J.22_The_National_Multisectoral_HIV_and_AIDS_Strategic_Framework_(NSF)_2018-2023.pdf

The Government of the Kingdom of Eswatini

The National Multisectoral HIV and AIDS Strategic Framework

(NSF) 2018 – 2023

June 2018

Foreword The Kingdom of Eswatini has made its commitment to End AIDS as a public health threat by the year 2022.

This target was initiated in 2015 as a pledge towards a First World Eswatini and is in line with the global

HIV/AIDS targets for 2030. Our commitment has seen an elaboration of plans and strategies to prevent new HIV infections and AIDS deaths through a multisectoral response, with the most recent being the extended National Strategic Framework (eNSF) and the Umgubudla Fast Track to End AIDS programme.

Through implementation of these initiatives, the Kingdom is proud to report that new infections have reduced by 44 percent since 2014, against a target of 50 percent. Over 80 percent of people living with HIV are alive and on treatment, and over 90 percent of those are virally suppressed. Moreover, the country has made large domestic investments in its HIV response, with public funds supporting 40 percent of the total cost and Government paying for virtually all antiretroviral drugs, since 2010.

In spite of all the gains, HIV and AIDS will continue to be high on the national agenda. This is because some sub- populations have not benefited from the strides made in prevention and treatment, with more than 2,500 new HIV infections occurring each year among young people aged 15-24, and with 15% of people living with HIV (PLHIV) not having tested and enrolled in care, the majority of whom being men and children under the age 14 years. Furthermore, other disease co-morbidities have emerged that pose a threat to the lives of those living with HIV.

To reverse this, we must continuously remain aware that AIDS is preventable and manageable. We must intensify and expand the measures at our disposal to prevent its spread and impact. The most important is to, firstly, make HIV prevention for the over 700,000 emaSwati who are HIV negative a priority, and, secondly, equally important to ensure that those who are living with HIV receive timely and quality HIV treatment to prevent their progression to AIDS. Thirdly, we must recognise that a multisectoral response is imperative to sustain the gains made, and we should collectively reduce all structural vulnerabilities that impede progress. This includes a broad economic resuscitation to support the fiscal demands of the lifetime treatment programme, economic empowerment of young people and the creation of a resilient social support system for those who are disproportionately affected by its impact.

This NSF 2018-2023 has been developed to super-fast track those ideals by detailing strategies that reach individuals, social networks, communities, and promote social change. It has been developed against the backdrop of an unstable and unpredictable financial resource climate, owing to the global flat-lining of resources for HIV/AIDS. Furthermore, our Government is faced with resource constraints in the light of extensive development priorities. In recognition of the realities, the NSF has included a chapter on innovative measures to support the fiscal sustainability of the response.

Finally, I again call for renewed commitment from all stakeholders in government, civil society, communities, people living with HIV/AIDS and the country’s development partners to make this dream possible. Our dream is to End AIDS by 2022.

Dr. Barnabas Sibusiso Dlamini

Prime Minister

Kingdom of Eswatini

Acknowledgements The National Emergency Response Council for HIV/AIDS (NERCHA) would like to thank His Majesty’s

Government and NERCHA Council for sanctioning the development of the National Strategic Framework

2018-2023. The NSF is presented as the multisectoral plan to build from the Umgubudla Roadmap for

Ending AIDS by 2022. Whereas the Umgubudla recommends five high level strategic interventions to be fast tracked, the NSF expands to include externalities that can be harnessed through integration with other development programmes and considers the existing financial realities during which the framework will be implemented.

NERCHA is grateful for the support provided by the Technical Advisory Teams from the United Nations offices in the Kingdom of Eswatini, UNAIDS, and United States Government’s PEPFAR team. The World

Bank is commended for providing an independent external peer review of the NSF.

This NSF is the cumulative effort of the National Steering Committee led by Dr. V. Magagula, together with the Thematic Technical teams and the National Health Financing task team. NERCHA is indebted to all multisectoral stakeholders; Government Ministries, development bilateral and multilateral partners, People Living with HIV and AIDS (PLHIV), implementing partners, Civil Society Organisations (CSO) and local communities; who collectively provided useful insight into the process. Central government ministries of Finance (MoF), Economic Planning and Development (MEPD) and Public Service were engaged to guide the capacity of government’s financial commitment to fulfilling this strategy as well as to promote mainstreaming of HIV synergies within the development sector.

I wish to recognise the commitment and passion of His Excellency the Right Honourable Prime Minister, Dr. Barnabas Sibusiso Dlamini for leading the national multisectoral HIV and AIDS response of the

Kingdom. The NERCHA Directorate would like to express appreciation for the unprecedent support, guide and oversight provided by the NERCHA council.

Lastly, I would like to thank the consultancy team that was supported by UNAIDS Mr. Tom Mogeni

Mabururu and Mr David Masengu and Dr Zara Shubber from the World Bank. The hard work by the

NERCHA team for coordination and leading the process is duly recognised

Mr. Khanya Mabuza

National Executive Director

National Emergency Response Council on HIV and AIDS (NERCHA)

