Swaziland FINAL_HLM_MTR Stock-Taking Final Report 2013.pdf

The Kingdom of Swaziland2011 UN General AssemblyPolitical Declaration on HIV/AIDSMid-term Review Report of the “Ten Targets”Final ReportMay/June 2013

ForewordThe 2011 UN “Political Declaration on HIV/AIDS: Intensifying our Efforts to Eliminate HIV/AIDS”builds on two previous political declarations: the 2001 Declaration of Commitment on HIV/AIDS andthe 2006 Political Declaration on HIV/AIDS.The 2011 Political Declaration on HIV/AIDS recognizes the urgent need to achieve the MilleniumDevelopment Goals (MDG) targets, particularly MDG 6 aimed at halting and reversing the HIVepidemic by 2015. It includes decisions and targets to be reached by 2015 aimed at; reducing by halfthe sexual transmission of HIV and HIV infection among people who inject drugs; increasing thenumber of people on treatment to 15 million; halving tuberculosis-related deaths in people livingwith HIV; eliminating new HIV infections among children; increasing resources for HIV in low andmiddle income countries; strengthening integration of HIV with health and development sectors;eliminating stigma and discrimination and travel restrictions; and addressing gender inequalities.This report presents the country’s progress towards meeting the ten targets of the Declaration.The Kingdom of Swaziland is committed to achieving the ten targets and positions the multisectoralresponse on HIV and AIDS as an integral part of the national development agenda. Since 2011, theKingdom has seen significant progress in the number of people accessing HIV treatment, Preventionof Mother to Child Transmission of HIV has been virtually eliminated at 6-8 weeks, HIV and AIDSprogrammes are being integrated into development sectors and funding for the response bydomestic sources is on an increase. In FY 2010/11 the Government of Swaziland was the sole funderfor ARV drugs and was able to meet national demand.The report provides a detailed analysis of the country’s progress in meeting the ‘Ten Targets’ of thePolitical Declaration, with recommendations. The recommendations will guide the country inensuring that the targets are met. Its development is based on a wide stakeholder consultationinvolving government, civil society, private sector, multilateral and bilateral partners.His Majesty’s Government recognizes the achievements the country has made but alsoacknowledges the challenges. It is my sincere hope that we accelerate our efforts in achieving theten targets by 2015.HLM Mid-Term Review for SwazilandPage i

AcknowledgmentsThe national midterm review of the 2011 UN “Political Declaration on HIV/AIDS: Intensifying ourEfforts to Eliminate HIV/AIDS” was commissioned by the Government of the Kingdom of Swazilandin collaboration with UNAIDS. The process started in March 2013, with the development of theGlobal AIDS Response Progress Report (GARP) which was a quantitative report summarising progressmade by Swaziland in the “ten targets” between 2011 to 2013. Key stakeholder interviews and thestocktaking workshop contributed to informing this report. The stocktaking exercise comprised of acritical appraisal of progress made, challenges and key recommendations to accelerate actiontowards meeting the High Level Meeting Targets by 2015.The National Emergency Response Council on HIV/AIDS (NERCHA) supported by UNAIDS, providedleadership in the development of this report. This was achieved through a widely consultativeprocess, involving multisectoral stakeholders. NERCHA acknowledges the contribution to thenational HIV response and the HLM report by government, civil society, private sector, multilateraland bilateral partners, people living with HIV and AIDS and all the people of the Kingdom ofSwaziland.Special gratitude goes to the key informants and all other respondents, who provided valuableinformation on the status of the response and insight on how best the country can accelerate theresponse to achieve the HLM targets.NERCHA would like to extend special gratitude to UNAIDS and the core team for the technical andfinancial support for this effort.HLM Mid-Term Review for SwazilandPage ii

Table of ContentsForeword .................................................................................................................................................. iAcknowledgments ................................................................................................................................... iiList of acronyms ..................................................................................................................................... iv1. Background and Context ..................................................................................................................... 11.1 Brief overview of the HIV epidemic and national response ......................................................... 11.2 Overall development since the adoption of the Political Declaration .......................................... 22. HLM Mid-Term Review Process and Methodology ............................................................................ 42.1 HLM Mid-term review processes .................................................................................................. 42.2 Utilization of the Ten Targets Tracking Tool ................................................................................. 42.3 Scope of the stocktaking exercise ................................................................................................. 42.4 Summary of Performance of National Response in intensifying efforts to meet PoliticalDeclaration Ten Targets ...................................................................................................................... 53. Target-by-Target Review and Analysis ................................................................................................ 83.1 Target 1: Halve sexual transmission of HIV by 2015 .............................................................. 83.2 Target 2 - Reduce transmission of HIV among people who inject drug by 50% by 2015 ....... 93.3 Target 3 - Eliminate HIV in children (PMTCT) and keep their mothers alive ........................ 103.4 Target 4 - Have 15 million people living with HIV on ART by 2015 ....................................... 113.5 Target 5 - Reduce tuberculosis deaths in PLHIV by 50 % by 2015 ........................................ 123.6 Target 6 - Close the Resource gap ........................................................................................ 143.7 Target 7 - Gender Inequalities: ............................................................................................. 153.8 Target 8 - Eliminate Stigma & Discrimination: ..................................................................... 163.9 Target 9 - Eliminate Travel Restrictions ................................................................................ 173.10 Target 10 - Strengthen HIV Integration: ............................................................................... 17Annexes ................................................................................................................................................. 20Annex 1 Ten-by-Ten Target Matrix ............................................................................................. 20Annex 2 Road Map ...................................................................................................................... 24Annex 3 Key informants .............................................................................................................. 26Annex 4 Stakeholders in Validation Meetings ............................................................................ 28Annex 5 References .................................................................................................................... 29HLM Mid-Term Review for SwazilandPage iii

