CONGRATULATIONS ESWATINI FOR COP23 APPROVAL

Key priorities based on the current stage of the HIV epidemic for COP23 are: high-impact combination prevention interventions for Adolescent Girls and Young Women (AGYW); scale-up of PrEP for key populations; pivots in the HIV testing strategy for children, AGYW, men aged 25 – 34, military and key populations; and client-centered services to close early antiretroviral (ART) initiation and treatment continuity gaps among men aged 25 – 34 years.

More specifically, COP23 will build on COP22 to tailor case-finding strategies to close testing gaps among adolescent girls and young women (15 – 24 years), men aged 25 – 34 years, female sex workers (FSW) and men who have sex with men (MSM), military and children.  These strategies will include using HIV self-tests (HIVST) as a screening tool, index testing and universal testing at selected entry points for the population groups with case-finding gaps. To close treatment gaps, particularly among men aged 25 – 34 years and military populations, COP23 seeks to institutionalize client-centered approaches to support adherence and prevent attrition as well as to bring clients who interrupted treatment back to care to maintain treatment continuity and viral suppression.

New interventions include pre-treatment viral load testing as part of the undetectable equals untransmittable (U=U) strategy, maximizing the use of digital health platforms and integrating HIV services with non-communicable disease (NCD) and male wellness services, as well as the use of strategic marketing and peer-to-peer approaches to reach wealthier men aged 30 and above.

Although Eswatini has the world’s highest HIV prevalence rate, with 24.9% of adults living with HIV, the Government of the Kingdom of Eswatini (GKoE), with PEPFAR, Global Fund and other donor support, has made striking progress in controlling the HIV/AIDS epidemic.  The recently completed 2021 Eswatini Population-based HIV Impact Assessment survey, locally known as “SHIMS3”, demonstrated sustained progress towards the ambitious UNAIDS 95-95-95 targets well before the global 2025 benchmark. SHIMS3 revealed that Eswatini is at 94-97-96 for adults 15 years and above. This is compared to the SHIMS2 (2016-2017) results of 87-89-91, reflecting laudable progress despite the threats presented by the COVID-19 pandemic and other overlapping crises.

SHIMS3 revealed that the 95-95-95 targets have been achieved for women, despite disproportionately holding the burden of the disease. The rate of new HIV infections has also dropped by nearly half in the past 5 years. Yet gaps remain among subpopulations. About 25% of men aged 25-34 who are living with HIV do not know their status and this increases to 34% for men having sex with men (MSM); approximately 4,000 individuals 15 years and older, mainly young women, continue to be infected with HIV annually, at a rate nearly seven times that of men; and 11% of children under 5 years are not virally suppressed. The 2021 Eswatini Violence Against Children Survey (VACS) demonstrates that gender-based violence continues to play a role, with 8% of women aged 13-24 reporting having experienced sexual violence at least once in their lifetime.

Alignment of PEPFAR Strategy and Government Strategic Objectives

PEPFAR Eswatini has engaged the government of the Kingdom of Eswatini in the planning process such that the PEPFAR strategy aligns with the government strategies as outlined in the National Strategic Framework. In COP 23 the focus will be prioritizing certain populations as means of addressing the remaining gaps to ending HIV as a public health threat. Through transformative partnerships with the private sector and other development partners, the HIV response will be transformed from being an emergency to a sustained response in line with Pillars 2 and 4 of the PEPFAR strategy. COP23 will see an increased role for the community in the HIV response through engagement of traditional leadership and community-based structures.

Health Equity for Priority Populations             

Adolescent Girls and Young Women (AGYW)

Eswatini has made significant progress in reducing new HIV infections; however, incidence among AGYW remains nearly seven times that of men, indicating the continued need for high-impact HIV prevention interventions for AGYW. Given that Eswatini is approaching epidemic control, COP23 presents an opportunity to make strategic shifts in AGYW programming.

