Guiding Principles for the Extended National Multi-sectoral HIV and AIDS Framework (eNSF) 2014-18 5 Mothers living with HIV who are trained and employed as part of a medical team to support, educate and empower pregnant women and new mothers about health and their babies’ health

22 NATIONAL STRATEGIC PLAN FOR ENDING AIDS AND SYPHILIS (2018 – 2022)

Figure 11: Conceptual Framework for eMTCT of HIV and Syphilis

Elimination of Paediatric HIV and Congenital Syphilis

Policy Leadership

Health Financing

Services Delivery

Human Resources

Community Health System

HMISCommodities

Health Systems Strengthening

a) Every child born and remain HIV free

b) Every pregnant woman living with HIV has access to lifelong HIV treatment

c) Every pregnant woman with syphilis effectively treated

Every child and adolescant living with

HIV has access to quality HIV treatment, care and support; and to realize their full potential without stigma and discrimination

Every adolescant and young woman able to protect themselves from HIV & syphilis infection;

and to realize their full potential without fear of sexual violence, abuse or exploitation

I.

Start Free

III.

AIDS Free

II.

Stay Free

“Start Free” refers to prevention of new HIV infections among children during pregnancy, birth and throughout the breast-feeding period as well as effective treatment of all identified cases of syphilis. The interventions under this Strategic Plan will primarily contribute towards “Start Free” via the 4 prongs of

PMTCT

“Stay Free” refers to the prevention of new HIV infections from among the adolescents and young women as they grow up, especially those who ‘started free’ as a result of the interventions. Interventions will be primarily based upon the National Multi-sectoral HIV and AIDS Framework and the male circumcision Strategic and Operational Plan for HIV Prevention.

“AIDS Free” refers to the provision of HIV treatment, care and support to children and adolescents living with HIV to attain the target of at least 90% being virologically suppressed and thus contribute towards prevention of further transmission. Interventions will be based on prong IV covered under this Strategic Plan and National HIV Health Sector Strategic Plan (NHHSP).

NATIONAL STRATEGIC PLAN FOR ENDING AIDS AND SYPHILIS (2018 – 2022) 23

Figure 12: Results Framework for eMTCT of HIV and Syphilis

The results framework has been summarised and illustrated in Figure 12.

• ≤ 500 New Paediatric HIV Infections as per 100,000 Live Births

• ≤ 50 Congenital Syphilis Cases per 100,000 Live Births

<5% new infections among children age 0 – 14 years

Reduced new infections among adolescents & young women age

10 – 24 years

90% decline in AIDS death in HIV+ children age 0 – 14 & adolescents

15 – 19 years

• <2% HIV zero-conversion among pregnant and lactating women retested

• <5% unmet need for FP among HIV+ women

• 95% HIV+ pregnant and lactating women and male partners on ART and virologically suppressed

• 95% HEI provided ARV prophylaxis

• 95% HEI & children tested at 2 18 months

• 95% of syphilis zero-positive cases given effective treatment

• Proportion of sexually active girls and boys reporting use of condoms

• Proportion of targeted adolescent girls, boys and young women for HIV testing

• Proportion of male children and adolescents with medical circumcision conducted

• 95% HIV+ children age 0 – 14 years provided care & ART

• 95% HIV+ adolescents provided care and ART

• 90% HIV+ children and adolescents on ART virologically suppressed

Policy Leadership

Health Financing

Services Delivery

Human Resources Commodities HMIS

Community Health SystemH

SS

O ut pu ts O ut co m e

In pa ct s

Start free Stay free AIDS free

Note: The results in Figure 12 for “Stay Free” will be aligned to those in the national multi-sectoral HIV and AIDS Framework, and the male circumcision Strategic and Operational Plan for HIV Prevention.

