Towards an HIV-free new generation
Von Bruno Gremion & Sybille N’Zebo
While socio-economic indicators have remained largely above the sub-Saharan countries average (for example literacy rate at 82%), Swaziland hit the international headlines for being the country the most affected by the HIV/AIDS pandemics. At the turn of the millennium, life expectancy became the lowest in the world, dropping from 61 year to 32 year as a result of the very high AIDS-related mortality. Since then, enormous efforts have been undertaken by the country with the support of the international community in the fight against HIV/AIDS.
Often called the "Switzerland of Southern Africa", the Kingdom of Swaziland is a tiny mountainous and landlocked country with a population of 1.3 million inhabitants. Although rapidly changing, the country remains strongly influenced by the traditional monarchic power structure and a deep Christian faith. The Swazi society is essentially rural (77% of the population) and can be qualified as rather conservative and male-dominated.
The current National Multisectorial Strategic Framework for HIV and AIDS 2009 – 2014, provides a strong framework for HIV prevention and treatment countrywide. Public investment in the health sector has been steadily growing and the government has more than doubled its allocation for the Ministry of Health (MoH) between 2007 and 2012. As a result, the coverage for HIV/AIDS prevention and treatment has steadily increased, with over 100 health facilities providing free HIV/AIDS related services, including provider initiated HIV testing and counselling (HTC), prevention of mother to child transmission (PMTCT), as well as antiretroviral therapy (ART) for AIDS patients. Thanks to the high ART coverage, the negative trend could be reversed in the recent years, with a reduction of mortality and increase of life-expectancy, which is now estimated at 49 years. The rapid increase of tuberculosis (TB) became a major source of concern in the past few years. About 80% of TB patients are co-infected with HIV/AIDS, and TB is responsible for about 50% of mortality amongst AIDS patients. In 2012, 70 health facilities are providing TB treatment, a sharp increase from 17 in 2009.
On the prevention side, efforts have brought mixed results. While PMTCT is well performing, it has been much harder to reach behavioural changes through promotion of abstinence, being faithful to the partner, delaying of sexual debut, reduction of number of sexual partners and consistent condom use. The prevailing traditional social, cultural and political environment does not favour a rapid behavioural change towards safer-sex practices. While stigmatisation towards people living with HIV/AIDS (PLWHA) has decreased, very conservative and judgemental positions in the society have certainly undermined prevention campaigns amongst high-risk groups, youth in particular. Condom promotion is still a taboo in schools, with the resulting risk of infection and a high rate of teenage pregnancies.
By 2013, the HIV incidence is still very high (2.6% yearly), while the prevalence remains the highest in the world with 26% of the adult population living with HIV (peak of 45% in the 30-34 age group).
The Swiss Red Cross (SRC) supported "HIV Integrated programme" in a nutshell
Since 2003, SRC has been partnering with the Baphalali Swaziland Red Cross Society (BSRCS), initially through supporting ART in BRSCS’ primary health clinics and prevention activities with youth. Soon activities were broadened to a comprehensive HIV programme, including the following three pillars: prevention (HTC, PMTCT, community outreaches, youth peer education programme), treatment and care (ART for HIV-infected patients, TB treatment, home based care programme), as well as impact mitigation (food security and nutritional support, support to orphans and vulnerable children, stigma reduction).
While the youth programme has a national coverage, the other activities are centred on the catchment area of two clinics run by the Swazi Red Cross: Mahwalala located in a periurban area of the capital city Mbabane and Sigombeni located in a rural area. The Red Cross clinics provide affordable primary health care services, includes treatment of common diseases at outpatient level, antenatal care (ANC), family planning (FP), child welfare (CW), health education, community outreaches, as well as comprehensive services related to HIV/AIDS: HTC, PMTCT, treatment of opportunistic infections (OIs) including tuberculosis (TB).
Successes and challenges
Over the years, the Red Cross clinics have acquired an excellent reputation amongst patients and authorities. Sigombeni clinics pioneered in the provision of ART in a rural environment, and the two clinics currently provide ART to over 1'800 AIDS patients (out of 83'000 countrywide). AIDS related morbidity and mortality dropped drastically over the past few years thanks to the free access to ART, although the recrudescence of TB is putting these recent progresses at risk.
