Médecins Sans Frontières in Swaziland

MSF’s involvement in HIV Aids projects in the sub-region of Southern Africa is not recent. Mozambique, Malawi, Zimbabwe, South Africa or more recently Lesotho are some of the countries in which our organization has implemented for a number of years programs that aim at reducing mortality due to HIV and AIDS. We have also been more recently focusing on the treatment of tuberculosis (TB), including drug-resistant TB, as the major co-infection of HIV.

Swaziland presents the highest HIV prevalence in the world (26% among the 15 to 49 age group) and one of the highest (it has the highest tuberculosis (TB) case notification rate in the world at 1262/100’000) rates of HIV/TB co-infection 80% - Source WHO). It also has the lowest life expectancy rate at birth (32.5 years according to Swaziland DHS 2007). In spite of other projects conducted in the region, this situation has pushed us to consider launching a rather ambitious project in order to impact on the co-infection (HIV-TB) through a “one stop shop” decentralized approach with significant involvement of non-medical people or lay people. The magnitude of the drug-resistant TB problem has also forced us to rethink our operational strategy on the ground and to focus a lot on community treatment supporters involvement.

This project was initiated mid-2007 and actually started in November 2007 after MSF signed a Memorandum of Understanding with Ministry of Health and Social Welfare. MSF committed to a 3-year project in Shiselweni Region. A team of 21 expatriate volunteers (including 8 medical doctors) as well as 100 Swazi and Zimbabwean staff are currently dispatched in the Shiselweni region of the tiny Kingdom to assist Ministry of Health staff implementing the project.

Swaziland is currently faced with dramatic HIV/AIDS and Tuberculosis (TB) epidemics threatening the existence of present and future generations of Swazi people. 26% of young adults are infected with HIV and will die in the years to come if not treated with ARV treatment. Despite the existing capacity to respond with health care and “impact mitigation”, Swaziland risks to become one of the first examples of countries where this “dual” HIV/AIDS-TB epidemic “overwhelms” the existing capacity and destabilizes its population.

A. The unprecedented levels of HIV and TB prevalence (up to 26% HIV prevalence among adults, highest level of TB case notification in the world) causing extremely high mortality rates and having devastating effects on Swazi society and economy (two-fold drop in life expectancy indicator in the span of one decade).

B. Despite some efforts demonstrated by the authorities and other actors present in providing access to ARV, there is a growing gap between numbers of people put on ARV and the ever faster increasing numbers of people in urgent need of ARV.

C. Swazi authorities expressed a clear interest to benefit from innovative approaches and operational strategies that will be developed in the field by MSF during the course of the project.

D. Acceptance that decentralization and wide community involvement with real task shifting must be the main strategy for “mass treatment” aimed at reducing the gap between people on ARVs and people in urgent need.

E. Opportunity to contribute to one of the first and most advanced test cases for a radical scale up of HIV and TB services requiring far reaching decentralisation of all HIV services as well as of TB diagnosis and treatment down to the level of health clinics and community level, with greater involvement of people living with HIV/AIDS (PLWHAs) and their communities.

F. Potential for continuity of HIV and TB services, because of the reasonable capacity of governmental and non-governmental actors in the country.

MSF’s key objective in Swaziland is to contribute to the reduction of mortality due to HIV and TB in Shiselweni region (208 000 inhabitants). This objective will be achieved through community based expanded access to good quality HIV & TB prevention, care and treatment through large-scale involvement of activists and people living with HIV/AIDS.

7. What are MSF’s specific objectives and strategy to achieve the main objective?

Decentralisation of HIV and TB services from Health Centres to Health Clinics to Communities with the attempt to bring closer to the population possibility for testing, early precision of diagnosis followed as soon as possible with adapted treatment for both HIV/AIDS and TB provided at one single location. This process also includes a rehabilitation of existing of clinics that are currently not sufficiently equipped to provide the fully comprehensive TB-HIV integrated services, including initiation on treatment. MSF is supporting financially this process in Shiselweni region, including the funding of new positions with the objective that the MoH will take over after 3 to 5 years.