*The silver level of the path to elimination(WHO AFRO, 2017)

CHAPTER 4

THE STRATEGIC

FRAMEWORK

NATIONAL STRATEGIC PLAN FOR ENDING AIDS AND SYPHILIS (2018 – 2022) 25

4.1: Strategic Vision, Mission and Goal

Strategic Vision

• Eswatini where mothers and their children are free from AIDS and syphilis

Strategic Mission

• To attain less than 500 new paediatric HIV infections, and less than 50 congenital syphilis cases per 100,000 live births, in Eswatini

Strategic Goal

• To eliminate new paediatric syphilis and HIV infections, and keep mothers alive through delivery of integrated continuum of maternal, newborn, child and adolescent health services

4.2: Strategic Objectives

By the year 2022:

1. To reduce transmission rate of HIV infections from mother to child to <5% upon cessation of breast feeding.

2. To contribute towards 50% reduction in AIDS-related death among children and their mothers living with HIV.

4.3: Results Framework

The Results Framework has been summarised and the main components as follows:

KR1 (Start Free): <5% new infections among children

• <1% HIV sero-conversion among pregnant and lactating adolescent girls and women who get re-tested for HIV (Prong I);

• <5% unmet need for family planning among adolescent girls and women living with HIV (Prong II)

• 95% pregnant and lactating adolescent girls and women living with HIV and their male partners initiated and retained on lifelong antiretroviral treatment with virological suppression (Prong III);

• 95% HIV exposed infants provided ARV prophylaxis;

• 95% identified syphilis sero-positive mothers given effective treatment.

KR2 (AIDS Free): Contribute to 50% reduction in AIDS-related deaths among the children living with HIV

• 95% HIV exposed infants (HEI) tested by PCR by age 2 months and have final diagnosis at cessa-tion of breast feeding.

• 95% of HIV positive infants and young children are identified and linked to ART within 4 weeks of diagnosis.

26 NATIONAL STRATEGIC PLAN FOR ENDING AIDS AND SYPHILIS (2018 – 2022)

4.4: Main Strategic Areas

The following are the main strategic areas for achieving the above key results;

1) Prevention of new infections among pregnant and lactating adolescents and women;

2) Prevention of unintended pregnancies among adolescents and women living with HIV;

3) Promotion of uptake, adherence and retention to care and antiretroviral treatment for pregnant and lactating adolescents and women;

4) Promotion of access to care, treatment and support for women, children living with HIV and their families;

5) Promotion of diagnosis and effective treatment of syphilis for pregnant adolescents, women and their male partners;

6) Strengthening of the health system capacity for delivery of equitable, high quality HIV-related services to children, adolescents and young women through:

a. Policy leverage to support provision of HIV related services within the MNCH platform

b. Leadership and governance in provision of services

c. Financing for HIV related services

d. Delivery of equitable and quality services

e. Human resources for health

f. Equipment, medicines and supplies security

g. Health management information system, including the Client Management Information System

(CMIS)

h. Community health system

CHAPTER 5

THE IMPLEMENTATION

28 NATIONAL STRATEGIC PLAN FOR ENDING AIDS AND SYPHILIS (2018 – 2022)

Strategies Interventions Time-Frame (Year)

Responsible 1

0 21 22

KRA 1: Reduced transmission rate of HIV and syphilis among children

1.1: Reduce new infections among pregnant and lactating adolescent girls and women

1.1.1: Increase uptake of HIV testing among all pregnant and lactating women and their partners at health facilities

X X X X X

MoH/SNAP

HTS

1.1.2: Promote innovative condom social marketing and distribution

X X X X X MoH/SRH

1.1.3: Provide HIV prevention package (PREP, PEP, Condoms- dual protection, STI screening and treatment) for HIV negative pregnant and lactating women and partners

X X X X X MoH/SNAP/SRH

1.1.4: Strengthen HIV prevention counselling and support for HIV negative pregnant and lactating women and their partners

X X X X X

MoH/SRH

1.1.5: Strengthen re-testing of HIV negative pregnant and lactating women and their partners

X X X X X

MoH/SRH

1.1.6: Promote family centred approach including index testing and male partner involvement at health facility and community level targeting households with pregnant and lactating women

X X X X X

MoH/SRH/SNAP

1.1.7: Strengthen postnatal care/ follow-up throughout the breast feeding period

X X X X X

MoH/SRH

1.2: Reduce unintended pregnancies among adolescent girls and women living with

HIV

1.2.1: Integrate Family planning services into all HIV service delivery points

X X X X X MoH/SRH

1.2.2: Provide information and counselling in all MNCH service delivery points

X X X X X MoH/SRH

1.2.3: Promote dual protection family planning methods among adolescents and women living with

HIV

MoH/SRH

1.3.1: Increase uptake of ARV for newly diagnosed pregnant and lactating women through addressing barriers related to disclosure, stigma and poor counselling with special focus on those identified in labour and delivery

