A glimpse at the Swazi response to HIV/AIDS - A speech by Dr. Okello

Swazi girls at reed dance (2006).

Dr. Okello is Swaziland’s National ART Coordinator. She gave an intereting presentation to our staff yesterday morning about the Swazi health care sector's response to HIV/AIDS. My abbreviated notes are attached below. It is a sort of a “State of the Kingdom” speech, but leaving out everything except HIV.

Mind you, that leaves plenty to talk about. I have included some of my own brief comments and clarifications [bracketed, in italics].

Brief bulleted summary of Dr. Okello’s speech:
Overview of HIV history and epidemiology
· In 2006: 25-29yo = 48% prevalence; 30-34yo (45.8%)
· 220,000 people living with HIV/AIDS (PLWA) in Swaziland; 15,000 children
· 17,000 die from AIDS in Swaz annually [per UNAIDS report, 2004 I believe]
· >50% are presenting in WHO clinical stage III or IV.
· Estimated number that need ARVs = 30k [only? not sure about this...]
Overview of NERCHA, the principal recipient for Global Fund monies in Swaziland
· [discussed in previous blog entry]
Swazi health sector response to epidemic: A roadmap and outline developed to define the sector’s technical response. Four priority areas include:
· (1) PMTCT: Goal = to reduce % HIV+ children by 30% by 2008
· (2) Pre-ARV: Goal = to increase preART time period to 7yrs by 2008 by improving access to testing [i.e. testing earlier and following pts for longer b/f they get too ill; this is difficult date to capture given the current state of the national database]
· (3) ART: Goal = to reach and treat 75% of PLWA who need ARVs by 2008.
· (4) TB/HIV: Goal = establish mechanisms for collaboration between programs.
· There are dozens more, but these are the pillars of the health care sector’s response.

Voluntary counseling and testing (VCT)
Number of VCT sites so far: 32
· 3 types: free-standing [only testing], integrated [with ART capabilities] , and mobile
· 10% of people have accessed testing since 2002 [unsure of the denominator - all Swazi adults, maybe?]
Partners in testing: PSI, TASC, BCHA (Business Coalition for HIV/AIDS)
Moving toward provider-initiated testing and counseling, where HCW speaks to pts about testing [previous practice to send patients for testing with little communication as to why]
New HIV testing and counseling guidelines being produced

Swaziland’s prevention of maternal to child transmission (PMTCT) response, in summary:
· PMTCT offered at 72 sites in the country
· In maternal child health (MCH) settings and maternity wards
· Some HAART [3 meds instead of 1-2] for pregnant women in ART clinics [depending on availability and CD4; primarily depends of availability].
· Partnerships ongoing with BAYLOR, EGPAF, UNICEF, COLLEGE, ICAP.
· Goal = to ensure integration of PMTCT and ART services.
· New Swazi PMTCT guidelines are recently out

[At this point in the presentation, the computer screen showed a warning that there was a virus trying to infect the clinic’s computer. Dr. Okello said, “Oh, sorry. The ministry of health memory sticks are often infected.” After realizing the irony in her remark, she said, “Yes, we have a very high prevalence.” We all had a laugh, albeit a somewhat nervous one.]

She continued:
To spread word about VCT and PMTCT, Swaziland has 4000 rural health motivators (RHMs), with training offered for >500 of these thus far
Training also offered to other community lay people called “Family Carers” (>700 were in place by end of 2006)

ART response, to date:
· MOH-sponsored ART launched in Dec 2003 at Mbabane Govt Hospital (MGH), w/ only 600 PLWA’s initially on ART.
· Effort was in partnership with public/private sector (company clinics, NGOs, private MDs)
· Currently 28 sites offering ART (6 hosp, 5 HCs, 1 PHU, 9 private clinics, 7 outreach/rural sites)
· Number of people on ART=17,500 and # started (at any time since 2003) = 22,500 [It is unknown what happened to those lost to f/u. Most probably either died or stopped taking ARVs.]
· 56% females, 8% on ART are children. [Too few.]
ART challenges:
· Increasing demand for ART (special challenge among Swazi males, who are hard to reach)
· Limited integration of ART services with general medical care
· Inadequate staff trained
· Limited availability of pediatric formulations
· Poor monitoring and f/u at the health center, esp at the community level
· Inconsistent availability of drugs for OI management in most facilities (even cotrim/bactrim is not offered free of charge at govt clinics)
Ongoing developments:
· Planning on early infant dx in cooperation with the Clinton Foundation.
· Finger stick blood samples for rapid tests in development; ongoing discussion with reference lab. Policy on this pending.

The end. Applause.

Question #1: How is govt monitoring/reinforcing adherence?
· Monthly visits required, with fixed appt date.
· Building HCW trust, changing paternalistic/demeaning attitude, which is all-too-often part of medical culture here.
· Pts encouraged to indicate any adherence problems in their govt-issued logbook.
· Pill counting also done in most clinics to measure missed/excess doses at each visit.
Question #2: Are PMTCT guidelines printed and avail in all clinics and maternity units?
· They are out and recommend dual therapy.
· Mother who are not willing to return can get NVP alone, w/o AZT
Question #3: Are there hemoglobin lab capacity in those clinics giving AZT? [There is a concern of worsening anemia with this med.]
· Such capacity is being rolled out as available.
Question #4: What is being done to strengthen system and avoid loss to f/u (LTF)?
· Recognizing Swaziland’s high rate of LTF (>30% in some govt clinics), we are moving toward provider-based ART care. LTF improving since this approach implemented, and rural clinics can do quite well as are more decentralized and “closer to the people.”
Question #5: What is actually being done to improve male involvement?
· “We have few strategies, and (…) are still tying to work it out.”
· One solution is to support private clinics, where males often seek their care [Swazi males often avoid public clinics because they are more sensitive about stigma, and are often the breadwinners.]

I welcome your comments.