Eswatini achieves the 95-95-95 HIV treatment target - a decade ahead of 2030 goal

The Kingdom of Eswatini has made major strides in the HIV response with the goal of ending AIDS as a public health threat by 2030. Eswatini, being the first African country to achieve and surpass the 95-95-95 global HIV treatment targets in 2020, has 94% of adults (15 years and older) living with HIV aware of their status, 97% of those who are aware of their status are on antiretroviral therapy (ART), and 96% of those on ART have achieved viral suppression. The number of new HIV infections shows a steady decline over the years from 14,000 in 2010, to 4,800 in 2020 and is projected to further decline to 4,300 in 2023. HIV-related deaths have also been on the decline from a peak of about 10,000 deaths in 2005 to 2,600 in 2021 and 2,370 in 2022 (2021 UNAIDs report). The Mother-to-child transmission of HIV has also dropped from 6.3% in 2017 to 1.2% in 2022.

The strong leadership at both the political and Ministry of Health (MoH) level coupled with World Health Organization Eswatini's (WHO) presence, has resulted in a well-coordinated response that also complements the support from partners’ evidence-based, patient-centered care at scale. In Eswatini, WHO recommendations are the primary documents that inform the implementation of health programs, including revision of National strategic plans and treatment guidelines to suit the Eswatini epidemic status. Over the years, Eswatini has been an early adopter of the WHO HIV treatment recommendations including, policy briefs, guidelines, and tools. This character trait is what has made the kingdom achieve the 95-95-95 treatment targets ahead of time leading to a decline in HIV new infections and HIV-related deaths.

WHO provided technical leadership and assistance to the Ministry of Health in policy dialogues, development, implementation, and review of the National HIV investment case, strategic plans, and guidelines. These documents created an enabling environment for the MOH and stakeholders including civil society groups to have a shared vision, harmonizing the national response implementation and resource mobilization efforts from Government and Donors.

Among the key milestones that WHO supported in the Eswatini HIV response is the establishment of the antiretroviral therapy (ART) program in 2003 to improve access to treatment and care services. The launch of the 3 by 5 initiative by WHO and UNAIDS was also conducted in the same year. The WHO policy guidance was key in mobilizing resources for the procurement of antiretrovirals (ARVs) and in guiding the clinical delivery of ART services in Eswatini. As a member of the HIV Treatment Technical working group, WHO has been readily available to the MOH and partners to provide technical guidance on treatment optimization initiatives. This led to the National HIV treatment guidelines changing as per WHO recommendations to more tolerable fixed-dose combinations that are given once a day with fewer side effects. As per WHO recommendations, the country phased out the use of stavudine d4T and introduced the fixed-dose combination with tenofovir disoproxil fumarate plus lamivudine (TDF/3TC) and Efavirenz (EFV). In 2016, Eswatini adopted the WHO treat-all policy. The policy was successfully implemented at scale translating the knowledge gained from the operational studies that were implemented in the country prior to WHO recommendations. These included the MaxART Early Access to ART for All (EAAA) study that was implemented by the MOH with support from partners and WHO. As more patients were being initiated, Eswatini scaled up differentiated ART services and provided different models of ART service delivery including fast track, community refills, and multi-month scripting. Currently, stable clients in Eswatini can receive up to 6 months’ supply of ART refills and clinical appointments.

As per WHO recommendations, task shifting of HIV testing services from nurses to lay counselors, adherence support to peer-peer, and introduction of Nurse-led ART initiation was introduced in Eswatini. This allowed for the rapid decentralization of ART initiation and follow-up care and improved treatment coverage. WHO also provided technical assistance to allow for the decentralization of laboratory services including Point-of-Care CD4 testing, DNA PCR testing, and viral load testing. In 2016, WHO technically led the assessment of the viral load testing capacity and provided recommendations for scale up which were adopted by MoH. One key recommendation from the assessment was to build the capacity of the National Laboratory including human resources, the supply chain system, and decentralization of viral load testing from the national referral laboratory to regional laboratories. The country adopted and implemented these recommendations with support from PEPFAR and Global Fund leading to wider access to viral load monitoring and adherence support. As of today, all four regions of Eswatini have laboratories that can conduct viral load testing. The decentralized testing improved viral load testing coverage and turnaround time for results to support clinical management.

In 2016, as part of local evidence generation to inform National Policy, PEPFAR and WHO supported the MOH to plan and conduct a HIV drug resistance survey as guided by the WHO global protocol. WHO provided technical assistance in the local adaptation of the HIV drug resistance (HIV DR) protocol, and in the analysis of the results. The survey findings were disseminated in 2018 and showed that in Eswatini, the HIV pre-treatment resistance among new ART initiators was 10.3% to non-nucleoside reverse transcriptase inhibitors (NNRTI). WHO recommends that countries with NNRTI resistance over 10% should urgently consider changing their first-line backbone to Dolutegravir. Following the survey results, WHO provided technical assistance to drive the change of the policy towards the introduction of the more potent and more tolerable Dolutegravir-based regimen in Eswatini. This policy is what really moved the country to the viral suppression rates observed today (of greater 95 % ) leading to the reduction in HIV deaths and new infections

As a country, Eswatini through MOH and health partners, will continue to push for policies and adopt evidence-based recommendations provided by WHO that will further complement the achievements that have been made thus far. The country plans to achieve 95-95-95 in all population groups and sustain the gains by building a resilient health system that is patient-centered.