MEDIA BRIEF

in Swaziland

on Prevention

of Mother-To-Child

Transmission

(PMTCT)

of HIV

on Prevention

of Mother-To-Child

Transmission

(PMTCT)

of HIVin Swaziland

MEDIA BRIEF

ii

TABLE OF CONTENTS

Acronyms iv

Glossary of some key terms v

Acknowledgement vi

INTRODUCTION: Background and rationale for this Media Brief 1

CHAPTER ONE: COUNTRY PROFILE: General Demographics, Politics and Social Climate 2

CHAPTER TWO: Epidemiological situation and spread of HIV and AIDS in Swaziland 4

CHAPTER THREE: Drivers of HIV and AIDS 7

CHAPTER FOUR: HIV Prevention Strategies 10

CHAPTER FIVE: Prevention of Mother to Child Transmission of HIV (PMTCT) 13

CHAPTER SIX: HIV Testing and Counselling 22

CHAPTER SEVEN: Some challenges in the PMTCT process 28

CHAPTER EIGHT: Conclusion and Recommendations 32

REFERENCES 34

iii

TABLE OF FIGURES AND BOXES

Figure 1. Map of Swaziland 2

Figure 2. Swaziland population distribution by region 2

Figure 3. HIV prevalence among population aged 2 years and older 4

Figure 4. HIV prevalence among antenatal clients in Swaziland (1992 – 2010) 4

Figure 5. Number of sites providing PMTCT from 2003 – 2010 17

Figure 6. PMTCT Regimen change from 2003 – 2010 20

Figure 7. HIV Testing Algorithm (For rapid testing in adults and children over 18 months) 22

Figure 8. MTCT elimination conceptual framework 29

Table 1. ANC HIV Prevalence by Regional Variation 5

Table 2. Risk Factors of mother to child transmission during pregnancy, labour and delivery andbreastfeeding 16

Table 3. Health Facility Coverage of PMTCT by Region 17

Table 4. Periods, timing and estimated rates of transmission 18

Table 5. Eligibility criteria for ART or ARV prophylaxis in HIV-infected pregnant women 21

Table 6. ARV prophylaxis regimen for HIV infected mothers and exposed infants: 26

Box 1 Comprehensive Care for an HIV Exposed infant 15

Box 2 Key Milestones in the PMTCT Program in Swaziland 18

Box 3 Interpretation of HIV test results 23

iv

AIDS Acquired Immunodeficiency Syndrome

ANC Antenatal Care

ART Antiretroviral therapy

ARV Antiretroviral

AZT Azidothymidine (Zidovudine)

CTX Co-Trimoxazole

DBS Dry Blood Spots

DNA Deoxyribonucleic acid

EID Early Infant Diagnosis

ELISA Enzyme-Linked Immuno absorbent Sero Assay

FP Family Planning

HAART Highly Active Antiretroviral Therapy

HIV Human Immunodeficiency Virus

IYCF Infant and Young Child Feeding

MCP Multiple Concurrent Partnerships

MDGs Millennium Development Goals

MNCH Maternal, Neonate and Child Health

MOH Ministry of Health

MOT Modes of Transmission

MTCT Mother-to-Child Transmission

NSF National Multisectoral Strategic Framework 2009 - 2014

NVP Nevirapine

PCR Polymerase Chain Reaction

PICT Provider Initiated Counselling and Testing

PMTCT Prevention of Mother-to-Child Transmission

PNC Post natal Care

RTI Reverse Transcriptase Inhibitor

SDHS Swaziland Demographic Health Survey

SRHU Sexual and Reproductive Health Unit

STIs Sexually Transmitted Infections

TB Tuberculosis

VCT Voluntary Counselling and Testing

WHO World Health Organisation

ACRONYMS

v

Antiretroviral drugs: These are medicines that are taken to slow down viral replication with theultimate aim of reducing the amount of virus in the body of someone livingwith HIV.

ARV Prophylaxis: This is when antiretroviral drugs are taken in order to prevent HIV infectionfrom happening.

CD4 cell count: CD4 cells are white blood cells that are responsible for immunity in the body.A CD4 cell count is a blood test performed to measure the number of CD4cells as a way to assess the strength of the immune system.

Chorioamnionitis: Inflammation of the chorion and the amnion, the membranes that surroundthe foetus.

Drivers of the epidemic: These are certain behaviours and circumstances that may put an individualin greater risk of contracting HIV.

Exclusive breast feeding: This is when a baby is only fed on the breast milk without any additional fluidsor foods.

HIV Incidence rate: The rate of new HIV infections over a period of one year.

HIV Prevalence: The overall prevalence of HIV includes the number of diagnosed as well asundiagnosed people infected with HIV in a given population.

HIV Transmission: HIV can be spread through unprotected and close contact with a variety ofbody fluids of an infected individual.

Immunodeficiency: As the HIV destroys and impairs the function of immune cells, infectedindividuals gradually become increasingly susceptible to a wide range ofinfections and diseases that people with healthy immune systems can fightoff.

Regimen: Is a set of prescribed treatments that may comprise of a number of types ofmedicines or foods or other activities.

Replacement feeding: This is when some other substance – fluid or solid is given to an infant inplace of breast milk.

Risk factors: These are situations that make something most likely to happen i.e. increasesthe chances of HIV infection.

Vertical transmission: The transmission of HIV from an HIV-positive mother to her child duringpregnancy, labour, delivery or breastfeeding.

Viral Load: Number of viral copies in the blood.

Weeks of gestation: The amount of time or duration of pregnancy.

GLOSSARY OF SOME KEY TERMS

vi

ACKNOWLEDGEMENTS

A number of stakeholders supported the compilation and production of this Media Brief on Preventionof Mother to Child Transmission (PMTCT) in Swaziland.

As Panos Institute Southern Africa (PSAf), we are greatly indebted to the Southern Africa DevelopmentCommunity (SADC) HIV and AIDS Fund for supporting Communicating HIV Prevention in SouthernAfrica Project, under which this Media Brief was published. We would also like to thank the SwazilandNational Emergency Response Council on HIV and AIDS (NERCHA) for supporting the research andcompilation of this publication.

The PSAf PMTCT Media Brief for Swaziland was compiled by Innocent Hadebe of NERCHA Swaziland,edited by Robert Makola, an independent media consultant. The publication was further edited byVusumuzi Sifile and Mamoletsane Khati of PSAf, and reviewed by Lilian Chigona.

For more information and to request for copies, please contact:

Panos Institute Southern AfricaPlot 9028 Buluwe Road, WoodlandsP. O Box 39163, Lusaka, ZambiaTel: +260-211-263258Fax: +260-211-261039Email: general@panos.org.zmWebsite: www.panos.org.zm© Panos Institute Southern Africa 2012

INTRODUCTION

1

BACKGROUND AND RATIONALE FOR THE MEDIA BRIEF

During the last 30 years, the HIV/AIDS pandemic has ravaged the world with very serious consequences. In order to reduce the impact of the pandemic on the health and development agenda of the variouscommunities, African countries, including Swaziland, have embarked on various initiatives, approachesand strategies, both locally and as part of global efforts.

In Swaziland, a relatively small country with a population of just above one million people, but severelyaffected by the pandemic, the media has played a critical role in enhancing the understanding of HIVand AIDS through information dissemination on the various aspects of the pandemic. However, localjournalists in the country have lacked a platform and readymade resource upon which to draw relevant,accurate and up-to-date information to facilitate their reporting on HIV and AIDS issues, including thecritical Mother-to-Child Transmission of HIV (MTCT).

This media brief on the Prevention of Mother-to-Child Transmission of HIV (PMTCT), therefore, has beendeveloped to provide journalists with the necessary information on the programme. PMTCT is one ofthe national priority biomedical strategies for HIV prevention, with a special focus on ensuring that fewerinfants are exposed to or infected with HIV from their infected mothers.

The brief is aimed at assisting the journalists to be able to report on PMTCT from an informed point ofview, thereby empowering the communities, families and especially mothers on the benefits of PMTCT,reduction of HIV infection risks for the HIV negative sexually active population and reduction of HIVincidence among babies born to HIV infected mothers.

The realization of the National Multisectoral Strategic Framework 2009 – 2014 impact level results ofhaving fewer infants becoming infected with HIV and fewer pregnant women becoming HIV positive isdependent upon the active participation of all the relevant stakeholders. In order to bring everybodyon board, the media has a pivotal role to play in promoting awareness for increased access to PMTCTand other HIV prevention services.

Though the country has made significant headway in reaching pregnant women with PMTCT servicesat antenatal care (ANC) and Maternal, Neonate and Child Health (MNCH) level, communication is stillvery essential to maintain and sustain the gains that have been achieved over the years. This is vitalif the country is to achieve virtual elimination of Mother-to-Child Transmission of HIV.

This brief will form part of the information resource base that can be used by a wide spectrum ofstakeholders, even beyond the media. The manual can be adapted for use as resource and referencematerial at media training institutions. The material can be reproduced and distributed for use as handouts as long as adequate acknowledgement of Panos Institute Southern Africa is given.