Contents

Foreword

Acknowledgements

List of Tables

List of figures

Abbreviations and Acronyms

Executive Summary

1. Introduction

1.1 Country context

1.2 Overview of HIV and AIDS

1.3 Epidemiological context

1.4 Drivers of the HIV epidemic

1.5 Vision and goal of the National Strategic Framework 2018-2023

1.6 Innovative approaches to Super Fast-Track the HIV response

1.7 Alignment of the NSF to global, regional and national frameworks

2. NSF Strategic Interventions

2.1 HIV prevention

2.1.1 Social and behaviour change (SBC)

2.1.2 Condom Promotion and Distribution

2.1.3 Economic empowerment for adolescents and young people

2.1.4 Voluntary Medical Male Circumcision (VMMC)

2.1.5 Pre-Exposure Prophylaxis (PrEP)

2.1.6 Post-Exposure Prophylaxis (PEP)

2.1.7 Prevention of Mother to Child Transmission of HIV (PMTCT)

2.1.8 Management and Treatment of Sexually Transmitted Infections(STI)

2.2 HIV treatment, care and support

2.2.1 HIV testing services (HTS)

2.2.2 HIV treatment Services

2.2.3 Management and treatment of TB/HIV co-infection

2.2.4 Management of HIV opportunistic infections and co-morbidities

2.3 Social Protection and Reduction of Structural Vulnerabilities

2.3.1 Support to orphaned and vulnerable children(OVC)

2.3.2 Gender Based Violence (GBV)

2.3.3 HIV related stigma, discrimination and human rights

3. Management of the HIV and AIDS Response

3.1.1 Multisectoral Coordination of the HIV response

3.1.2 HIV mainstreaming

3.1.3 Strengthening Health, Community and Social Services systems

3.1.4 Advocacy and communication for the HIV response

3.1.5 Strategic Information and Research

4. Sustainable financing of the HIV response

4.1.1 Resource needs for implementing the NSF during 2018 – 2023

5. NSF implementation arrangements

Annex 1: NSF Results Framework

Annex 2: Multisectoral Response Coordination Architecture

List of Tables Table 1: SBC outcome results

Table 2: Condom promotion and distribution outcome results

Table 3: Economic empowerment outcome results

Table 4: VMMC outcome results

Table 5: PrEP outcome results

Table 6: PEP outcome results

Table 7: PMTCT outcome results

Table 8: STI outcome results

Table 9: HTS outcome results

Table 10: ART outcome results

Table 11: Retention and viral suppression outcome results

Table 12: TB/HIV co-infection outcome results

Table 13: Management of HIV opportunistic infections and co-morbidities outcome results

Table 14: OVC support outcome results

Table 15: GBV outcome results

Table 16: HIV stigma outcome results

Table 17: Multisectoral coordination outcome results

Table 19: External mainstreaming outcome results

Table 20: HIV Synergies in Government Ministries, private sector and development partners

Table 21: HSS outcome results

Table 22: CSS outcome results

Table 23: Advocacy and communication outcome results

Table 24: Strategic information outcome results

Table 25: Sustainable financing outcome results

Table 26: HIV financing by source of funds, Eswatini, 2013

Table 27: Total cost of NSF 2018-2023

List of figures Figure 1: NSF conceptual framework

Figure 2: Trends in new HIV infections, 2010-2030, Eswatini

Figure 3: HIV Prevalence by age and sex, Eswatini, 2017

Figure 4: HIV prevalence among 15+, and youth and adolescents aged 15-24, Eswatini, 2017

Figure 5: HIV incidence by age and sex, Eswatini, 2016/17

Figure 6: AIDS deaths with and without ART, Eswatini, 2002-2018

Figure 7: Alignment of the NSF and other key frameworks

Figure 8: Males who are circumcised by region, Eswatini, 2017

Figure 9: Males who are circumcised by age, Eswatini, 2017

Figure 10: PMTCT maternal cascade, Eswatini, 2016

Figure 11: HIV positivity rates among people tested, Eswatini, 2010-2015

Figure 12: HTS uptake by service point, Eswatini, 2016

Figure 13: HIV Treatment cascade by age and sex, Eswatini, 2016

Figure 14: HIV treatment cascade for children aged 0-14 years, Eswatini, 2016

Figure 15: Trends in loss to follow up and deaths among PLHIV, Eswatini, 2009-2015

Figure 16: HIV testing and treatment among TB Patients, Eswatini, 2016

Figure 17: Health system Building Blocks

Figure 18: Annual costs of the NSF 2018-2023, Eswatini

Figure 19: NSF cost by programme, Eswatini

Figure 20: Cost estimate for HIV Prevention by intervention areas

Figure 21: Cost estimate for HIV Treatment and Care by intervention areas

Figure 22: Cost estimates for Response Management by intervention areas

Figure 23: Funding commitment for the NSF, Eswatini

Figure 24: Funding and gap comparison by three scenarios, Eswatini

Figure 25: HIV Coordination structure for the NSF 2018-2023, Eswatini

Abbreviations and Acronyms

AGYW Adolescent Girls and Young Women

ANC Antenatal Care

AYP Adolescents and Young People

ART Antiretroviral Therapy

BMU Basic Management Unit

CHIMSHACC Chiefdom Multisectoral HIV and AIDS Coordinating Committee

CSOs Civil Society Organisations

CMIS Client Management Information System eNSF Extended National Multisectoral HIV and AIDS Strategic Framework

