With 26 percent of the adult population infected with HIV, Swaziland has the world’s highest HIV prevalence. The country is also faced with a tuberculosis (TB) epidemic. TB is the leading cause of death among people living with HIV, and is becoming more difficult to treat following the emergence of drug resistant forms of the disease. In Swaziland more than 80 percent of people infected with TB are living with HIV.

Since 2008, Médecins Sans Frontières (MSF) has been supporting the Ministry of Health of Swaziland to respond to the HIV/TB dual epidemic through the decentralisation of integrated HIV/TB care in Shiselweni region, an area with the most difficult access to health care services. Five years on, all 22 local clinics in Shiselweni offer integrated care and treatment to more than 17,000 HIV positive patients and more than 10,500 TB patients have been treated.

This year, MSF took the opportunity to retrospectively analyse the outcomes of the project A report on the outcomes of the project entitled, “Making a difference: Decentralisation of HIV/TB Care in Shiselweni Region of Swaziland,” was recently launched, outlining the evolution of the project between 2008 and 2013.

We review the project outcomes with Elias Pavlopoulos, the outgoing Head of Mission for MSF in Swaziland.

Can you explain what ‘decentralisation of integrated HIV and TB care’ exactly means, and why has this been important as a focus of the project?

It means being close to people’s homes, bringing care to where the patients live. We brought care from the hospitals, directly to the primary health care clinics. The best way to do this in a resource-limited setting like Swaziland was to start with task-shifting. This means that duties –mainly those of nurses– are distributed to lay counsellors and expert patients (people living with HIV/AIDS and TB), therefore freeing up nurses for other tasks. Overall, it has improved the acceptance of medical services among the affected population and also decreased stigma, a crucial barrier to accessing care. We found it improved both the self-esteem of affected people and their acceptance by the community.

Decentralisation and task-shifting also need to be combined with proper infection-control measures in the clinics, and laboratory services need to be closer to the patients to monitor their health properly.

Why is the project so innovative?

We have the viral load machine which is now more affordable. The viral load shows the number of copies of the HIV virus present in the blood and it is a crucial tool to see how a patient is responding to ART or if there is a resistance to first-line drugs. The CD4 count1 machines are now portable and can be set up almost anywhere, making what we call “the point-of-care” easy. This point-of-care can then be set up in rural or remote settings, directly reaching the patients who need to access all the care they need in the same spot.

Add the laboratory services to the point-of-care, portable and affordable machines and you have the possibility to reach out to a lot more people and follow them rigorously. We have a real arsenal with which to fight HIV and TB.

The emergence of new tools to fight HIV represented a good opportunity for the international community to tackle the fight at the next level – to start thinking about “curbing the epidemic” as we like to say. We are in a more mature phase of dealing with the epidemic. It is now in the hands of states and other actors to seize the moment and use these tools effectively.

Did you expect these outcomes?

As MSF, we did not know what to expect when we first arrived in Shiselweni in 2007 because the epidemic was so big. The only idea at this time was to work. No one could envision that in five years we would have 80 percent coverage of ART, simply because we did not know how far the collaboration with the Ministry of Health would go, or the results it would give. The collaboration with the Ministry of Health and the scale up by MSF greatly contributed to the good results that we have today in Shiselweni.

By the end of 2013, we had 83 percent of people in need of ART already on treatment in Shiselweni. In real figures, this equates to approximately 18 000 people. This is defined as universal coverage, according to the World Health Organization (WHO). There has also been a reduction of TB cases. Shiselweni was one of the regions most heavily affected by HIV/TB co-infection. Increasing coverage of HIV care led to a sharp reduction in new TB cases each year. When I arrived in Swaziland in 2011 we were seeing around 2,000 new TB infections per year. Now we are at 700 new cases per year in Shiselweni. This is a massive improvement.

Another achievement is the fact that patients are adhering to their treatment. People are alive and remain on treatment for a long time after starting their treatment course. Some 88 percent of people are still on treatment after six months and 82 percent after 12 months. The number of people retained in care continues to grow every day. There has also been a reduction in other opportunistic infections over the five years.

Is Swaziland out of the woods, is the country curbing the epidemic?

No, not at all, HIV/AIDS is not over yet. We have succeeded in reducing the effects of the epidemic but we still have a long road ahead to have fewer new infections. In 2008 there were 2.7% new infections in Swaziland. This has been reduced to 2.1 percent. This is still high, and we still have a lot of new infections each year. This is the next thing we need to control.

What still needs to be done?

The first thing was to ensure the scale up of access to ART, which we achieved in the first five years of the project. Now, we have to ensure that we move towards curbing the epidemic through the use of treatment and prevention approaches. But we still have a long way to go. In 2012, we introduced treatment as prevention through Prevention of Mother-to-Child Transmission - option B+. This means that as soon as a mother is HIV-positive, she starts her ART. We look forward to introducing early access to ART for children and all HIV positive adults in this phase of the project. These “treatment as prevention” strategies have the potential to accelerate the gains achieved and thus begin to turn back the HIV and TB epidemics that have cost tens of thousands of lives in Swaziland.

We have also demonstrated that the psycho-social support to patients can be replicated in other parts of the country. The Ministry of Health of Swaziland considers the work done in Shiselweni as an example of quality of care and could envisage that some elements of the programme are replicated elsewhere.