ONECHAPTER COUNTRY PROFILE:

GENERAL DEMOGRAPHICS, POLITICSAND SOCIAL CLIMATE

2

Swaziland is a small landlocked countrysituated in the southern part of Africa.It has a surface area of 17,364 squarekilometres, and is bordered by theRepublic of South Africa, almost entirely,and Mozambique to the east. Accordingto the 2007 Population Census, thepopulation of Swaziland is estimatedat 1,018,449 people, of which 481,428are males (47%), and 537,021 females(53%). The population is evenlydistributed across the four regions ofHhohho, Lubombo, Manzini andShiselweni, though the Manzini Regionhas a higher population compared tothe other three regions. (Fig. 1).

The young people, under the age of 20years, form 52% of the population and79% of the population live in the ruralareas. The total fertility rate is estimated

Figure 1. Map of Swaziland

at an average of 3.8 births in a woman’s life. Theliteracy rate among women of reproductive ageis 91%, with 59% having a secondary educationor higher.

Swaziland is divided into four administrativeregions, Hhohho in the north of the country,Lubombo, which forms the eastern part, Manziniin west-central and Shiselweni to the south. Thecountry is further divided into 55 constituenciesknown as Tinkhundla and 360 chiefdoms andtowns.

It became an independent kingdom in 1968, withHis Majesty the King as the Head of State andthe Prime Minister as the Head of Government.

Figure 2: Proportion of population distributionby region

3

Swaziland is classified as a lower middle income country with per capital income of US$2,580 (2007),and has an economy that is largely agriculture-driven.

South Africa accounts for 80% of its imports and 60% of its exports. Swaziland’s Economic growthhas slowed down in the last twenty years from a gross domestic product growth rate averaging 8.4%during 1981-1990 to 2.6% during 2001-2008. The economic slowdown has been driven mainly byfluctuations in the performance of the agricultural sector due to climatic conditions and global fluctuationsin the price of agricultural products.

TWOCHAPTER EPIDEMIOLOGICAL SITUATION AND

SPREAD OF HIV AND AIDS IN SWAZILAND

4

Swaziland is among the countries severelyaffected by the HIV and AIDS epidemic.Despite the curbing efforts made in theresponse, the HIV prevalence rate is stillexceptional ly high and has reachedunprecedented levels. The SDHS 2007indicated that in the general population aged2 years and older, HIV prevalence was 19%,and 26% among the sexually active populationaged 15 – 49 years. It also indicated thatfemales (22%) were more infected than males(15%).SDHS, 2007

Figure 3: HIV Prevalence among population aged 2and olderIt is worth noting that the age groups mostly

affected are the reproductive groups aged 25-29 years for females (49%) and 30 – 39 yearsfor males (45%), as reflected in (Figure 3)above. HIV infection is high in females aged15 – 29 years (32.3%) as compared to theirmale counterparts (14%). This indicates ahigher vulnerability of females at an early ageas compared to males.

HIV / AIDS among pregnant women

A trend analysis, using data from the bi-annualHIV Serial Sentinel Surveillance Survey, 2010,indicated that the prevalence among pregnantwomen is showing some stabilisation afterrapidly increasing through the 1990s andslowing down after 2004. The stability maybe observed between 2006 and 2010 (Figure4).

Figure 4: HIV prevalence among antenatal clients inSwaziland

Source: 12th Sero-Sentinel Surveillance Report, 2010

Percentage HIV positive

HIV Prevalence 3.9 16.1 26 31.6 34.2 38.6 42.6 39.2 42 41.1

2010200820062004200220001998199619941992-10

0

10

20

30

40

50

5

Regional ANC HIV prevalence

Regional HIV prevalence has guided the national prevalence curve. Over time, the Manzini regionobserved high prevalence until 2004, when it peaked to 45.1% and thereafter assumed a downwardtrend. Currently, Manzini has the lowest prevalence of 39.5%. On the other hand, Hhohho, which hadthe lowest prevalence of 15.5% in 1994, has seen an upward swing, reaching 41.9%, Lubombo Regionreaching 43.3% and Shiselweni region reaching 40.2% in 2010 (Table 1)

(Table 1). ANC HIV Prevalence by Regional Variation

As earlier stated, HIV infection is present in a considerable percentage of adults aged 50+ years (14%)and young children aged 5-14 years (3%). This may be attributed, most probably, to the high incidenceof sexual abuse. HIV prevalence by sex and age group shows that the female-to-male ratio of infectionis dramatically different in age groups, and HIV prevalence rapidly increases in women between the agegroups 15-19 (12% HIV positive), 20-24 (38% positive) and 25-29 (49% HIV positive).

Some basic statistics about HIV in Swaziland

• The HIV incidence rate is at 2.9%.HIV Prevalence: • population aged 2 years and older at 19%• population aged 15 – 49 years at 26%• pregnant women at 41.1%

• 94% of new infections occur through heterosexual contact. About 68% of new infections in adultsoccur in persons above 25 years of age, the majority of whom are married or cohabit with a steadypartner.

• The majority of new infections are in females.• The majority of new infections in children, 0-14 years, are due to mother-to-child transmission during

pregnancy, childbirth and breastfeeding.• MTCT contributes about 11% of the total annual national incidence rate• About 47.3% women have been tested for HIV and know their status• About 32.2% of men have been tested and know their status• HIV counseling during ANC is at 81.5%• HIV testing during ANC is at 77.4%• About 19.1% men aged 15-59 years are circumcised• Sex before age 15 years is at 3.8% for young women and 2.6% for young men.• Age-mixing among sexual partners, 14.1% women and 0.5% men

Region Number Tested Number positive Percentage Positive 95% Confidence Interval

Hhohho 468 196 41.9 37.4; 46.5

Manzini 519 205 39.5 35.3; 43.9

Shiselweni 378 152 40.2 35.2; 45.3

Lubombo 330 143 43.3 37.9; 48.9

National 1695 696 41.1 38.7; 43.4

12th national HIV Sero-Surveillance among women attending antenatal care services in Swaziland

• Sex with multiple partners, 2.7% women and 15.4% men• Condom use during sex with multiple partners is at 73.1% women and 69.2% men• Condom use during sex with non-regular partners is at 76% women and 93.1% men• Condom use with non-regular partners is at 73.1% women and 90.6% men. The probability of using

a condom during higher risk sex increases with educational attainment in men and women, and ishigher in younger age groups than older adults.

6

THREECHAPTER DRIVERS OF HIV AND AIDS

7

The main mode of HIV transmission is through heterosexual contact. According to the Swaziland HIVPrevention Response and Modes of Transmission Analysis (MOT) 2009, approximately 94% of newinfections in adults arise from heterosexual transmission. Given that this is the main mode of HIVtransmission in Swaziland, the following specific sexual behaviours put people at risk of HIV infectionand are by no means listed in order of priority.

Multiple Concurrent Partners

Multiple Concurrent Partners (MCP) can be generally defined as sexual behaviour distinguishable byhaving two or more sexual partnerships that overlap in time or in the same time period. This type ofsexual behavior increases the risk of HIV infection and has been recently identified as the most immediatecause of new HIV infections and significantly correlates with the majority of drivers of the epidemic.MCP is tacitly accepted in the Swazi socio-cultural dynamics and men are more likely to have multiplesexual partners as compared to women. This behaviour has improved over the years. According tothe Swaziland Multiple Indicator Cluster Survey (MICS) 2010, 15% of men aged 15–59 years had sexwith more than one partner in the last 12 months, whereas only 3% of women aged 15–49 years engagedin such an activity in the last 12 months preceding the survey. This is lower when compared to theSwaziland Demographic and Health Survey (SDHS, 2007), which stated that 23% of men and 2% ofwomen, aged 15-49 years, reported having sex with more than one partner in the 12 months precedingthe survey.

Early Sexual Debut

By the age of 18 years, 48% of women and 34% of men aged 15 – 24 years reported having had sexualintercourse and, of these, 7% women and 5% men initiated sexual activity before their 15th birthday(MICS, 2010). The median age of sexual debut in Swaziland is around 17 years and the average ageof marriage is 26 years (SDHS, 2007). Premarital sex, and often with more than one partner, is usuallypracticed within the ten-year period. Young rural females were significantly more likely to have initiatedsex before age 15 or age 18 compared to young urban females, and the opposite can be said aboutthe urban men who would start to have sexual intercourse earlier than their rural counterparts.

Low and Inconsistent Levels of Condom Use

The use of condoms during sex, especially with non-regular partners, is critical for reducing the spreadof HIV. The male condom is 98% effective if used correctly and consistently and the female condom85% (MICS, 2010). The MICS indicated that 67% women and 93% men had sex with a non-marital,non-cohabiting partner in the last 12 months. Of those, 73% women and 91% men reported that acondom was used the last time they had sex with such a partner. This has indicated some improvementin condom usage when compared to the SDHS findings which stated that, 55% women and 68% men

8

who had more than one sexual partner in the past 12 months reported having used condoms the lasttime they had sex. Only 22.4% women currently married or in relationship reported using a condom.