PEPFAR/E will continue to strengthen provision of sustainable clinical services through health facilities, DREAMS on Wheels (DoW) mobile outreach services, and facility-based youth friendly corners.  PEPFAR/E will also support the Ministry of Health to increase the number of facilities that fulfill national standards for Adolescent Youth Friendly Health Services (AYFHS). Further, PEPFAR/E will work with the Eswatini government to explore the introduction of waivers for the most vulnerable AGYW to address the challenge of user fees that impact the uptake of clinical services. PEPFAR/E will implement a novel model for sustainable Adolescent and Young People (AYP) services in 5 non-DREAMS sites by leveraging existing non-PEPFAR HIV prevention services. PEPFAR/E will also work with the Ministry of Education and Training (MoET) to institutionalize in-school evidence-based prevention and norms change programming for AGYW and ABYM, as well as provide technical assistance to the Deputy Prime Minister's Office (DPMO) to strengthen the coordination of the national GBV response.

Adolescent Boys and Young Men (ABYM)

PEPFAR/E will also strategically target Adolescent Boy and Young Men (ABYM) to better control increase in infections among AGYW building on the existing programs that AGYW and Peace Corps have. ABYM and the sexual partners of AGYW will receive a package of care designed primarily to reduce HIV transmission to AGYW by intentionally strengthening engagement with partners of AGYW. ABYM will be reached through intensified index case testing and those who are already aware of their status will be encouraged to uptake ART and adherence to improve VLS. PEPFAR/E will develop a package for ABYM to address GBV as harmful social norms as GBV is a driver of HIV infection amongst AGYW. Since 2014, Peace Corps (PC) Eswatini has been engaging Adolescent Boys and Young Men (ABYM) (ages 9-24) in HIV/AIDS prevention programming through its Boys Reaching Out (BRO) clubs. The BRO programming was re-designed in 2021 to complement the goals and objectives of the AGYW DREAMS program and ensure that ABYMs receive equitable services and information as a supplement to the DREAMS services provided to AGYW.

Prevention of Mother-to-Child transmission of HIV (PMTCT)

Figure 3.3a FY22 PMTCT Cascade

In FY22, the Eswatini PMTCT program continued to demonstrate high performance in the key PMTCT indicators, as shown in Figure 3.3a, by the high levels of awareness of the HIV status at the first antenatal care visit (ANC1), high ART coverage among pregnant women living with HIV, high proxy early infant diagnosis (EID) coverage and low mother-to-child transmission (MTCT) rates.

Despite the successes highlighted above, the program needs to address the remaining gaps which include but not limited to high seroconversion rates among pregnant and breastfeeding women and suboptimal pre-exposure prophylaxis (PrEP) coverage. To address these gaps, PEPFAR/ESWATINI will implement the following activities in COP23: cohort tracking of mother-baby pairs utilizing the mother-baby pair linking functionality in CMIS and ensuring longitudinal follow up; expansion of standardized HEI cohort tracking from birth through to adolescence by ensuring linkages with the existing platforms such as the OVC and the Community Mentor Mothers; supplementing testing by following non-traditional testing schedules of Mother/Child pairs; utilizing the one-stop-shop model for the provision of HIV/FP services at facility and community levels; scale up PrEP coverage among PBFW through universal offer and the opt-out approach; and expansion of coverage of near or point-of-care testing for VL using the existing GeneXpert platforms.

Key Populations

PEPFAR/Eswatini supports equitable KP programming targeting harmful social norms, policy and legal barriers, weak health and community systems to facilitate the provision of comprehensive and client centered diagnostic, prevention, and treatment services for key populations prioritizing FSW, MSM, TG, PWID, people in prisons, MWPS and children of KP. Diagnostic services include HIV and recency testing. Combination prevention biomedical services include pre-exposure prophylaxis (PrEP), post exposure prophylaxis (PEP), condoms and lubricants, sexual and reproductive health services such as STI screening and treatment, and family planning. Behavioral combination prevention services include information provision for creating demand for HIV services including increasing the use of condom and lubricant, GBV prevention and response, including psychosocial mental health support.

Structural combination prevention interventions include access to justice, stigma and discrimination reduction, advocacy for an enabling policy and legal framework, social protection, and economic strengthening. The treatment package of HIV services includes linkage to and provision of antiretroviral treatment, and adherence and psychosocial support for viral suppression. The PEPFAR/E program will continue to support KP-specific mobile and community drop-in centers, and service delivery platforms in designated hotspots to address challenges in access as well as to support mainstream health facilities in providing KP competent services.