Q&A: How Swaziland got on track to contain the world's highest HIV prevalence

PARIS — Dr. Velephi Okello arrived at last week's International AIDS Society Conference on HIV Science with big news. The deputy director of health services at Swaziland's ministry of health was presenting the findings from a new survey showing that the country — which has the highest adult HIV prevalence in the world — is on track toward epidemic control.

Swaziland has nearly halved the number of new HIV infections among adults since 2011, an achievement largely made possible by rapidly scaling up the number of people accessing antiretroviral therapy, or ART. The latest Swaziland HIV Incidence Measurement Survey, or SHIMS 2, funded by the United States President's Emergency Plan for AIDS Relief showed more than 80 percent of adult HIV patients are now taking the drugs and 73.1 percent are virally suppressed.

Research has established that increasing the number of people who are virally suppressed — which means that while the virus remains in the body, it is virtually impossible to detect — is critical to reducing HIV transmission. Virally suppressed patients are unlikely to pass the infection.

At 28.8 percent, Swaziland still has the highest adult HIV prevalence in the world. But experts said the recent gains signal the country will reach the point at which new HIV infections fall below the number of deaths of HIV-infected people. Okello spoke to Devex about the significance of the recent findings and how Swaziland achieved them. Our conversation has been edited for length and clarity.

What were the most critical components of how you achieved these results?

Swaziland has always had that severe HIV epidemic, and we took time to act on it. We didn't know much about incidence then [the rate of new diagnosis]. But we could just see that prevalence was a problem [how widespread the disease was]. I think we initially acted on the prevalence. We can't have more people living with HIV.

When we reached around 2010, we saw the curve of prevalence starting to stabilize. We started feeling we needed incidence measurements now to compare. Bringing down prevalence will take a lot of time, because there's a huge pool of people who are HIV-positive in the country.

SHIMS 1 came as an incidence study in 2011, and it helped us also convince our politicians. Our politicians were saying, "You're wrong. These are figures that are cooked. You people just want money from donors." We said, "No, incidence is still the highest in the world."

How did they respond once you had the data to present?

We were able to scale up ART, because we asked them to ring fence the money. We were going through financial hurdles, with cash flow problems. But we were able to convince politicians to ring fence the money for drugs. Everything else, all the partners helping us, they are helping us because we committed to buying the drugs. So let's not drop that commitment.

Right now we are at around 200,000 people on ART. We're spending way beyond 400 million [South African] rands ($30.65 million), only on drugs. We're not talking about other things around it, like reagents [the mixture added to a sample of a person's blood to conduct a rapid HIV test]. We've requested that donors and partners assist us with the other things, such as reagents, trainings. But the staff is government, fully.

More prevention, like condom use, continues to be scaled up. But for me, what has made the major impact is the evidence that if you put as many people as possible on treatment within your population, you will see a reduction in the rate of new infections. I think for us, that is proof. And also it validates the amount of money we are spending. In proportion to the total health budget, this is around a third, only for antiretrovirals. There are still other drugs and salaries [to pay].

What are the next steps in your response?

The people who are missed [in accessing treatment] will be hiding somewhere because of stigma. These are key populations — men having sex with men, commercial sex workers. We've established a program already that brings these people out, [for example if] it means meeting them at night. It's a sensitive area. In the rest of Africa, men having sex with men [aren't recognized]. Commercial sex workers are there. We're trying to have those sensitive programs to make sure they get tested, they get treatment. They're not marginalized in the health facilities.

Is the government also paying for this?

Partially the government, but a lot of donors as well. PEPFAR is assisting to scale up. The program for key populations has always been there, but it's only now, with PEPFAR assistance, that we're coming out to say, “who are the other key populations?” The prisoners. The young girls. Identifying those specific groups that we think are hiding or are unable to access services.

What lessons can other countries and donors take from your success?

I think the most important thing is for the government to be in the driver's seat, but [it should] accept assistance when there are challenges. Also being open to new ideas, to changes. I know we tend to be very rigid sometimes. We [now] tend to keep an open mind, although fine tuning things to fit the local communities.

There are a lot of initiatives that partners have assisted us with, such as the linkage to care approach. Initially, when they first talked about this, I thought, “I'm concerned about people on treatment, I need to keep them on treatment. It's taking a lot of effort to do that. Now you want me to go and search for people and hold them by the hand? Don't they know where the clinic is?” We were thinking: “It's going to take too much work, the nurses won't do it.”

But now it's engrained. Health workers feel responsible that after testing, if there's a way, they'll find somebody who can accompany the person to the next point. They do emphasize the checking up, the phone calls. There's a follow up. It’s just changing the way we think.

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