Low Levels of Male Circumcision

As a traditionally non-circumcising nation, Male Circumcision (MC) in Swaziland has remained very lowwith only 8% of men being circumcised. With the roll out of the MC for HIV Prevention, there has beensome improvement to 23% (MICS, 2010) in 2011, but it is still lower that the NSF target of 30% (NSF,2009.) The country adopted MC as an HIV Prevention Strategy following approval and recommendationfrom WHO and UNAIDS, which was informed by three randomized controlled clinical trials which wereconducted in South Africa, Kenya and Uganda. These demonstrated the potential to reduction of HIVinfection in circumcised men by almost 60%.

Inter-Generational Sex

According to the SDHS, 7% of young women who had engaged in high risk sex in the last twelve monthsreported having sex with a man ten or more years older. This is higher among older girls living in ruralareas, but decreases with higher levels of education. The 2010 Swaziland MICS shows that for womenaged 20–24 years who are in marriage or in a union, the most frequent spousal age difference is 5–9years at 39%, followed by 0–4 years at 37%. About 22% of women aged 20–24 years are married orin union with spouses who are 10 years older or more.

Income Inequality (Poverty)

Various studies show that it is not necessarily poverty, but income inequality, which is high in Swaziland,that drives the epidemic. Income inequality is associated with more young girls engaging in what hasbeen referred to as “transactional sex” or sex for favours and in the process taking more risks towardsHIV infection.

Mobility and Migration

Migration and mobility pose an increased risk of HIV, both to the one who is traveling and the one leftbehind. This is not simply because men return home to infect their rural partners, but also becauserural women become infected outside their primary relationships (Lurie et al.)

A significant percentage of Swazis are mobile. Oscillatory migration is a significant factor in sexualbehaviour and new HIV infections. The SDHS reported that 42% were away from home or at an assignedduty station for more than five days at a time, at least five times in the past 12 months, mostly for work-related reasons. A large majority are married or in long-term cohabitating relationships, and there islow condom use with non-regular sexual partners. HIV prevalence amongst these short-term mobilepeople is more than double than in the general population. Patterns of risky sexual behaviour also differfor men and women who are away from each other, and focus on the non-travelling partner is alsoneeded.

9

Commercial Sex

According to the MARPS Bio-Behavioral Surveillance Survey (BSS) Results: Men Who Have Sex withMen (MSM) and Sex Workers (SW), 2012, the overall HIV prevalence among sex workers is 70.3%,which is almost double that of the general population. The majority of female sex workers are youngwomen between the ages 21 and just above 30 years and 88.8% are single or never married and mostof them (53.4%) have achieved some secondary level school education.

There are also some male sex workers. The most frequent number of clients that they serve is between2 – 4 clients per month at 43.7% followed by 5 – 10 clients per month at 33.2% and for 66.7% of them,sex work is the only source of income. Reported condom use with new clients in the past monthpreceding the survey was 74.2%. Worth noting, though, was the frequency of condom break or slippagewith any partner in the past month, which was at 55.3%.

Gender Inequalities and Sexual Violence

Many cultural norms and values shape negative gender relations that help drive the epidemic. InSwaziland, being a patriarchal society, culturally men have a large degree of control over women. Theprevailing values and norms uphold men’s privileges and tend to constrain women’s autonomy. Thesevalues and norms are deep-rooted, and gender discriminatory beliefs are held by many men and women,which also facilitates the tacit acceptance of sexual violence. The 2007 ‘National Study on Violenceagainst Children and Young Women in Swaziland’ found that violence against female children is highlyprevalent, with approximately one in four females having experienced physical violence as a child.Among the 18-24 year old females, nearly two in three had experienced sexual violence. Overall, 48%of females reported that they had experienced some form of sexual violence in their lifetime, and 21%said they had experienced some form of sexual violence in the preceding 12 months. Over half of allincidents of sexual violence were not reported to anyone, and less than one in seven incidents resultedin a female seeking help from available services.

Alcohol and Drug Abuse

The SDHS noted that engaging in sexual intercourse while under the influence of alcohol can impairjudgment, compromise power relations, and increase the possibility of engaging in risky sexual behaviour. The 2007 Alcohol Use and Sexual Risks for HIV/AIDS in Sub-Saharan Africa: Systematic Review ofEmpirical Findings, showed a consistent association between alcohol and sexual risk taking. Men aremore likely to drink and engage in higher risk behaviours, whereas women’s risks were often associatedwith their male partner’s drinking. Alcohol and sexual risks are also linked with sexual coercion andpoverty.

FOURCHAPTER HIV PREVENTION STRATEGIES

10

Preventing new HIV infections in Swaziland is vital in the efforts to reverse the epidemic and achievethe national targets of the response. HIV prevention strategies, therefore, remain critical for the nationalresponse to the epidemic while effective prevention of new infections will also have long term collateralbenefits for treatment, care and support and impact mitigation.

The HIV prevention interventions are designed to reduce exposure to HIV, reduce the probability oftransmission when exposed, and influence change in societal norms, values and practices that tendto impact on peoples’ ability to adopt key prevention behaviour.

According to the National Multisectoral Strategic Framework (NMSF) 2009 – 2014, the strategic directionfor HIV prevention is to ensure that interventions reduce the incidence rates to levels at which theepidemic starts declining and, hence, the following are the five thematic impact level results:

1. The rate of HIV incidence per year is reduced from 2.9% in 2008 to below 2.3% by 2014.2. The percentage of HIV infected infants born to HIV positive mothers is reduced from 21.5% in 2008

to 10% in 2011 and 5% in 20143. The percentage of young people aged 15-19 years who are HIV infected is reduced from 10.1% for

women in 2007 to 8% in 2014 and from 1.9% in 2007 for men to 1.5% in 20144. The percentage of pregnant women aged 15-24 years who are HIV infected is reduced from 38.1%

in 2008 to 37% in 2011 and 35% in 20145. The percentage of female sex workers who are HIV positive is reduced from 23% in 2007 to 20%

in 2014.

To achieve these results, the country has HIV Prevention programme strategies which are divided intotwo categories according to their levels of priority. The following are “priority one” interventions:

1. Social and behaviour change communication programmesTarget population:

(a) Youth aged 15 – 24 yearsIndicators:• Increased percentage of in-school youth aged between 15 – 19 years who have attended life

skills education to 60% by 2011 and to 95% in 2014.• Increased percentage of young people aged 15-24 who have been reached with social and

behaviour change communication programmes from 54% in 2008 to 60% in 2011 and 69% in2014.

• Increased percentage of primary and secondary schools that provided life-skills education withinthe last academic year from 44% in 2008 to 90% in 2014 for primary schools and 71% in 2008to 95% in 2014 for secondary schools.

• Increased number of trained and active peer educators from 900 in 2008 to 4500 in 2014.

11

(b) Adults 25 years and olderIndicator:• Increased percentage of couples reached with relationship strengthening and social/behavioural

change communication programmes to 40% in 2011 and 60% in 2014.

(c) Mobile and migrant populationIndicator:• Increased percentage of formally employed workers reached with a minimum package of HIV

Prevention programmes in the last 12 months• Increased number of large enterprises / companies that have HIV and AIDS workplace policies

and programmes from 48% in 2011 to 75% in 2014

2. Increased and comprehensive knowledge of HIV and AIDSTarget population:

(a) Young people aged 10 – 24 yearsIndicator:• Increased percentage of young people aged 10-24 who cite a member of the family as a source

of HIV and AIDS information from 39.2% in 2006 to 60% in 2014.

(b) Young people aged 15 – 24 yearsIndicator:• Increased percentage of young people aged 15 to 24 who both correctly identify ways of

preventing the sexual transmission of HIV and who reject major misconceptions about HIVtransmission, from 52% in 2007 to 78% in 2014.

(c) Most at Risk Populations (MARPS)Indicator:• Increased percentage of most-at-risk populations who both correctly identify ways of preventing

the sexual transmission of HIV and who reject major misconceptions about HIV transmission,from 46.2% in 2008 to 70% in 2014.

3. Scaling up of Prevention of Mother-to-Child Transmission of HIVTarget population:

(a) HIV Positive pregnant women, their infants and sexual partnersIndicator:• Increased percentage of HIV positive pregnant women who received a course of ARV prophylaxis

to reduce MTCT from 65% in 2007 to 90% in 2014.• Increased percentage of pregnant women who were tested and received their results [during

pregnancy, labour and delivery, during post-partum period (<72 hours) and those with previouslyknown HIV status] for a new pregnancy, from 67% in 2007 to 75% in 2011 and 90% in 2014.

(b) Women aged 15 – 49 yearsIndicators:

• Decreased percentage of women aged 15 to 49 who did not want any more children when theyfell pregnant, from 36.9% in 2007 to 20% in 2014.