The Red Cross clinics do follow the national protocols, and receive free supply of ARV, TB drugs and laboratory tests from the MoH. In 2013, the government has started subsidizing part of the salary costs for nurses, and it is expected that the clinics will soon be able to sustain themselves financially without the support of SRC. However, important institutional challenges still need to be addressed in order to maintain the quality standards and reduce the high staffs turnover, in a context where the number of nurses is critically insufficient countrywide.
Home based care (HBC) is provided in the catchment area of the clinics by a network of 100 Red Cross care facilitators, who are in the process of being integrated into the government network of community health motivators. More than 200 orphans and vulnerable children (OVC) receive material (payment of school fees and uniforms, food parcels to the most needy) and psycho-social support from the programme, while the establishment of backyard gardens aims at improving the nutritional status of the beneficiaries.
The youth programme is contributing to awareness raising, behaviour change and stigma reduction through a combination of drama play, class sessions and peer to peer education provided by Red Cross volunteers. The true impact of the youth programme remains however difficult to measure, and is confronted to the huge challenge of promoting behaviour change in such traditional environment. The decrease of 4% between 2010 and 2012 in the HIV prevalence rate (42% to 38%) amongst pregnant women attending ANC at the two clinics seems to indicate a moderate downward prevalence trend amongst young adults
Prevention of Mother to Child Transmission (PMTCT)
In Swaziland, virtually all HIV infections in children are due to mother-to-child transmission, which can occur either during pregnancy, labour and delivery, as well as during breastfeeding. The risk of HIV transmission from a positive mother to the baby is estimated at 30-45%. As the current HIV prevalence amongst Swazi pregnant women is 41%, approximately 12-18% of all new-born would contract HIV within their first two years of life without PMTCT intervention. Therefore, in terms of prevention, the PMTCT component of the programme is certainly the most successful intervention.
When PMTCT services were established in Swaziland in 2003, estimated 5’400 infants contracted HIV from their mother each year. By 2009, this number was reduced to 2'300, and the national objective is to eliminate the mother to child transmission by the year 2015 with a residual number of 250 cases per year (corresponding to 5% of infected infants born from HIV positive mothers).The Guidelines for Prevention of Mother to Child Transmission of HIV provide the national framework for the implementation of PMTCT through a four pronged approach:
1. Primary prevention of HIV infection among women of child bearing ag
2. Prevention of unintended pregnancies among HIV positive women
3. Prevention of MTCT from HIV positive women to their babies during pregnancy, labour and breastfeeding periods
4. Care, support and treatment for HIV positive women and their families.
While progresses have been rather slow for prong 1, 2 and 4, spectacular results have been obtained in preventing the transmission from HIV infected pregnant women, through the provision of effective ARV prophylaxis given to both the woman and the infant according to the following algorithm:
The Red Cross contribution
In the two clinics supported by the SRC programme, 350 pregnant women are attending ANC services each year. Virtually all of them (99.6%) have accepted to be tested for HIV/AIDS, and the prevalence rate is 38%.
Depending on whether the woman is eligible for ART (respectively is already on ART), specific prophylaxis is provided to the HIV positive women following the national protocols (see chart above). In 2011, 98% of the exposed babies tested negative at the age of 6 weeks, while in 2012 the perfect score of 100% was achieved.
However, the excellent results obtained at the age of 6 weeks must be tempered by the difficulty met by the programme to follow-up the babies until they are weaned from breastfeeding. The clinic still needs to improve patient follow-up, through an increased networking with the community health motivators and efficient tracing by the follow-up assistants.
Another challenge is to regularly and systematically test all HIV negative pregnant women during each ANC visit in order to detect possible sero-conversions during pregnancy. Such repeated testing is vital, as newly infected persons do present a particular high viral load with an increased risk of infecting the foetus. This unfortunately occurred once in 2012, when a baby considered non-exposed did test positive at the age of 6-week. A lifelong treatment awaits him, unless future medical progresses will a day allow a complete healing.
Looking back in the mirror, tremendous progresses have been achieved over the past decade. Once considered an inaccessible dream for the developing world, PMTCT has now become accessible to virtually all pregnant women in Swaziland.