EID Early Infant Diagnosis

FP Family Planning

FSWs Female Sex Workers

GBV Gender Based Violence

HCWs Healthcare Workers

HMIS Health Management Information System

HTS HIV Testing Services

IEC Information, Education and Communication

IMCI Integrated Management of Childhood Illness

IPD In Patient Department

KP Key Population

LSE Life-Skills Education

MICS Multiple Indicator Cluster Survey

MSM Men who have sex with men

MTCT Mother to Child Transmission of HIV

NCDs Non-Communicable Diseases

NERCHA National Emergency Response Council on HIV and AIDS

NOP National Operational Plan

NSF National Multisectoral HIV and AIDS Strategic Framework

OIs Opportunistic Infections

OPD Out Patient Department

OVC Orphans and Vulnerable Children

PEP Post-Exposure Prophylaxis

PHU Public Health Units

PITC Provider Initiated Testing and Counselling

PMTCT Prevention of Mother to Child HIV Transmission

PNC Post-Natal Care

POC Point of Care

PrEP Pre-Exposure Prophylaxis

PSHACC Public Sector HIV and AIDS Coordination Committee

REMCHACC Regional Multisectoral HIV and AIDS Coordinating Committee

RMNCAH Reproductive Maternal Neonatal Child and Adolescent Health

SADC Southern Africa Development Community

SBC Social and Behaviour Change

SDHS Eswatini Demographic and Health Survey

SHIMS Eswatini HIV Incidence Measurement Survey

SI Strategic Information

SRH Sexual and Reproductive Health

STI Sexually Transmitted Infection

SWANNEPHA Eswatini National Network of People Living with HIV/AIDS

TB Tuberculosis

TIMSHACC Tinkhundla Multisectoral HIV and AIDS Coordinating Committee

TWG Technical Working Group

VMMC Voluntary Medical Male Circumcision

Executive Summary

Overview

The National Multisectoral HIV and AIDS Strategic Framework (NSF) 2018-2023 is a five-year policy and planning document that has been developed to guide focused resource allocation, programming and implementation of the HIV response in the Kingdom of Eswatini. The vision for this NSF is to

End AIDS as a public health threat by 2022 through epidemic control by focusing on drastically reducing new infections and AIDS-related deaths.

To achieve this, the NSF has laid down innovative strategic directions that build from the Umgubudla

Roadmap for Ending AIDS (2016) to super-fast track the national response in the next five years. These include:

• Delivering comprehensive HIV prevention, treatment, care and support services as an integrated package to fast track the reduction of new infections and improve mortality.

• Timely quality HIV treatment services that integrate prevention and curative services of HIV co-morbidities to sustain the survival rates of people living with HIV and AIDS and contribute to fewer new infections through viral suppression.

• Developing local HIV responses to effectively micro-target priority and key populations.

• Transforming HIV coordination to effectively support the implementation of localised and differentiated responses.

• Mechanisms to facilitate sustainable financing of the response.

• Making available and use of granular data to inform localised response programming.

• Holding stakeholders accountable for NSF results.

This framework is premised on: the 2016 UN Political Declaration on HIV and AIDS: On the Fast-

Track to Accelerate the Fight against HIV and to End the AIDS Epidemic by 2030; Sustainable

Development Goals (SDGs); HIV Prevention 2020 Road Map; the African Union catalytic framework to end HIV/AIDS, TB and eliminate malaria in Africa by 2030; SADC policies on HIV and AIDS;

The Swaziland Development Index 2022; the Umgubudla investment case and recent technical policy guidance on HIV prevention, treatment and care.

NSF Goal and Impact targets

Eswatini has made major strides in its HIV response. New HIV infections have reduced by 44% in the past five years since 2014 and by year 2017, the initiation of PLHIV on ART had been accelerated to reach 85% of PLHIV; 92% of those are virally suppressed. Over 70,000 AIDS-related deaths have been averted since the introduction of antiretroviral therapy in 2003. 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 by year

2022, the current incidence rate of 1.5% 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 enrolled in care, while more children and men living with HIV are not virally suppressed.

To support the goal to End AIDS by 2022, the NSF has made achieving the following population-level impact targets a priority:

1. Reduction of HIV incidence among persons aged 15-49 years by 85%.

2. Reduction of HIV incidence among persons aged 15-24 by 85%.

3. Reduction of new HIV infections among infants aged 0-1 year to less than 0.05%.

4. Reduction of AIDS deaths by 50%.

NSF Conceptual framework and core interventions

The conceptual framework illustrated below shows the approaches for achieving impact targets of the NSF.

This is premised on implementing selected NSF core interventions that are centred towards (i) Combination

HIV prevention strategies to drastically reduce new infections, (ii) Scaling up treatment and care services of PLHIV to achieve viral suppression and reduce AIDS related deaths and (iii) Strengthening cross-cutting areas to create an enabling environment for improving gender equity and women’s empowerment, addressing gender based violence, and promoting and protecting human rights including the elimination of

HIV stigma and discrimination. These will be supported by improved coordination and strengthened systems to ensure efficient and effective delivery of HIV and AIDS services.

Figure 1: NSF conceptual framework

The strategic orientation of each of the core programmes (interventions) is as follows:

1. Social and behaviour change (SBC) as a cross-cutting programme to deliver risk reduction education and generate demand for the uptake of HIV services. Its focus will be on ensuring that people who are HIV negative remain uninfected and that those who are HIV positive have access to and adhere to treatment. SBC will target priority populations including adolescents and young people, men 25 years and older, key populations and the general public.

2. Condom promotion and distribution will ensure that condoms and lubricants are available at the right places for different populations. Strategic focus will be to promote consistent and correct condom use. The programme will be integrated in other programmes including VMMC, PrEP, STI, HTS, MNCAH, SRH, ART and general men’s health. Innovative strategies for demand creation, developing positive risk perception and promoting consistent condom use will be promoted and barriers to condom use investigated to develop new approaches.