• Reduced % of HIV positive women aged 15- 49 with unmet need for family planning from 13%in 2007 to 5% in 2014.

12

4. Male Circumcision:Target population:HIV negative men aged 15 – 24 years and new born childrenIndicators:• Increased number of young men aged 15 – 24 years who are circumcised from 2 500 in 2008

to 111 000 in 2014• Increased number of newborns who are circumcised within 5 days of birth to 13 200 in 2011

and to 33 000 in 2014

The “priority two” interventions are those which need to continue because of their importance insustaining the gains that have already been achieved in HIV Prevention or with the general response.These are the following:

(a) HIV Testing and Couselling (HTC)Target population:(a) People Living with HIV (PLHIV)Indicator:• Increased percentage of people 15 years and older who know their HIV status has increased

from an estimated 20% in 2008 to 70%.

(b) All persons:Indicator:• Increased number of people aged 2 years and older who have tested for HIV in the last 12

months and know their status, from 22% in 2007 to 50% in 2014 for women and 9% in 2007to 40% in 2014 for men.

(b) Post Exposure Prophylaxis and Universal PrecautionsTarget population:All eligible personsIndicator:• Increased number of health facilities that provide PEP from 12% in 2008 to 30% (all sites

providing ART) by 2014.

(c) Treatment of Sexually Transmitted Infections (STIs)Target population:All sexually active personsIndicator:• Reduced percentage of persons who present with genital ulcers from 20% in 2007 to 15% in

2014.

FIVECHAPTER PREVENTION OF MOTHER TO CHILD

TRANSMISSION OF HIV (PMTCT)

13

The PMTCT programme in Swaziland was officially launched in 2003 and has since then been implementedas part of the Maternal, Newborn and Child Health (MNCH) programme services. Notable progress hasbeen achieved in the service coverage since the commencement of the programme. At its inception,for example, the programme had only 3 health facilities offering the PMTCT services. These increasedsubstantially to 137 in 2008, and peaked to a total of 150 facilities by 2010. (FIGURE 5).

What is PMTCT?

The transmission of the Human Immunodeficiency Virus (HIV) from an HIV infected mother to her childis called Mother-to-Child Transmission (MTCT). This can occur during pregnancy, labour and deliveryand breastfeeding. The PMTCT is a highly effective intervention which ensures that an HIV infectedmother does not pass the infection to her child. This can be achieved through giving the HIV infectedpregnant women Antiretroviral (ARV) drugs to prevent them from transmitting HIV to their children, bothbefore and after birth. This is a vital part of the programme because it ensures that children in Swazilandare born free of HIV and that they are prevented from acquiring the virus from an early age.

The four prongs of PMTCT

Before examining in detail how the HIV virus is transmitted from mother to child, it may be necessaryto outline the approach that has been laid out to fight infections at that level. Strategically, the PMTCTprogramme in Swaziland is being implemented through a four-pronged approach as follows:

Prong 1:The primary focus of Prong 1 is on keeping HIV-negative pregnant women and partners of pregnantwomen HIV-negative. This new approach is based on recent research in Swaziland that showed highlevels of new HIV infections of about 5% occurring during the last trimester of pregnancy.

Programme strategiesThe strategic focus for Prong 1 is to target women and partners who test negative, with strong emphasison HIV risk reduction and the practice of safe sex. Consistent and correct condom use is stressed aspart of safe sexual behaviour for all pregnant women and their partners.

Prong 2:The primary focus of Prong 2 is on the prevention of unwanted pregnancy among the HIV positive

women. The emphasis is on ensuring that actions are being taken in health facilities to ensure that

staff is trained and ready to provide family planning to eligible women and ensure that these services

are widely available and easily accessible.

14

Programme strategiesThe strategic focus of Prong 2 includes counselling and provision of family planning methods. Pregnantwomen and their partners are encouraged to discuss and plan for their contraceptive needs after delivery.

Prong 3:The primary focus of Prong 3 is the reduction of HIV transmission from infected pregnant mothers totheir unborn babies during pregnancy, labour and breastfeeding periods. According to the PMTCTguidelines, ARV prophylaxis has to be started at as early as 14 weeks gestation. HIV retesting isscheduled for the pregnant women 8 weeks after their first negative test, during the last trimester andat 6 weeks postpartum in order to identify new HIV infections and provide ARV prophylaxis immediately.

Prong 4:Having learned that focusing only on women after they are infected and pregnant will not lead us to ageneration free of HIV, Prong 4 provides an opportunity to provide treatment, care and support for thewoman, her partner and the family from before conception and continuing into early childhood.

Programme strategiesBoth Prongs 3 and 4 are specific for HIV infected women and their families to ensure that the appropriateinterventions to reduce MTCT (ARV prophylaxis, ART, good obstetric practices and monitoring of labourand delivery) and HIV treatment, care and support services are provided for the mother, infant andfamily, respectively.

HOW IS HIV TRANSMITTED FROM MOTHER TO CHILD?

The mother-to-child transmission of HIV can occur during different stages in the child’s life, i.e. pregnancy,labour and delivery and breastfeeding. For all these stages of transmission, the level of the mother’sviral load is the most important. The MTCT of HIV is most likely to occur when there is a high maternalviral load and a low CD4 count.

The three modes of transmission are discussed below.

In pregnancy (utero transmission)

This may happen if the placenta is damaged, which creates a possibility for HIV-infected blood fromthe mother to transfer into the blood circulation of the foetus. It may also happen during Chorioamnionitis,which is usually caused by a bacterial infection, and this has been associated with damage to theplacenta and increased transmission risk of HIV. This is thought to happen either through infected cellstraveling across the placenta, or by progressive infection of different layers of the placenta until thevirus reaches the foetoplacental circulation.

The reason we know that utero transmission happens is that a proportion of HIV positive babies testedwhen they are a few days old already have detectable virus in their blood. Usually it takes several weeksfrom the time someone is infected until HIV shows in their blood. The rapid progression of HIV diseasein some babies is evidence that it happens.

During labour and delivery (intrapartum transmission)

15

HIV transmission during labour and delivery is thought to happen when the baby comes into contactwith infected blood and genital secretions from the mother as it passes through the birth canal. Thiscould happen through ascending infection from the vagina or cervix to the foetal membranes andamniotic fluid, and through absorption in the digestive tract of the baby.

Alternatively, during contractions in labour, maternal-foetal micro-transfusion may occur. Evidence tothis is:• 50 percent of babies who turn out to be infected test HIV negative in the first few days of life.• There is a rapid increase in the rate of detection of HIV in babies during the first week of life.• The way that the virus and the immune system behave in some newborn babies is similar to that

of adults when they first become infected.

It is also shown by the success in preventing it from happening. This includes:• Treatments that have reduced transmission risk, even when given only in labour• Delivering the baby by Caesarean section before labour starts (where applicable).

If it takes a long time to deliver after the membranes have ruptured (waters breaking) or if there isprolonged labour, the risk of transmission in women not receiving ARV treatment or prophylaxis isincreased.

A premature baby may be at higher risk of HIV transmission than a full term baby.

Breastfeeding

HIV transmission at this stage is thought to be through breast milk, which gets through the mucosallining of the gastrointestinal tract of infants. The gastrointestinal tract of a young baby is immature andmore easily penetrated than that of adults. It is believed that damage to the intestinal tract of the babymay be caused by the early introduction of other foods, particularly solid foods and thus increase therisk of infection. Under the MTCT process, it is worth noting, that the most important thing is not howit happens, but how we can prevent it from happening. ARVs have demonstrated that this is feasible.

MTCT and breastfeeding

Exclusive breastfeeding is considered a safe infantfeeding practice that can reduce MTCT. Nationalguidelines for PMTCT recommend exclusivebreastfeeding for 6 months, coupled with anappropriate prophylaxis regimen for mother and infant.

A protocol for comprehensive care of exposed infantsincorporates key components of care such as accessto PMTCT services; completion of PMTCT regimen,including NVP prophylaxis during breastfeeding whenthe mother is not on ART; support of infant feedingmethods to reduce postnatal transmission; accessto co-trimoxazole prophylaxis for infants; monitoringfor early childhood development of infants; andcompletion of infant immunization regimens.

Box 1: Comprehensive Care for a HIVexposed infant.

1. Document PMTCT regimen received bymother and the infant

2. Test for HIV and give results, when indicated3. Assess growth and development4. Give immunization5. Provide prophylaxis (CTX, IPT)6. Treat infection early7. Ask about household TB contacts8. Counsel on infant feeding and nutrition9. Ensure that the family is receiving HIV care,

FP, social support10. Maintain suspicion of HIV infection

10 key elements of the clinic visit

16

Breastfeeding recommendations

• Under 6 months: Exclusive breastfeeding (only medicines can be taken, no water or other foods.)• 6-12 months: breastfeeding PLUS complementary feeding• At 12 months: Assess nutrition and diet and make recommendations for feeding based on mother

and infant HIV status

Knowledge about PMTCT in Swaziland

The knowledge of MTCT in the population is an important step for women and men to avoid infectingtheir unborn babies. The overall PMTCT knowledge level among women aged 15 – 49 years and menaged 15 – 59 years is 95% for women and 94% for men. These are the people who know that HIV canbe transmitted from mother to child. Men and women residing in the Manzini region are most likely toknow about PMTCT when compared with those in the other regions.