In the situation of limited medical qualified human resources the Task Shifting from Medical Doctors to Nurses to Lay Counsellors/ Expert Patients is regarded as one of the most important activities, intended to match already prohibitively high and still ever growing demand in HIV and TB care.

Treating the patient, not the disease; any HIV detected patient has to be screened for TB and vice-versa. That is why we want to contribute to the setting up of “one stop TB/HIV point” integrated into the primary and secondary health care structures.

Wide involvement of the communities (through community leadership, activists, patient support groups and other local initiatives) is of utmost importance in three principal domains:

Prevention – by rising awareness, health education and by increasing availability and growing utilization of VCTs (Voluntary Counselling and Testing) by general public
Case-finding/detection - through increased utilization of VCTs, detection and referral of symptomatic patients (both TB and AIDS)

Case-holding/adherence - through community involvement into improved follow-up and adherence of stabilised patients on ARV and TB patients, while on Continuation Phase (CP) of the treatment (either with first or second line anti-TB drugs)

At the moment, the Swaziland project is entirely funded with private funds raised from the general public in Switzerland and Austria.

In decentralising TB/ HIV services the coverage is increased from 9 clinics in 2008 to 17 clinics in 2009. The number of patients receiving anti-retroviral (ART) consultation and refill at decentralized level has increased from 575 (2008) to more than 1200 (2009). Out of the 17 clinics three (3) clinics are accredited and ready to initiate ART and TB treatment in a routine basis.

In Shiselweni region, we have managed to initiate more than 2400 new patients on ART in 2008 and 2656 new patients were initiated on drug sensitive TB treatment (2008) including 42 on treatment for Drug Resistant TB. However, it must be noted that currently our adherence rates remain very insufficient (75% still on treatment after one year). There are currently (end of June 2009) 7’531 patients on ART in Shiselweni including 504 children.

On TB, during 2008, a total of 2296 patients (1096 male, 1200 female) patients were diagnosed with drug sensitive TB in all three main health facilities of the region and started on treatment. While 35 % (804) of patients were smear positive pulmonary TB, 20.5% (472) of patients were pulmonary TB patients without sputum smear test done. This category of diagnosis is unacceptably high. However, with strong emphasis on sputum smear test in all patients the trend is progressively declining over the year 2008. Smear negative PTB and extra pulmonary TB account to 23.4% (538) and 21.1% (484) of cases respectively.

During the first and second quarter of 2009, in Shiselweni region, a total of 1,087 patients were diagnosed with drug sensitive TB.
84% of TB patients have tested for HIV and there is an increase from the previous year, which was 73%. 82% of these tested HIV positive. Among the one who are HIV positive 32% were on ART at the end of TB treatment. The figure for the previous year is 11.3%. Although there is improvement from the previous year, still large proportions of co-infected patients remain with out ART. Integration of ART care in the TB clinic is hoped to improve the situation and this activity will closely be monitored.

During 2008, 36 new patients were diagnosed with MDR TB in Shiselweni region. By the end of 2008 there were 51 patients receiving treatment for drug resistant TB in the region. As per end of September 2009, MSF was treating 86 patients suffering from drug-resistant TB in Shiselweni region.

MSF has a coordination office based in Mbabane. It also has a field office in Nhlangano where most of the staff is based. From that office, MSF teams operate in the 3 health zones of the region namely Hlatikulu, Matsanjeni and Nhlangano. Our doctors and nurses assist the ART clinics and TB clinics staff in the 3 main health centres (Hlatikulu Hospital, Nhlangano Health Centre and Matsanjeni health Centre) as well as the nursing staff working in the rural clinics. We are also involved in improving the delivery of lab services at the 3 main facilities. MSF teams are currently (since March 2009) working with 17 clinics of the region in the provision of VCT, CD4 samples collection, sputum collection, refill of ARVs and patient support and counselling. Tracing of defaulters on TB treatment and ART is intensive and case detection has started as well.

Questions and Answers about MSF activities in Swaziland