MoH/SNAP/SRH adherence and retention in care for pregnant and lactating adolescent girls, women and HIV exposed infants

1.3: Increase ARV uptake, NATIONAL STRATEGIC PLAN FOR ENDING AIDS AND SYPHILIS (2018 – 2022) 29

1.3: Increase ARV uptake, adherence and retention in care for pregnant and lactating adolescent girls, women and HIV exposed infants

1.3.2: Improve adherence to treatment through addressing barriers related to disclosure, stigma and counselling

1.3.3: Strengthen peer support system for HIV positive pregnant and lactating women

1.3.4: Increase community awareness on eMTCT and importance of ARVs for pregnant and lactating women using evidence based

X X X X X

MoH/SRH/Heal th promotion

1.3.5: Increase uptake of ARV prophylaxis for HIV exposed children through integration in MNCH

1.3.6: Increase capacity of health care workers to provide comprehensive PMTCT services

X X X X X

MoH/SRH

1.4: Increase access to care, treatment and support for women, children living with HIV and their families

1.4.1: Identify and retain breastfeeding women and their infants in the continuum of care

X X X X X

MoH/SRH

1.4.2: Increase access to viral load testing and manage appropriately all those failing (not virologically suppressed)

X X X X X

MoH/SNAP

1.5: Increase access to syphilis testing and treatment

1.5.1: Strengthen syphilis testing and treatment for pregnant women by ensuring uninterrupted supply of syphilis test kits and drugs at all facilities

X X X X X

MoH/SRH

1.6: strengthen private sector involvement in eMTCT

1.6.1: Advocacy for private health facilities to report on MTCT and syphillis

X X X X X MoH/SRH

1.6.2: Engage private institutions in mobilization for eMTCT

X X X X X MoH/SRH

KRA 2: Contribute to 50% reduction in AIDS-related deaths among children living with HIV

2.1: Increase diagnosis for HIV exposed infants and link to

ART

2.1.1: Strengthen EID and re-testing for final diagnosis for HIV exposed children after cessation of breastfeeding or at age 18 months

MoH/SNAP/SRH

2.1.2: Strengthen linkages between diagnosis of HIV among children and the initiation of ART within 4 weeks of diagnosis

30 NATIONAL STRATEGIC PLAN FOR ENDING AIDS AND SYPHILIS (2018 – 2022)

Cross-cutting: Strengthened capacity of the health system for delivery of equitable, high quality HIV-related services

3.1: Enhanced policy leverage for service provision within the MNCH platform

3.1.1: Review, update and widely disseminate the policy guidelines, including the use of pre-exposure prophylaxis (PREP)

X X X X X

MoH/SNAP/SR H

3.1.2: Review, update and disseminate job-aides for eMTCT based on the “three frees”

X X X X X MoH/SRH/SNA P

3.1.3: Advocate for policy change to promote community based distribution of family planning service at community level

X X X X X

MoH/SRH

3.2: Good leadership and governance in service provision

3.2.1: Strengthen intra-sectoral and inter-sectoral partnerships at national and regional levels for eMTCT of HIV and syphilis

X X X X X

MoH/SRH

3.2.2: Conduct joint planning and coordination meetings involving development and implementing partners

X X X X X

MoH/SRH

3.2.3: Identify and map key stakeholders including networks of people living with HIV and advocate for accountability from political and civic leaders at central and regional levels

X X X X X

MoH/SNAP/SR H

3.3: Improved financing for HIV related services

3.3.1: Advocate for increased resource allocation to eMTCT activities at all levels

X X X X X

MoH/SRH

3.3.2: Leverage existing financing mechanisms for increased access to MNCH and adolescent health services

X X X X X

MoH/SRH/SNA P

3.4: Improved delivery of quality services

3.4.1: Promote implementation of integrated HIV and syphilis service delivery models within the MNCH platform

X X X X X

MoH/SRH

3.4.2: Engage the private sector and other stakeholders in delivery of quality eMTCT services

X X X X X

MoH/SRH

3.5: Aligned and competent human resources for health

3.5.1: Build capacity of health care providers for delivery of quality services for eMTCT of HIV and syphilis, including comprehensive family planning

X X X X X

MoH/SRH

3.5.2: Conduct mentorship and on-job training for health workers at the implementing health facilities to cover infant ART initiation, identification of children failing…