About 61% of women and 50% of men know all the three modes of MTCT while 5% of women and6% of men did not know of any specific way. Approximately 73% of women and 66% of men knowthat HIV can be transmitted during pregnancy, while 88% women and 83% of men know that HIV canbe transmitted during delivery. In addition, 80% percent of women and 76% of men know that HIV canbe transmitted by breastfeeding (12th Sero-Sentinel Surveillance, 2010).

During the three phases of possible mother to child transmission of HIV, there are risk factors whichmay increase the risk of infection. Table 4 below articulates the risk factors at these different stages,which are during pregnancy, labour and delivery, and during breastfeeding.

(Table 2). Risk Factors of mother to child transmission during pregnancy, labour and delivery andbreastfeeding

Pregnancy Labour and Delivery Breastfeeding

New HIV infections duringpregnancyHigh maternal viral loadLow maternal CD4 countMalaria infectionSexually transmitted infections(STIs)Maternal malnutritionAnaemiaChor ioamnion i t i s ( f romuntreated STI or Viral orbacterial infections infections)

High maternal viral loadLow maternal CD4 countRupture of membranes more than4 hours before deliveryInvasive delivery procedures (e.g.,episiotomy, artificial rupture ofmembranes, amniocentesis,vacuum or forceps)Chorioamnionitis (from untreatedSTI, other infection or due toascending infection followingprolonged rupture of membranes)Premature deliveryLow birth weightBreaks in sk in or mucousmembranes of the baby

New HIV infections duringpregnancyHigh maternal viral loadLow maternal CD4 countDuration of breastfeedingMixed feeding (e.g., food orfluids in addition to breastmilk)Breast abscesses, nipplefissures, mastitisPoor maternal nutritionalstatusOral disease in the baby (e.g.,thrush or sores)

17

Figure 5: Number of sites providing PMTCT from 2003 - 2010

(Table 3). Health Facility Coverage of PMTCT by Region

Number of facilities

offering ANC services

47

57

37

30

171

No. and % of Facilities

offering PMTCT Service 2008

39 (83%)

43 (75%)

31 (84%)

24 (80%)

137 (80%)

No. and % of Facilities

offering PMTCT Service 2010

42 (89%)

44 (77%)

36 (97%)

28 (93%)

150 (88%)

Region

Hhohho

Manzini

Lubombo

Shiselweni

Total

Source: SAM 2010

The high antenatal care (ANC) attendance in Swaziland of 97% puts the provision of PMTCT servicesat an advantage. As HIV testing is part of the ANC package, Swaziland has also witnessed a tremendousincrease in the proportion of women tested for HIV during pregnancy. By the end of 2010, about 82%of pregnant women were tested for HIV. The HIV prevalence among pregnant women was estimatedat 41.1%. Similarly, the country has also applauded itself on the increase in ARV uptake among pregnantwomen, either for PMTCT or for their own health, from 4% in 2004 to about 85% in 2012.

PMTCT facilities in 2010 (SAM, 2010)PMTCT facilities in 2003

18

4.3.1 Mother to Child HIV Transmission

in Swaziland:

Approximately 30,000 deliveries are registered inSwaziland every year. With HIV prevalence amongpregnant women of 41.1% (12th Sero-SentinelSurveillance Report, 2010), approximately 13,000HIV exposed infants are delivered annually. By2011, 79% of pregnant women were tested forHIV at ANC. Of those who tested positive andwere eligible for ART, 91% received a completecourse of antiretroviral prophylaxis while 15% ofthose were already on ART.

Clinical records show that only 4% of children aged 6-8 weeks born to infected mothers are HIV positive.

HIV testing is an entry point to primary prevention of HIV among young women of reproductive age,prevention of HIV from HIV infected mother to the child and ensures access to treatment and careservices for HIV infected women , families and children.

4.3.1.1 Periods, timing and estimated rates of transmission:

Table 2 below shows the periods and rates of transmission and estimated number of infants exposedto HIV annually if PMTCT services are not put in place. With the new guidelines, Swaziland now hasthe opportunity to prevent more infant HIV infections by providing ARV prophylaxis and treatment fromearly pregnancy, through-out labour and delivery and through the breastfeeding period.

Box 2: Key Milestones in the PMTCTProgram in Swaziland

• 2002: PMTCT Guidelines 1st Edition• 2002: PMTCT Program piloted in 3 facilities• 2003: PMTCT Strategic Plan 2003-2005• 2006: PMTCT Guidelines 2nd Edition• 2007: PMTCT Operational Plan 2007-2011• 2009: Early Infant Diagnosis of HIV using

DNA PCR fully established in the Country• 2010: PMTCT Guidelines 3rd Edition• 2011: E l iminat ion Framework and

Operational Plan 2011-2015

Of the approximately 13,000 HIV exposed babies each year in Swaziland, an estimated 5,200 of these,without any interventions, would be HIV-infected. In 2009, an estimated 2,300 infants became infectedduring pregnancy, delivery and breastfeeding, indicating that PMTCT interventions prevented nearly56% of HIV infections in infants born to HIV positive mothers.

(Table 4): Periods, timing and estimated rates of transmission

Period of

Transmission

Pregnancy

Labour and delivery

Breastfeeding

Overall for 24 months

Transmission

Rate %*

5-10%

15-20%

10-15%

30-45%

Estimated annual number of

infected infants (13000 exposed)

650-1300

1950-2600

1300-1950

3900-5850

Adapted from deCock et al, JAMA, 2000, 283:1175-1182.

19

TRENDS IN THE SWAZI PMTCT PROGRAMME

The increase in the number of health facilities offering PMTCT services resulted in an exponential growthin the use of PMTCT services by 2010. The high antenatal care (ANC) attendance of 97% puts theprovision of PMTCT services at an advantage. As HIV testing is part of the ANC package, Swazilandhas also witnessed a tremendous increase in the proportion of women tested for HIV during pregnancy.By the end of 2010, about 82% of pregnant women were tested for HIV. The HIV prevalence amongpregnant women was estimated at around 41.1%1 Similarly, the country has also exceeded its expectationson the increase in ARV uptake among pregnant women, either for PMTCT or for their own health, from4% in 2004 to about 85% by end of 20102.

During the early days of the programme since its launch in 2003, a single dose of Nevirapine (NVP) wasadministered to the HIV infected women at the onset of labour and NVP syrup to the baby within 72hours after birth to reduce mother-to-child HIV transmission.

In 2007, the country introduced use of more efficacious ARV regimen of AZT from 28 weeks of pregnancy,NVP+3TC+AZT during labor and delivery with the ‘tail’ (3TC+AZT) for one week, and infants receivedNVP plus one week of AZT.

Since 2007, a dual ARV regimen of AZT and NVP has been used with a 7 day ‘tail’ of AZT+3TC tominimize NVP resistance. With these new 2010 guidelines, more efficacious ARV regimens are beingmade available for HIV-infected women and their infants.

By the end of 2010, Swaziland had made commendable progress in expanding PMTCT services andin delivering ARVs to HIV infected pregnant women. For the first time, ARV prophylaxis could be givento make breastfeeding safer for HIV infected women. The new guidelines have ensured improved qualityof care for both mother and child and include provision of more efficacious ARV regimens to HIV infectedwomen from as early as 14 weeks gestation, and to exposed infants during breastfeeding.

About 76% of all HIV infected pregnant women received a full course of PMTCT prophylaxis in 2010while 73% of pregnant women were assessed for ART eligibility (CD4<350), and 44% of those eligiblewere initiated.

Early infant diagnosis using DNA PCR testing is also recommended for all exposed infants at 6 weeks. This is a new technology used for HIV early detection testing. The test looks for the DNA copy of theHIV virus itself in the blood instead of testing for HIV antibodies. It is extremely accurate, sensitive andthe cutting edge of HIV early detection testing. This new technology can detect HIV as early as 28 daysof exposure. DNA PCR is a virologic testing method using the Dried Blood Spot (DBS) technique. Thistest detects viral DNA and can be used to definitively diagnose children less than 18 months of age.This test is >96% sensitive at detecting HIV in infants as early as four weeks after birth.

It is these new guidelines that have provided regimens with very high efficacy to reduce mother-to-childtransmission below 5%.

1 Swaziland 12 Round HIV sentinel Surveillance Report, 2010.2 Ministry of Health Routine HMIS Database.

20

For the first time, these recommendations include use of ARV for HIV-exposed infants who arebreastfeeding as a way of making breastfeeding safer for women with HIV and start of ARV prophylaxisas early as from 14 weeks of gestation (Figure 6).