3. Economic empowerment will address structural vulnerability to HIV infection caused by poverty and unemployment, among adolescents and young people. These will be offered opportunities to improve their livelihoods through: entrepreneurship training; reintegration of teen mothers into schools; and facilitating access to income-generating opportunities. Economic empowerment components will be integrated into other HIV programmes.

4. Voluntary medical male circumcision will be scaled up to target younger men by using two approaches: (i) institutionalising MC in public health facilities and (ii) scaling up Early Infant Male

Circumcision as a long-term sustainability strategy. Demand creation will be intensified to address the social norms and cultural and religious beliefs hindering VMMC uptake.

5. Pre-Exposure Prophylaxis will target sub-population groups that are at a substantially higher risk of HIV acquisition with priority given to adolescent girls and young women, pregnant and lactating women, sero-discordant couples, female sex workers and men who have sex with men.

6. Post-Exposure Prophylaxis will be offered to all persons who are exposed to HIV infection through sexual assault and accidental occupational exposure. Studies will be made to ascertain population-level efficacy and affordability for its roll-out for use in consensual high-risk sex in line with WHO guidelines.

7. Prevention of mother to child transmission of HIV, syphilis and hepatitis will embrace the double elimination of mother to child transmission of HIV and syphilis, and extend the scope to include hepatitis B. The programme will intensify the four PMTCT prongs to all HIV positive mothers, HIV negative mothers, their exposed infants and male partners. These services will be complemented with strong linkages to communities to support lifelong ART.

8. The prevention and treatment of sexually-transmitted infections (STIs) programme will be strengthened to contribute to the reduction of HIV infections through education, screening and treatment of STIs. Selected HIV services will be integrated at STI service points to include condom distribution and screening for PrEP eligibility, VMMC and HTS. STI clients who test HIV positive will be referred for ART.

9. HIV testing services will aim at ensuring that 95% of PLHIV know their status through case-finding methodologies that increase the chances of finding PLHIV and link them to care and treatment. Strategic approaches will be deployed to reach hard to reach populations such as adolescents and young people, adult men, key populations, mobile populations, prisoners and persons living with disabilities. Those testing HIV negative will be linked to HIV prevention services. Self-screening for HIV will be promoted to sustain regular testing for HIV negative persons.

10. HIV care and treatment will aim to ensure that 95% of PLHIV who know their HIV status are on treatment and that 95% of those on treatment are also virally suppressed by strengthening linkages from HTS to minimise loss of clients, deploying approaches to initiate priority and key populations and improving adherence to lifelong treatment. To support this, differentiated service delivery models, routine viral load testing and HIV drug resistance monitoring will be scaled up.

Treatment regimens will be continuously reviewed to adopt those with better treatment outcomes and lower cost. The screening and treatment of TB/HIV co-infection will be sustained while the scope for HIV treatment will be expanded to screen for other related non-communicable diseases that are emerging as people age with HIV.

11. Social protection and reduction of structural vulnerabilities will include support for the full mainstreaming and institutionalisation of OVC programmes whilst programmes will continue to target OVCs for HIV prevention, treatment and care. The prevention and management of gender-based violence, reduction of stigma and discrimination, and promotion and protection of human rights will be a priority.

12. System strengthening, enabling environment and HIV mainstreaming includes strengthening health, community and social services systems as critical enablers to deliver quality HIV services and scale up the mainstreaming of HIV synergies in private and public sectors.

13. Coordination and advocacy for HIV response will be designed to support localised responses and planning for impact. The capacity of coordination structures will be strengthened while mechanisms will be established for programme coordination and for regular reviews of the NSF at national and regional levels. Advocacy will also be undertaken to rally all stakeholders to support the vision of ending AIDS by 2022.

14. Mechanisms for sustainable financing will be intensified since this NSF will be implemented in a resource-constrained environment. A two-pronged strategy has been proposed to mobilise resources from domestic, private and international sources and to maximise allocative and implementation efficiencies.

15. Strategic information and research will be strengthened to produce regular granular data to inform local responses and ensure efficient data flow and decision-making at national and regional levels. Financial data will also be produced to inform cost-efficiency analyses and identify ways of maximising resources.

Implementation of the NSF

The NSF will be implemented through a multisectoral approach at national and decentralised levels.

All sectors -public, private and civil society- will be involved in its implementation with the support of technical and development partners. Implementation will take the form of policy, planning, financing, implementation, advocacy and monitoring. The processes for implementation will include:

1. The National Operational Plan: A costed 2-year rolling National Operational Plan (NOP) will be developed to transform NSF strategies into action in order to achieve output level results shown in the NSF Results Framework (see Annexe 1). The NOP will be updated annually.

2. Advocacy and communication: Advocacy and communication for the response will be undertaken at national, regional and community levels as well as internationally to sustain commitment to the response, ensure that implementers align to the NSF, influence integration, strengthen community systems and community involvement; and to showcase Eswatini’s successes in the HIV response.

3. Sustainable Financing: An HIV financing committee will be established to lead resource mobilisation and implement the financing strategies outlined in section 4 of this document.

Mechanisms to undertake regular expenditure tracking and other efficiency analyses will be put in place to support a consistent flow of funds, and an effective and efficient response.

4. Thematic and Programme technical working groups: TWGs will be established to review progress in the implementation of all key areas of the NSF and provide feedback for policy and decision making.

5. Coordination structures: Sectors will be streamlined to coordinate the implementation of NSF strategies within their constituencies, review progress, identify bottlenecks and develop solutions.

Decentralised regional and community committees will play a similar role at local levels.