Towards an HIV free generation: a vision under threat…
Once considered a utopia, the constant improvement of PMTCT services over the past 10 years has greatly contributed to approaching the vision of creating an HIV-free generation, and consolidating this success will remain within the future priorities. But dark threatening clouds are still obscuring the horizon…
The current prevention programmes targeting the youth are largely reflecting the local conservative environment, sometimes reinforced by the same conservative orientation of a few powerful donors. The inclusion of sexual and reproductive health (SRH) within the school curriculum is still in its infancy, and school-based peer education programmes do mainly focus on delaying sexual debut and preaching abstinence rather than informing and educating on safer sexual practices, in particular condom use.
As a result of the relative failure of the current prevention campaigns amongst youth, the teenage pregnancy rate remains extremely high (one out of four girls will have their first child in their teens), which is not surprising considering than only 43% of the sexually active young women have reported using a condom during their first sexual intercourse.
A lot of these early pregnancies are due to intergenerational sex, in particular through the widespread phenomenon of sugar daddies, usually elder males providing material support to young girls in exchange of sexual favours. Exposing this young generation to another age group with high prevalence provides an open door for a rapid transmission of HIV, first to the young women and then to their male peers, considering the high number of sexual partners and relatively low level of condom use. While the HIV prevalence is "only" 1.9% amongst boys aged 15-19 year old, it reaches 10.1% for girls in the same age group!
The main challenge for the coming 10-20 years will be to retain PMTCT successes and provide an appropriate combination of school-based sexual education, provision of youth-friendly SRH services and promotion of safer sex practices. With the involvement of all stakeholders, including the government, traditional leaders, development agencies and, last but not least the youth themselves, the next utopia will be to concretise this new vision to keep the new generation HIV-free!
*Sybille N'Zebo is the Swiss Red Cross Health Advisor in Swaziland and Bruno Gremion the Swiss Red Cross Country Representative in Swaziland.
Bonsiwe is a 26 year old Swazi woman living in the outskirt of Mbabane. Mother of a nine year old daughter to whom she gave birth while she was still a schoolgirl, Bonsiwe married her current partner in June 2011. A year later, she got pregnant for the second time and attended antenatal care (ANC) at the nearby Mahwalala clinic run by Baphalali Swaziland Red Cross.
During her first ANC visit in October 2012, Bonsiwe, who was unaware of her HIV status, accepted to test. She first became deeply chocked and cried a lot when she learned that she was HIV positive. Silungile, the nurse who attended Bonsiwe, provided her with the best possible counselling. Understanding that she had a chance to give birth to an HIV negative baby, Bonsiwe decided to fight and became stronger and stronger despite the bad news.
Due to her relatively high CD4 count and good health status, Bonsiwe was not eligible for ART initiation, but received instead the standard prophylaxis composed by AZT intake during pregnancy, intrapartum ARV combination during labour, followed by a tail treatment for 7 days post delivery.
Between October 2012 and March 2013, Bonsiwe attended a total of 4 ANC visits, during which she was not only monitored for her health status, but also further counselled and informed about the upcoming treatment and procedures, as well as the importance to adhere to exclusive breastfeeding would she elect to breastfeed. A strong relation established between Bonsiwe and her nurse Silungile who followed her throughout her pregnancy.
After her second ANC visit, Bonsiwe disclosed her HIV status to her husband. While he demonstrated a supportive attitude, he has so far refused to test. Bonsiwe is urging him to get tested, either on his own or during a couple counselling session.
On 17 March, Bonsiwe gave birth at Mbabane Hospital to Sokaya, a strong boy proudly weighting 3.5kg, who also has to recieve nevirapine (NVP) prophylaxis. As she has decided to breastfeed her child, she will need to continue administering Sokaya with the NVP prophylaxis until after stopping breastfeeding.
On 3rd May, Bonsiwe returned to the clinic for the Child Welfare consultation, during which a blood sample was taken from Sokaya and send to the laboratory for the crucial 6-week HIV testing. As soon as the clinic received the results from the laboratory, Silungile called the mother to inform her that her child was negative. What a joy for Bonsiwe, who can now envision a bright future for her two children, the elder daughter being also negative. Her gratitude towards Silungile who took such good care of her is without limit.
But the fight is not over, as she needs to consistently give Sokaya his NVP prophylaxis until she stops breastfeeding. For herself, the fight is only starting, as she knows that sooner or later, she will have to start a lifelong ARV treatment, a condition sine qua non in order to see her two children growing up.