(Figure 6). PMTCT regimen change from 2003 – 2010

2003:

Mother: Single does NVP at onset of labour

Baby: NVP within 72 hours post delivery

2007:Mother: AZT at 28 weeks gestation. Intrapartum - 3TC + NVP + AZTand a ‘tail’ of 3TC + AZT for 7 days post delivery

Baby: If mother received AZT beyond 4 weeks before delivery - NVPat birth + AZT for 1 week post delivery

If mother received AZT for less than e weeks before delivery - NVP at birth+ AZT for 4 weeks post delivery

2010:Mother:AZT at 14 weeks gestation unit delivery. Intrapartum - 3TC + NVP +AZT and a Tail of 3TC + AZT (7 days post delivery)

Baby:NVP at birth until 1 week after cessation of breastfeeding

For mothers already on HAART (Eligibility criterion – CD4 350 andbelow + WHO clinical stage 3&4) AZT + 3TC + NVP

Baby–NVP at birth + 6 weeks post delivery

TREATMENT ELIGIBILITY CRITERIA UNDER PMTCT

While prevention measures are critical to the fight against HIV, treatment during the post-infection periodis an important strategy. While the treatments available on the market may not completely eliminatethe virus, they help to boost the CD4 count in the body of the infected mother, while at the same timelowering the viral load.

21

Lower CD4 count and the emergence of HIV-related signs and symptoms is an indication of an advancedHIV disease state during which the majority of vertical transmissions from an HIV infected mother toher unborn baby may occur. It is estimated that initiating treatment at a CD4 threshold of <350 wouldprevent 80% of maternal deaths and postnatal infant infections. It is for this reason that all HIV positivepregnant women should urgently be assessed for antiretroviral treatment eligibility and treatment shouldbe promptly initiated for those who are eligible.

The 2010 guidelines promote starting lifelong ART for all pregnant women with severe or advancedclinical disease (stage 3 or 4), or with a CD4 count at or below 350 cells/mm3, regardless of symptoms. This ART eligibility criterion is the same as those for adults in general, which emphasizes the need foraccess to CD4 testing.

The new PMTCT ARV guidelines recommend that HIV positive pregnant women in need of treatmentfor their own health should start ART irrespective of gestational age and should continue with it throughoutpregnancy, delivery, during breastfeeding and thereafter.

The timing of ART initiation for HIV-positive pregnant women is the same as for non-pregnant women,i.e. as soon as the eligibility criteria are met.

The new guidelines have improved the quality of care for both mother and child and included provisionof more efficacious ARV regimens to HIV infected women from as early as 14 weeks gestation, and toexposed infants during breastfeeding (Table 3).

PMTCT services are provided within the Maternal, Newborn and Child Health (MNCH) services. ThePMTCT services begin with the routine offer of HIV testing as an integral part of ANC services. HIVtesting became integrated as part of the antenatal care services and may be viewed as the entry pointinto the PMTCT programme, primary prevention of HIV among young women of reproductive age,prevention of HIV from HIV infected mother to the child and treatment and care services for HIV infectedmothers, families and children to access treatment and care services.

(Table 5). Eligibility criteria for ART or ARV prophylaxis in HIV-infected pregnant women

WHO clinical

stage

Stage 1

Stage 2

Stage 3

Stage 4

CD4 Count not

available

ARV prophylaxis

ARV prophylaxis

ART

ART

CD4 <=350 cells/mm3

ART

ART

ART

ART

CD4 >350 cells/mm3

ARV prophylaxis

ARV prophylaxis

ART

ART

CD4 Count available

SIXCHAPTER HIV TESTING AND COUNSELLING

22

HIV Testing and Counselling (HTC) is a pivotal element in the implementation of the PMTCT programme.The most effective way to prevent mother-to-child transmission of HIV involves a long course ofantiretroviral drugs which have to be taken by the HIV infected mother from pregnancy, through labourand delivery and during breastfeeding, which dramatically reduces the risk of infection to the child. Forthe success of the PMTCT programme, HIV Testing and Counselling have to be offered to all womenat ANC, as early as 14 weeks during pregnancy. This gives sufficient time to proffer the necessaryinterventions for infection reduction. HTC, therefore, becomes paramount and the entry point for otherHIV interventions including PMTCT.

HTC testing algorithm

(Figure 7). Serial HIV Testing Algorithm (For rapid testing in adults and children over 18 months)

TEST A: Determine

HIV POSITIVEHIV NEGATIVE(Report as negative)

Repeat test by 12 weeks TEST B: Unigold

HIV NEGATIVE(Report as Inconclusive)

SEND TO NATIONAL LABORATORY TEST C: ELISA

HIV POSITIVE(Report as positive)

HIV NEGATIVE(Report as negative)

HIV POSITIVE(Report as positive)

23

Swaziland has adopted the WHO/UNAIDSrecommended approaches to providing HTCservices, namely provider-initiated HIV testingand counselling (PIHTC) and client-initiatedHIV testing and counselling (CIHTC) which iscommonly referred to as Voluntary Counsellingand Testing (VCT).

The “3Cs” Principle in HTC

The “3Cs” principle for both CIHTC and PIHTCare voluntary and the “3Cs” of informedConsent, Counselling and Confidentialitymust be observed in both the PIHTC and theCIHTC.

(Box 3) Interpretation of HIV test results

• If the Determine test gives a negative result,the result is negative, record as Non Reactive(NR).

• If the Determine test gives a positive result,perform another test with Unigold.

• If both Determine and Unigold tests resultsare positive, the result is positive for HIV,record as Reactive (R).

• If Determine test is positive and Unigold testis negative, the result is inconclusive. Sendthe same specimen to the laboratory to betested with a tiebreaker.

I. Informed consentInformed consent is a pre-requisite for HIV testing in Swaziland. Conducting an HIV test without thepatient’s or client’s informed consent is both unethical and illegal as it breaches the individual’s rightsand freedom of choice. Consent is implied or expressed; hence verbal consent is encouraged whilewritten consent is also accepted. For consent to be considered informed, clients or patients shouldbe made aware of the indication for, process of, the benefits and implications of being tested for HIVas well as explanation of follow up services. Patients and clients must provide consent without coercion. Further, refusing an offer for HIV testing should not have detrimental consequences with respect toaccessing needed services that do not depend on ascertainment of sero-status.

II. CounsellingAnyone requesting or being offered an HIV test should receive adequate pre-test counselling or pre-test information before an HIV test is carried out as well as post-test counselling after testing. In addition,follow-up supportive counselling and appropriate referrals should be availed as per prevailing circumstancesand needs of the client or patient.

III. ConfidentialityAll medical records, whether they involve HIV related information or not, should be kept in a confidentialmanner. Health care workers and other HTC service providers with a direct role in the management,care or support of patients or clients should have access to their health record on a “need to know”basis. This shared confidentiality is vital to the provision of appropriate prevention, treatment care andsupport of clients. With these principles in mind, results of HTC should be documented in a standard,confidential manner. (R) For “reactive” (positive) and NR for “non-reactive” (negative). Shared confidentialityshould be discussed during the pre-test information and counselling sessions and re enforced duringpost-test sessions.

24

Paediatric HTC

Principle of paediatric HTC

Early diagnosis for HIV in exposed children is an essential part of any national HIV care and treatmentstrategy and this has a direct effect in the prognosis of these infants. The early diagnosis of childreninfected with HIV has many benefits for the children themselves, and the obvious one being theopportunity for children to access life-prolonging ART. Prompt and early diagnosis and treatmentinitiation in HIV-infected children markedly reduces their morbidity and mortality and can improvetreatment response and result in better clinical outcomes.

The guiding principle for providing HTC to children is based on the UN Convention on the Rights of theChild which states that, “the best interests of the child shall be a primary consideration” in allactions concerning children. Similarly, like in the HIV testing and counseling procedures for adults, the“3 Cs” principle of obtaining informed consent, ensuring confidentiality of the process and result, andproviding counselling and support to both children and their caregivers have to be observed andmaintained at all times.

I. ConsentParents, guardians, health or social workers may provide informed consent for HTC. For children underthe age of 18 years, the National Multisectoral HIV and AIDS Policy (2006) states that consent for HIVtesting, care, and treatment “…shall be sought from parents, guardians, caregivers, or health and socialworkers.” This policy allows healthcare providers to obtain consent from any of these individuals if theybelieve that testing is in the child’s best interest, or to refuse testing if they determine that testing wouldpotentially harm the child or family. The healthcare provider should always exercise professionaljudgment regarding the caregiver’s intent for testing and the child’s readiness to receive and acceptthe results of his/her HIV test.

II. ConfidentialityConfidentiality in the context of HTC refers to the privacy of the interaction between the client and theprovider. Any information related to a patient’s medical condition must be kept confidential. The child’sHIV status can only be shared with that child’s parents or guardian and the medical team caring for thatchild. All HTC sites must ensure the policies, training, and infrastructure needed to uphold patientconfidentiality and to protect patient privacy is in place.