6. Monitoring, Evaluation and Research: M&E and research will be strengthened to produce granular and localised information through strategies laid out in section 3 of this document. A costed M&E and research (Strategic Information) framework will be developed to guide all monitoring, evaluation and research activities. Annual reviews of the NSF will be conducted each year. While the mid-term and end-of-term evaluations will be conducted in 2020 and 2022, respectively.

1. Introduction

1.1 Country context

The Kingdom of Eswatini is in the Southern African region and has a total land area of 17,364 square kilometres. The country is administratively divided into four regions, namely Hhohho, Manzini, Lubombo and Shiselweni. It has a population of 1.1 million people almost evenly distributed between males (48.6%) and females (51.4%). Population distribution varies across the four administrative regions with Manzini having the highest proportion (32.6%) followed by Hhohho (29.3%), Lubombo (19.4%) and Shiselweni

(18.7%). Children aged 0-14 years constitute 35.5% of the population while adolescents and young people aged 15-24 years are 20.7%1.

On the economic front, Eswatini’s economy is experiencing its weakest performance in 34 years. Gross

National Product contracted by 0.9% in 2016 largely due to a persistent drought, currency depreciation and weak regional economic conditions. Additionally, over the years government’s public-sector wage bill has increased in a context of declining revenues, threatening fiscal sustainability2. The country’s Human

Development Index decreased between the years 1990 and 2015, from 0.548 to 0.541 in 2015, showing a decline of 1.3%. When discounted for inequality, the HDI falls to 0.361, reflecting a loss of 33.3%3. In the same period, life expectancy decreased by 10.6 years, while mean years of schooling increased by 2.0 years and the Gross National Income (GNI) increased by 13.2%. These social development indicators demonstrate the need to accelerate service delivery, especially for the poor.

Neonatal mortality rate per 100 live births is 21.4 (2016); under five mortality rate is 70.4/per 1000 live births (2016); maternal mortality is estimated at 389 per 100,000 live births, total fertility rate is 3.1 while contraceptive use (modern methods) among women 15-49 years is estimated at 65.5%4. The HIV response, therefore, is being implemented within a context of limited fiscal space, high poverty level, gender and income inequalities, and weak primary healthcare.

1.2 Overview of HIV and AIDS

The Kingdom of Eswatini has made major strides in its HIV response. At the political level, commitment to the response has been sustained at the highest levels and a target to End AIDS as a public health threat by 2022 has been established since 2015. The extended National Strategic Framework (eNSF) was supported by the Umgubudla fast track targets to make this vision operational through an HIV investment case approach which maximises resources for implementing technically effective interventions for combination prevention, and comprehensive HIV treatment for all people living with HIV(PLHIV).

As a result, the HIV prevalence rate has stabilised to 27.4% and new HIV infections have reduced by 44% in the past five years, from 2.9% to 1.5%. Figure 2 below shows the steep reduction in the number of new

HIV infections since 20105, levelling off from year 2020 onwards as the impact of current programmes reach their maximum effect. Initiation of PLHIV on ART has been accelerated to reach 85% by 2018.

To date, over 70,000 AIDS-related deaths have been averted since the introduction of antiretroviral therapy in 2003. These are key indicators suggesting that the country is on the right trajectory to Ending AIDs as a public health threat.

1 Population Census Preliminary Report, 2017 2 World Bank, 2016 3 Swaziland Human Development Report, 2015 4 World Health Organization Data 5 In figure 1, the middle line is the mid-point (average new infections) while the dotted lines represent the upper and lower bounds.

Despite these achievements, there is more work to be done. Evidence shows that the epidemic has shifted from what was known traditionally as a generalised epidemic to higher micro-epidemics impacting adolescent girls and young women aged 15-24, adult men aged 25 and older, mobile and migrant populations, and key populations.

Moreover, evolving structural vulnerability factors such as poverty, unemployment and gender based abuse render certain populations to be most affected by the epidemic.

These dimensions present a new challenge since the HIV response can no longer be provided as a

‘one size fits all’. Thus, the NSF ushers in the era of micro HIV responses that are tailored for sub-populations and locations in order to achieve the ideal of ending AIDS by 2022.

Source: HIV Estimates and Projections (prelim.2017)

1.3 Epidemiological context

Prevalence by age and sex: According to the SHIMS 2016/17, HIV prevalence increases with age for both sexes, reaching an earlier peak in women at 35-39 years (54.2%) and later for men at ages 45-49 (48.8%).

Disparity in prevalence by sex is most pronounced among adolescents and young people with 20-24-year-old females having five times higher (20.9%) prevalence than their male counterparts (4.2%). One in every five young women 20-24 years is HIV positive, increasing to one in every three for women aged 25-30 6.

HIV prevalence among adolescents and young people is indicative of new infections acquired rather than a survival effect of the treatment programme.

Figure 3: HIV Prevalence by age and sex, Eswatini, 2017

Source: SHIMS 2016/17

6 SHIMS 2016/17

54.2

48.8

0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+

P er ce n ta g e

Ages

Female Male

Figure 2: Trends in new HIV infections, 2010-2030, Eswatini

HIV prevalence among people 15 years and older was 27.2% in 2017 with women being more affected

(32.5%) than men (21.3%). In the same year, prevalence among adolescents and young people aged 15-24 was estimated at 9.6% (16.2% for females and 3.0% for males)7.