III. CounselingIn the case of paediatric HTC, the child’s parent or guardian is counseled to ensure informed consent.Where appropriate, family/couple pre-test counseling should be given to both the parents of the child.The child should be offered testing following the counseling of parents, guardians or caregivers. Thosewho have informed the health care staff that their child is not to be tested should have their wishesrespected. Post-test counselling and appropriate referral to services for infected children must be madein the case of a positive test result.

25

Indications for paediatric HTC:Exposed infants or children <18 months are those who:

• Are born to HIV+ mothers• Test positive on a rapid antibody test even if the mother’s status is unknown.

Paediatric HTC SettingPaediatric HIV testing should be conducted in all HTC settings and entry points where adult testing isoffered. It should also be offered in paediatric specific settings including child welfare and paediatricwards.

Programme AchievementsThe key PMTCT programme implementation achievements include:

1. The increase in the service provision sites, for universal access to services; and2. The improvement on the treatment regimen from a single dose to a more efficacious ARV treatment

for PMTCT.

The recorded programme achievements have surpassed the Swaziland National Multisectoral HIV/AIDSStrategic Framework (NSF) 2009 – 2014 output level results of increasing the percentage of healthfacilities offering ANC services that also provide minimum package of PMTCT to 85% in 2011. Thisputs the country in line with its output level results of achieving 95% by 2014.

As stated earlier in this brief, there are 33,000 infants delivered annually in Swaziland and an estimated13,563 (41%) of whom are born to HIV infected mothers. Without intervention, the transmission rateof MTCT is estimated at 20%. With the single dose of Nevirapine, it drops to 11%, and to 4% and 2%with the dual and triple treatment, respectively. Clinical records show that only 4% of children aged6-8 weeks born to infected mothers are HIV positive. (Swaziland HIV Estimates and Projection Report,2010).

In 2009, an estimated 2,300 infants became infected during pregnancy, delivery and breastfeeding,indicating that PMTCT interventions prevented 59% of HIV infections in infants born to HIV infectedmothers. Antenatal coverage is almost universal with 97% of pregnant women attending ANC servicesat least once. Attendance by skilled personnel is also significant with 74% of women delivering athealth facilities.

Early infant diagnosis using the DNA PCR testing is also recommended for all exposed infants at 6weeks.

DNA PCR is a virologic testing method using the Dried Blood Spot (DBS) technique. This test detectsviral DNA and can be used to definitively diagnose children less than 18 months of age. This test is>96% sensitive at detecting HIV in infants as early as four weeks after birth.

26

(Table 6) ARV prophylaxis regimen for HIV infected mothers and exposed infants:

Pregnant womenwith indications forART (CD4 count<350cells/ or WHO stage3/4)

Pregnant womenwho are not yeteligible for ART (CD4count>350 cells/ andWHO

HIV infected womenseen in labour whohave not receivedARV prophylaxis

AZT start ing at14weeks or as soonas feasible thereafter

AZT 600mg + 3TC150mg + NVP200mg (stat)

AZT/3TC x 7 days

For breastfeedinginfantsDaily NVP from birthfor a minimum of 6weeks, and until 1week a f t e r a l lexposure to breastmilk has ended.Infants receivingreplacement feedingonlyDaily NVP from birthuntil6 weeks of age

Regimen for HIV Infected Mothers

Ante - Partum Intra - Partum Post- Partum Regimen forInfants

AZT+3TC+NVP AZT+3TC+NVP

AZT 600mg + 3TC150mg + NVP200mg (stat)

AZT+3TC+NVP

AZT/3TC x 7 days

Daily NVP for 6weeks

Capacity building for health care personnel

About 80% of health care providers, from a variety of health care delivery sites, have been trained onthe WHO adopted PMTCT guidelines. These training programmes were lead by the Sexual andReproductive Health Unit (SRHU), in the Ministry of Health, in collaboration with some external cooperatingand developmental partners and the UN agencies. Other forms of support received for the PMTCTprogramme included the provision of drugs as well as human resources in form of mentors andsupervisors to ensure adherence to the implementation of the PMTCT guidelines as well as the availabilityand access to services.

PMTCT Programme Opportunities

The PMTCT programme is well positioned to intensify and scale up the current response to achieveelimination targets. Among the opportunities to capitalize on are:

• Strong national commitment for PMTCT from the highest levels of government, development partnersand civil society.

• Financial and technical resources are available to support current MTCT elimination efforts.• The revised guidelines have been developed and are available for nationwide dissemination to

improve the scope of services and standardize the quality of care offered to pregnant women andbreastfeeding to prevent MTCT.

27

• The high ANC attendance rate (97%) and facility based deliveries (80%) can be leveraged to expandaccess to pregnant women to receive HIV testing and other PMTCT interventions to reduce therisks for MTCT during pregnancy, intra-partum and immediate post-partum.

• Immunization coverage for DPT is over 80% for DPT 1, which provides another opportunity toprovide mother-infant pairs with PMTCT services in the post-partum period.

• Location of PMTCT within the MNCH platform provides an entry point for the provision of integratedSRH and HIV services.

• Strong repeated post-test counselling for HIV negative pregnant women to support them to remainHIV negative, including support for condom use.

SEVENCHAPTER SOME CHALLENGES IN THE PMTCT

PROCESS

28

At 41.1%, Swaziland’s HIV prevalence rate among pregnant women is still very high. It can be translatedinto an estimated 13,536 pregnancies or HIV exposed infants a year. Within this context, HIV-relatedillnesses have become the leading cause of death for mothers and children, accounting for an estimated46% of maternal deaths and 47% of under-five deaths. Complications related to poor management ofbleeding during pregnancy and after delivery are the most frequent obstetric complications and a majorcause of maternal mortality.

Some of the constraints cited as contributory factors affecting the success of the PMTCT programmeinclude:

• Failure to adequately address primary prevention of HIV among HIV negative pregnant women sothat they remain negative.

• A low contraceptive prevalence rate which is at 47.7%, resulting in a high risk of early and unwantedpregnancies.

• Lack of access to quality and safe labor and delivery services.• Insufficient skilled personnel, equipment and supplies in the existing health facilities, especially in

clinics at the community level, which are closer to the majority of the people.• Inadequate referral systems at all levels which may be interpreted as lack of transport systems for

emergency obstetric cases as well as poor road networks, especially in the rural areas, where themajority of the population reside.

• Lack of community involvement particularly for men, in SRH issues including PMTCT.• Lack of waiting wards in most of the hospitals and health centers to accommodate women that

reside far from these facilities.• Poor follow-up of HIV positive mothers and HIV exposed children in care stand out as major barriers

to universal access to PMTCT services.

These challenges are evident through the high Maternal Mortality Rate (MMR) which stands at 589 per100,000 despite the high rate of 97% of pregnant women attending ANC at least once during theirpregnancy and 74% of pregnant women being attended to by skilled personnel during delivery. Onlyabout 47% attend ANC at least four times, and even lower, at 20%, who do so during the first trimester.

Virtual elimination of Mother to Child Transmission of HIVAs most of the countries with a high HIV prevalence rate among pregnant women, the Government ofSwaziland has called for the virtual elimination of Mother-To-Child Transmission by the year 2015.According to WHO, virtual elimination of MTCT is defined as <5% transmission of HIV from mother tochild, or 90% reduction of infections among young children by 2015.

The National Framework for Accelerated MTCT action (2011 – 2015), entitled “Elimination of New HIVInfections among Children by 2015 and Keeping Their Mothers Alive” was developed in 2011. The

29

strategy development process was led by the Ministry of Health in collaboration with numerous institutionsand individuals who provided technical and financial support.

The main focus of the strategy was to ensure strengthening and acceleration of the efforts to eliminateHIV transmission to children and improve the survival of mothers over the next four years, which willstrengthen and accelerate efforts to prevent HIV infection among infants and children, and to keep theirmothers alive.

(Figure 8). MTCT elimination conceptual framework

Virtual elimination strategic goal:The goal of the MTCT elimination strategy is to reduce new HIV infections among children to <5% by2015 and improving the survival of their mothers. It targets contributing to the attainment of MillenniumDevelopment Goals 4, 5 and 6, for, potentially, achieving an HIV free generation.

Priority ActionsThe Conceptual Framework for Elimination of MTCT aligned a number of priority actions which areneeded to address the current gaps and bottlenecks in service delivery in order to scale up PMTCT tothe level required to meet elimination targets, based on the gaps analysis of the PMTCT programme.These priority interventions include the following:

I. Coverage, Quality and AccessExpanding access to quality comprehensive PMTCT care at all ANC facilities by:• Integrating PMTCT interventions into the MNCH platform at each entry point (ANC, FP, Labour &

Delivery, Postnatal, including services targeting adolescents and teenage mothers), and strengtheninglinkages to TB, ART and other relevant services.

National strategic framework for accelerated MTCT action 2011 – 2015

Conceptual Framework for the Elimination of MTCT

• Geographic coverage (Population - Facility):bringing services closer to all women andchildren in need

• Quality/efficacy of interventions: providing themost efficacious/quality interventions

• Utilization of services

Health Systems StrengtheningStrengthening the MNCH platform through

innovations and quality improvement

Wo

rkin

g w

ith

com

mun

itie

s fo

rco

mm

unit

iesC

Q

U

30

• Enhancing capacity of MNCH for the early detection, care and treatment of HIV in pregnant andbreastfeeding women, their partners and infants.

• Incorporating quality peer support services provided by mentor mothers to increase knowledge,reduce stigma, and limit barriers to demand.

II. Health Systems Strengthening by:• Supporting translation of revised PMTCT guidelines (2010) into practice at regional and facility level

through dissemination to, and training of, service providers at all levels.• Developing packages of integrated services that respond to the specific context (community) and

needs of sub-groups (i.e. HIV negative women, care for HIV exposed infants including infant feeding,Family Planning at treatment centres).

• Disseminating guidelines and standard operating procedures to guide and support integrated care(HCT, PMTCT, FP, ART, TB) to women, children and their families.

• Capacity building and training of service providers to promote standardized services.• Addressing stigma and discrimination by health workers.• Encouraging male participation within the MNCH platform by changing health worker attitudes and

providing appropriate, male-friendly services.• Integrating supply chain management to minimize stock-outs of all diagnostics, drugs and other

essential commodities required in an integrated setting, rather than using vertical/silo type mechanisms.• Reviewing roles and responsibilities of the current workforce to address issues of work load and

inform formalization of task shifting/sharing including identification of tasks to be shifted to midwifes,nurses and the various cadres of community health workers (such as mentor mothers) and accreditationof training and remuneration.

• Addressing issues with the Human Resource system to ensure adequate staffing levels, timelyplacement of personnel and improved remuneration to encourage both retention and professionalperformance.

III. Working with Communities for Communities by:• Increasing community support, participation and mobilization for uptake of PMTCT, and strengthening

of community based referral and support networks.• Capacity building of civil society organizations and existing structures to deliver a continuum of

prevention, treatment, care and support services at community level.• Behaviour change communication interventions to promote involvement of male partners, significant

family members and communities to create a supportive environment for PMTCT.

Impact Target:The strategy impact level target is: Reduced new HIV infections in infants from 12% in 2010 to <5% by

2015

Outcome targets:There are five outcome level targets strategically aligned for the attainment of this impact indicator, andthese are:

1) Reduced new HIV infections among women attending MNCH facilities from 10% in 2010 to 5% in2015.

31

2) Reduced unmet need for family planning among women living with HIV from 37% to 5% in 2015.3) Reduced mother to child transmission of HIV during pregnancy, childbirth and breastfeeding from

12% in 2010 to <5% in 2015.4) Reduced HIV related deaths among mothers and children below five years by 75% by 2015.5) Improved health and community systems capacity to deliver quality prevention, care and treatment

services across the MNCH platform by 2013.

Output targets:Under these outcome targets are numerous output indicators to ensure that the outcome level targetsare met and eventually achieve the impact target.

EIGHTCHAPTER CONCLUSION AND

RECOMMENDATIONS

32

Conclusion

While Swaziland is a reasonably small country geographically and demographically, the country hasone of the world’s highest HIV prevalence rates. It is worth noting that HIV and AIDS remains a seriouschallenge in Swaziland, not only as a health issue but cutting across the country’s entire developmentspectrum.

There are a number of initiatives that are underway in Swaziland at a local level and as part of the globalresponse, but there is still a lot that needs to be done to reduce the high prevalence rate. The mediaíscoverage of HIV and AIDS in Swaziland also still leaves a lot to be desired, as the media reports generallytend not to adequately bring out the latest details about the pandemic in Swaziland and globally. Thisin turn results in members of the public not getting that information, which is of great essence in theirparticipation in the response.

The present and future success of national and global efforts to curb HIV and AIDS in Swaziland,including PMTCT, will in many ways depend on the efforts being put in place now.

Information plays a key role in influencing the decisions and actions individuals take, and as such themedia has a key role to play in ensuring that free flow of accurate information to foster decision making.Correct and timely information helps people appreciate the critical nature of the HIV and AIDS situationin Swaziland, and the role they can play in addressing the problem.

Effective decision making and action is only possible where there is accurate, up to date and easilyaccessible information. People can only make meaningful decisions on a subject to the extent to whichthey are informed about it. In this brief, it can be concluded that while there are a number of interventionsand initiatives to curb HIV and AIDS in Swaziland, the lack of information on the subject continues toslow progress.

There is a strong relationship between HIV prevalence and MTCT, and as such PMTCT is a key componentof the national response to the pandemic. Access to comprehensive information on PMTCT is of greatessence for the national response to be successful.

The media is a hub in promoting community awareness on HIV prevention and PMTCT interventionsfor better health outcomes of women living with HIV and their exposed and infected babies. It isrecommended, therefore, that apart from using this manual as a source of accurate data for theircoverage of HIV and AIDS, and PMTCT themes in particular, media houses should feel free to reproducethe information contained therein as part of training material for their Journalists, as long as adequatecredit is given to Panos Institute Southern Africa (PSAf).

33

Recommendations

The success of the national response to HIV and AIDS in Swaziland can only succeed with the collectiveefforts of different stakeholders drawn from government, civil society, private sector, cooperating partners,the media, academia, and most importantly the ordinary citizenry.

The following recommendations can also contribute towards the success of the HIV response inSwaziland:

• Framework for unlimited media access to information: The media (journalists and mediainstitutions) need to have unlimited access to information on national and global efforts to addressthe pandemic. The media can only inform and educate the nation to the extent to which they (themedia) appreciate the subject. For this to happen, different stakeholders involved in the nationalresponse to HIV and AIDS should take deliberate measures to engage the media as a key partnerof the national response.

• Setting up of a resource centre/focal point for journalists: The NERCHA, government and otherstakeholders participating in the national response should establish a focal point through which themedia can easily access up to date information on HIV and AIDS, PMTCT and other related issues.The reason why the mediaís coverage of HIV prevention is partly due to the lack of a clear mechanismfor coordinating media coverage of the subject. As highlighted in this media brief, there are a numberof initiatives to address HIV and AIDS in Swaziland, but most of this information is not readilyavailable to the media.

• Establishment of a strategic platform for information sharing: Journalists in Swaziland havelacked a platform through which they can access information and participate in the debate aboutHIV and AIDS. This could be done through incorporating journalists into the formal structures thatcoordinate the national response, such as the NERCHA. This will enable the media to be an activepart of the response. More exposure will also enable the journalists to generate and disseminateinformation that may be used to guide planning processes.

• Research: There are a number of initiatives and interventions to address HIV and AIDS in Swaziland,but these are not yet translating into a significant reduction of the prevalence rate. There is needfor more investment into research to determine the various factors causing this trend, and use theresearch as the basis for decision-making, to ensure that the responses are targeted and responsiveto the needs of the ordinary Swazis. The media can and should also play a role in this research,generating evidence and ground breaking information to guide the response.

• Monitoring and evaluation systems: In order to clearly determine the impact of the variousinitiatives in place to address HIV and AIDS, there is need for a clear institutional monitoring andevaluation framework. It is recommend that individual journalists and media institutions should alsobe part of this mechanism. Good media coverage can also be the basis for monitoring, trackingand evaluating the national response.

1. Draft National HIV Prevention Policy, 2011.

2. Improving the Quality of Maternal and Neonatal Health Services in Swaziland: A Situation Analysis,May 2011, Ministry of Health

3. Ministry of Health Routine HMIS Database

4. National Strategic Framework for Accelerated MTCT Action, 2011 – 2015

5. Service Availability Mapping, 2010

6. Swaziland 12 Round HIV Sentinel Surveillance Report, 2010

7. Swaziland HIV Prevention Response and Modes of Transmission Analysis, 2008

8. Swaziland National Guidelines on HIV Testing and Counselling, November 2009

9. Swaziland National Multisectoral HIV & AIDS Strategic Framework 2009 – 2014.

10. WHO, 2010 PMTCT Strategic Vision, 2010 – 2015. Preventing mother-to-child transmission of HIVto reach the UNGASS and Millennium Development Goals. MOVING TOWARDS THE ELIMINATIONOF PAEDIATRIC HIV | FEBRUARY 2010 [On line] From: http://whqlibdoc.who.int/publications/2010/9789241599030_eng.pdf

34

REFERENCES

dmukand@yahoo.com

Vision: A southern African communitythat drives its own development

Contact us

Regional Office

Email: general@panos.org.zm

Mozambique Focal Point

Av. Vladmir Lenine

568-1st Floor

Tel/fax: +258-1-21305064

Email: mozambique@panos.org.zm

South Africa OfficeP.O. Box 3286, Parklands, 2121

Jan Smuts Avenue, 3rd Floor

Rosebank, 2196

Johannesburg

Email: admin@panos.org.za

Panos Institute Southern Africa