Figure 4: HIV prevalence among 15+, and youth and adolescents aged 15-24, Eswatini, 2017

Source: Spectrum HIV Estimates, 2018

Prevalence among key populations: Key populations are particularly vulnerable to HIV infection due to their high-risk sexual behaviour and higher internal and external stigma and discrimination which constitutes as a major barrier to their service uptake. HIV prevalence among FSW is estimated at 60.5% while prevalence among MSM is 12.6%. Although the population size of the two key populations is relatively small compared to the general population8, they contribute a significant proportion of HIV infections relative to their population size. On the other hand, prevalence of syphilis among MSM was 1.2% and 6.6% among FSW9.

HIV incidence: Incidence among people 15+ years decreased from 2.70% in 2010 to 1.4% in 2017.

Incidence is higher among women (1.37%) than men (0.93%) aged 15 years and older. The variation in incidence by sex is most pronounced among adolescents and young people (AYP) aged 15-24 with females having an incidence of 1.9% compared to 0.8% among males10. The number of annual new infections was estimated at 7,000 in 2017 broken down to 6150 infections among people 15 years and older and 850 among children 0-14 years11.

7 Spectrum, 2018 8 Population size for FSWs estimated at 12.300 and MSM at 5,700 in 2017 9 HIV among Female Sex Workers and Men Who Have Sex with Men in Eswatini study, 2013

10 SHIMS2, 2017

11 Spectrum, 2018

Figure 5: HIV incidence by age and sex, Eswatini, 2016/17

People living with HIV: An estimated 210,000 people are living with HIV comprising 90,000 males and

120,000 females. 13,000 children are living with HIV while 197,000 are adults12. 84.7% of the PLHIV know their HIV status, 87.4 % of those diagnosed with HIV are on ART and 91.9% of those that are on

ART are virally suppressed13.

HIV and opportunistic infections and co-morbidities: TB/HIV co-infection is estimated at 60% and mortality among TB/HIV co-infected persons is 14%. With an increasing number of people ageing with

HIV, non-communicable diseases (NCDs) are emerging as a major concern. These include but not limited to cancers, diabetes, hypertension and mental illnesses.

AIDS deaths: Annual AIDS deaths have steadily decreased over the years to 3,500 in 2017, and almost evenly distributed among women and men14. The number of orphans due to AIDS-related causes decreased by 16% between 2013 and 2017. The number of orphans due to AIDS-related causes is higher than those orphaned by other causes15.

Figure 6: AIDS deaths with and without ART, Eswatini, 2002-2018

Source: Spectrum 2018

12 Spectrum, 2018

13 SHIMS, 2017

14 Spectrum, 2018 15 Spectrum 2018

10000

12000

14000

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

N u m b er o f d ea th s

Year

Number of AIDS Deaths (with ART) Number of AIDS Deaths (without ART)

1.4 Drivers of the HIV epidemic

Low comprehensive knowledge about HIV among adolescents and young people: comprehensive knowledge about ways of preventing HIV infection among young people declined from 58.2% in 2010 to

49.1% in 2014 among females and from 53.6% to 50.9% among males in the same period16. Further, knowledge levels among children 10-14 years is estimated at 34.6% with a slight difference between males

(33.8%) and females (35.6%)17. This underscores the relevance of a dynamic life-skills programme for in-and out- of school youth.

Early sex debut: the SDHS 2007 and MICS 2010 and 2014 show that more females aged 15-24 (6.9%, 3.8% and 3.0% respectively) have sex before the age of 15 compared to males (4.8%, 2.6% and 2.8% respectively). Although this shows a downward trend, 48% females and 34% males have begun sex by age

18 indicating a rapid increase in debut between the ages of 15 and 1818.

Dropping out of school: Education is a key factor in determining sexual debut and activity. A survey carried out in 2017 found that 30% of girls aged 15-22 years were sexually active compared to 80% of their counterparts who were out-of-school. Resultantly, HIV incidence and prevalence is almost four times higher among girls out of school than those in school19. A female with tertiary education is more likely to delay sex debut (less than 1% reporting sex before age 15) compared to those with primary education only

(8%)20. Therefore, keeping girls in school has a protective effect on reducing HIV spread.

Poverty and unemployment: According to the labour force survey of 2016, unemployment among adolescents and young people aged 15-24 is estimated at 51.6% and poverty levels are estimated at 63.0% based on the 2009/10 Swaziland Household Income and Expenditure Survey (SHIES). Poverty and unemployment are interrelated factors that deprive adolescents and young people (especially girls and young women) access to secure livelihoods and expose them to risky sexual relationships with power imbalances.

Intergenerational sex: Although intergenerational sex between adolescent girls and young women

(AGYW) 15-24 and older men has declined from 14.4% in 201121 to 8.7% in 201722, it is still a significant problem that contributes to HIV infections. AGYW engage in sex with older men who are within age groups with a higher HIV prevalence. This is shown by the higher HIV prevalence among girls between the age groups 15-19 and 20-24, which are 7.2% to 20.9% respectively, while prevalence for boys aged 15-19 is

3.9% and increases marginally to 4.2% for those aged 20-24. On the other hand, HIV prevalence starts increasing at a higher rate when men reach age 25 years and above which could imply that these men start engaging in sex with women within their ages who already have higher HIV prevalence. AGYW are vulnerable to risky sexual interactions partly due to gender norms which make it difficult for them to negotiate safe sex, poverty and unemployment and low knowledge on HIV prevention.

Multiple sexual partnerships and condom use: Condom use among persons aged 15-49 years during high risk sex has declined in the last five years. The proportion of men 15-49 years with more than one partner who reporting using a condom in the last sexual encounter declined from 82.6% in 201423 to 66.2% in 201724 and from 66.0% to 63.5% among women during the same period. Condom use among young

16 MICS 2010 and 2014

17 SHIMS 2016/17

18 SDHS, 2007

19 Sitakhela Likusasa Impact Evaluation

20 MICS 2014

21 Comprehensive HIV Epidemiological and Prevention Response Analysis report 2017

22 SHIMS 2016/17

23 MICS 2014

24 SHIMS 2016/17

people 15-24 engaged in high risk sex also declined from 69.6% in 201425 to 61.8%26 and from 94.8% in

2014 to 74.7% among males in the same period.

Low levels of male circumcision: The prevalence of circumcision among males 15 years and older is relatively low (26.7%) and is lower in older men, from 38.2% among 15-19-year olds to 7.5% among those aged 65 years and older27. Negative social norms and cultural and traditional beliefs are reported as barriers to uptake of male circumcision.

High onward transmission rate from those recently infected and not yet on treatment: about 15% of

PLHIV are not on ART and it is becoming harder to identify, test and put this cohort on ART. This group also comprises of persons likely to have been recently infected, who have no knowledge of their HIV status and are involved in onward transmission. Finding PLHIV who do not know their status and initiate their treatment is a key strategy for reducing new infections and AIDS deaths.

HIV stigma and discrimination: Although recent data on stigma is not available, focus group discussions held with men, adolescents and young people, people, community leaders and PLHIV indicated that the prevalence of self and external stigma is high and hinders service update28.

Gender-based violence: 1 in every 3 women will experience some form of sexual violence by the time they are 18 years old29. Recent evidence shows that 6.6% of adults 15 years and 1.9% of children aged 10-

14 experienced sexual abuse while about 4.6% of married women aged 15-49 experience physical and sexual violence from a male intimate partner. This shows that children start experiencing violence very early in their lives. Experience from GBV programmes shows that coercion and fear of repercussions prevent survivors of SGBV from reporting and seeking care and redress.

1.5 Vision and goal of the National Strategic Framework 2018-2023

Vision and Goal of NSF

The National HIV and AIDS Strategic Framework (NSF) is a five-year policy document designed to guide the national multisectoral HIV and AIDS response between 2018 and 2023. The vision of the national HIV response is to End AIDS as a public health threat by 2022.

The goal of the NSF is to super-fast track the HIV response to reduce new HIV infections by 85% and

AIDS related mortality by 50% from 2017 levels by 2023.

NSF Impact level targets

To realise its vision, Eswatini aims to achieve the following impact targets by 2023:

1. Reduction of HIV incidence among persons aged 15 -49 years by 85%.

2. Reduction of incidence among persons aged 15-24 by 85%.

3. Reduction of new HIV infections among infants aged 0-1 year to less than 0.05%.

4. Reduction of AIDS deaths by 50%.

25 MICS 2014

26 SHIMS 2016/17

27 SHIMS 2016/17

28 Stigma Index last carried out in 2010. Focus group discussion were held with PLHIV, Adolescents, young people, adult men and women during the evaluation of the eNSF in 2017 29 Study on Violence against Children & Young Women, UNICEF 2017

1.6 Innovative approaches to Super Fast-Track the HIV response

Eswatini seeks to super-fast track the HIV response to achieve the vision of ending AIDS within an environment of complex micro sub-population epidemics and constrained fiscal space amid declining international financing for HIV. The following innovative strategic directions will be pursued:

(i) Delivering HIV prevention, treatment, care and support services as an integrated package to fast track reduction of new infections: This includes a mix of biomedical and non-biomedical approaches with proven efficacy for direct and non-direct prevention efforts. These include male circumcision, condoms, prevention of mother to child transmission, pre- and post-exposure prophylaxis, prevention and treatment of STIs, HIV testing services and other behavioural interventions for risk reduction. These will be delivered as a package to provide individuals with options that work best for them through different platforms in private and public-sector settings, including community outreach, at schools, and health facilities. The strategy recognises ongoing clinical trials for preventive vaccines and supports their introduction thereafter.

(ii) Developing local HIV responses to effectively micro-target priority and key populations: This will be a shift from one national HIV response to localised HIV responses that address the specific needs of local communities and sub-populations given their epidemiology. Localised responses will be planned at Tinkhundla and chiefdom levels. The ambitious national level targets will be cascaded to local levels and disaggregated by population, sex and age among other factors. This approach will ensure that “no one is left behind”.

(iii) Making available and use of granular data to informal local responses: The development of local responses and effective micro-targeting of priority and key populations will be driven by granular data. M&E systems will be configured to collect granular data, make the data available in real-time and allow progress reviews and analysis of gaps and sub-population needs at local levels.

(iv) Transforming coordination to effectively support implementation of localised and differentiated responses: The focus of response coordination has so far been at the national level. This strategic framework transforms coordination to local levels in order to put communities at the centre of the response, ensuring young people’s participation and specifically adolescent girls and young women. This approach will propel implementation of localisation and micro targeting approaches.

This will also harmonise coordination with M&E strategic directions.

(v) Holding stakeholders accountable for results: In addition to the transformation of coordination, mechanisms will be in place to hold implementing partners accountable for results and ensure that all NSF strategies are being implemented and targets being met. Accountability mechanisms will be established at national and regional levels.

(vi) Sustainable financing of the response: Given the limited fiscal space and significant reliance on donors to fund critical areas of the response, the NSF proposes a two-pronged resource-mobilisation strategy. The first will be to mobilise resources from traditional and non-traditional domestic sources which will include a private equity investment fund and other innovative options.

The second approach is to maximise allocative and implementation efficiency through improved expenditure tracking, efficiency and cost-benefit analyses and improving effectiveness of implementation strategies.

1.7 Alignment of the NSF to global, regional and national frameworks

The NSF is inspired and aligned to key policies and frameworks guiding the fight against the HIV epidemic at the global, regional and national levels.

At the global level, the NSF is aligned to the Sustainable Development Goals (SDGs) in particular goals 2, 3, and 16. The NSF is also aligned to the 2016 UN Political Declaration on HIV and AIDS, the HIV 2020

Prevention Road map, the “three frees” targets, the Global Strategy for Women’s Children’s and

Adolescents’ health (2016-2030), and WHO guidance on treatment and care.

At the regional level, the NSF is aligned to the African Union Agenda 2063, Southern African Development

Community (SADC) declarations and policy frameworks for combating HIV: The Regional Indicative

Strategic Development Plan (RISDP) for strengthening HIV prevention, treatment and care, socio-economic impact mitigation and monitoring; and the SADC declaration on Gender and Development.

At the national level, the NSF is also aligned to the National Development Strategy (NDS), Swaziland

Development Index 2022, Umgubudla investment case and recent technical policy guidelines for delivering

HIV prevention, treatment and care and support services. Figure 7 illustrates the alignment of the NSF with key global, regional and national targets.

Figure 7: Alignment of the NSF and other key frameworks http://www.sadc.int/issues/hiv-aids/ http://www.sadc.int/issues/hiv-aids/

2. NSF Strategic Interventions

2.1 HIV prevention

Introduction

Preventing new HIV infections is a major focus of the HIV and AIDS response because over 800,000 people are HIV negative. The primary objective of the prevention programme is to accelerate the reduction of new infections among all populations by giving priority to populations with higher vulnerability to HIV acquisition and transmission based on geographic locations, behaviour, sex, economic status and other factors.

Biomedical advancements as well as an increased understanding of routes of transmission have contributed to evidence-based models and strategies for preventing new infections. The NSF makes high impact combinations of behavioural, biomedical and structural prevention interventions a priority based on their efficacy to accelerate the reduction of new infections among populations with high vulnerability to acquiring or transmitting HIV. Combination prevention packages will be offered using differentiated approaches that are appropriate for each priority and key population at granular levels in response to geographic incidence and other vulnerabilities.

This priority is also premised on the 5 pillars of the global HIV prevention road map. It is also based on the

3 frees framework to ensure that AGYW remain HIV negative. People living with HIV will also be provided with key prevention interventions.

2.1.1 Social and behaviour change (SBC)

Programme objective: To promote delayed sexual debut among young people and reduce risky sexual behaviour among all sexually active individuals whilst concurrently promoting the uptake of HIV services.

Target populations: Young people, and all sexually active individuals targeting adolescents and young people aged 15-24 years, key populations, people with disability and adult men 25 years and older are the focus of social and behavioural change

Key outcome targets

Table 1: SBC outcome results

Indicator Disaggregation Baseline

(Source)

Targets for years

2020 2023

% of young people who answered correctly to all

HIV knowledge questions

ALL aged 10-14 34.6

(MICS, 2014)

52 60

% of young people who both correctly identify ways of preventing sexual transmission of HIV and reject major misconceptions about HIV transmission

ALL 50

(MICS 2014)

69 75

Male 50.9

(MICS 2014)

Female 49.1

(MICS 2014)

69 75

FIVE PILLARS OF HIV PREVENTION

1. Combination prevention for adolescent girls and young women

2. Combination prevention with key populations

3. Voluntary medical male circumcision and sexual and reproductive health services for men and boys

4. Comprehensive condom programmes

5. Rapid introduction of pre-exposure prophylaxis

% of young women aged 15-24 who had sex with a partner who was 10 or more years older in the past

12 months

- 8.74

(SHIMS 2016/17)

5 3

Situational analysis

SBC aims to promote delayed sexual debut among young people, promote positive sexual behaviour and uptake of HIV services. Interventions addressing risky sexual behaviours are provided at national and community levels, targeting young people who are in and out of school, women, men and adolescents and community leaders. Key and most-at-risk populations are reached with tailored interventions. SBC is also implemented as an overarching intervention consolidating all communication for all HIV response interventions and critical enablers.

Despite this, comprehensive HIV knowledge is very low among adolescents and young people. The percentage of females aged 15-24 with comprehensive knowledge declined from 58.2% in 2010 to 53.6% in 2014 while there was a slight increase in the percentage of males with comprehensive HIV knowledge from 49.1% to 50.9% in the same period. Only 34.6% of males aged 10-14 have comprehensive knowledge about HIV. Shiselweni region has the lowest proportion of both females (26.6%) and males (25.3%).

Risky sexual behaviour such as early sexual debut, having multiple and concurrent sexual partners and intergenerational sex exposes young people, especially young women, to HIV infection. The median age at first intercourse is 16 years for girls and 18 years for boys, but 4% young women aged 15-19 had sex before age 15. Trends in intergenerational sex show that 14.1% of young women aged 15-24 years engaged in intergenerational sex in 2014 (MICS) and dropped to 8.74% in 2017 (SHIMS2). The proportion of people who have multiple sexual partners remains higher among men while casual sex, on the other hand, has increased among both sexes as 13.4% and 40.9% of men aged 15-49 have multiple sexual partners and casual sex respectively, while 37.3% of same aged women engage in casual sex30.

During the NSF period, SBC…