List of acronymsABC - Abstinence, Be faithful and CondomiseAIDS - Acquired Immune Deficiency SyndromeAMICAALL - Alliance of Mayors’ Initiative on AIDS at Local LevelANC - Antenatal CareART - Antiretroviral TherapyARV - Antiretroviral DrugsAZT - ZidovudineBCC - Behaviour Change CommunicationCANGO - Coordinating Assembly of NGOsCBO - Community based organizationsCCM - Country Coordinating MechanismCHBC - Community Home-based CareCSW - Commercial Sex WorkerDPM - Deputy Prime MinisterEMIS - Education Management Information SystemGFATM - Global Fund to fight AIDS, TB and MalariaHCW - Health Care WorkersHIV - Human Immunodeficiency VirusHMIS - Health Management Information SystemHTC - HIV Testing and CounsellingIEC - Information, Education and CommunicationMC - Male CircumcisionM&E - Monitoring and EvaluationMARPs - Most-at-risk populationsMOE - Ministry of EducationMOF - Ministry of FinanceMOEPD - Ministry of Economic Planning and DevelopmentMOH - Ministry of HealtheMTCT - Elimination of Mother-to-Child TransmissionNAP - National Action PlanNASA - National AIDS Spending AssessmentNBTS - National Blood Transfusion ServiceNTCP - National Tuberculosis Control ProgrammeNERCHA - National Emergency Response Council on HIV and AIDSNARTIS - Nurse-led ART initiationNGOs - Non-Government OrganisationsNSF - National Strategic FrameworkNSP - National Strategic PlanNVP - NevirapineOIs - Opportunistic InfectionsOVC - Orphans and Vulnerable ChildrenPEP - Post Exposure ProphylaxisPLHIV - People Living with HIVHLM Mid-Term Review for SwazilandPage iv

PMTCT - Prevention of Mother-to-Child TransmissionRHMS - Rural Health MotivatorsSDHS - Swaziland Demographic and Health SurveySNAP - Swaziland National AIDS ProgramSOP - Standard Operating ProceduresSTI - Sexually Transmitted InfectionSWABCHA - Swaziland Business Coalition on HIV and AIDSSWANNEPHA - Swaziland National Network for People Living With HIV and AIDSTB - TuberculosisTWG - Technical Working GroupUN - United NationsUNAIDS - Joint United Nations Program on HIV/AIDSUNICEF - United Nations Children’s FundURC - University Research CouncilVCT - Voluntary Testing and CounsellingHLM Mid-Term Review for SwazilandPage v

1. Background and ContextSwaziland is a landlocked country in southern Africa with a land surface area of about 17,364 squarekilometres. It is divided into four administrative regions namely Hhohho, Shiselweni, Manzini andLubombo. It is further subdivided into 55 Tinkhundla (constituencies) and 360 chiefdoms and towns.The estimated population of the country is 1,018,449 people, with 52 percent under the age of 20years, while 52.7% are females. The country is classified as a low-middle income country with anincome per capita of 3,475 (US dollars) in 2012 although the last twenty years have seen economicgrowth decline drastically from averages of 8% per annum to averages of 2%. An estimated 81% ofthe population lives on less than US$2 per day source.1.1 Brief overview of the HIV epidemic and national responseSwaziland’s HIV prevalence is estimated at 26 per cent of the population aged 15–49 years(Swaziland Demographic and Health Survey, 2007). The country has a tuberculosis (TB) incidencerate of 1,380 TB cases per 100,000 per year (Ministry of Health Annual TB Report, 2012). The SDHSof 2007 shows that women aged 15–49 have a higher prevalence than men (31 per cent and 20 percent respectively), with prevalence peaking earlier among women (25–29 years) than men (30 – 34years). The peak in HIV prevalence has shifted to older ages for both sexes to 30 - 34 year olds forwomen and 35 – 39 year olds for men SHIMS, (2011). HIV prevalence among Men having Sex withMen (MSM) is 17.7% and high among sex workers at 70.3% (BSS MARPS, 2011). HIV prevalence isevenly distributed across the regions in the country. Life expectancy at birth had declined from ahigh of 60 years in 1997 to 33 years in 2001 and in 2007 it stood at 47 years for women and 43 yearsfor men (PHC, 2007).According to the SHIMS (2011) HIV prevalence is 31% and incidence is 2.38% in the age group 18 –49 years. There are 3 incidence peaks for women in the ages 18 – 19, 20 – 24 and 35 – 39, whilethere is one peak for men at ages 30 – 34. The Modes of Transmission Report (2009) shows that over90% of new infections occur through heterosexual contact and about 68% of all new HIV infectionsin adults occur in persons above 25 years.Figure 1: HIV Incidence 2011, by genderHLM Mid-Term Review for Swaziland Page 1

The knowledge of one’s HIV status among the 15-49 age group has increased from 16% (SDHS, 2007)to 40%; 47% among women and 32% among males (MICS, 2010)The devastation of the AIDS epidemic is evident from the rising number of orphaned and vulnerablechildren as well as other devastating social and economic impacts.National HIV ResponseThe national response has evolved from health sector focus to a multisectoral approach guided bythe results oriented and evidence based planning. The National Multisectoral Strategic Frameworkon HIV and AIDS 2009-2014 (NSF) has guided the response since the 2011 Political Declaration,whose goal is ‘To contribute to the improvement of the Swaziland Human Development Index from0.542 in 2008 to 0.55 in 2014’. The NSF has four thematic areas of prevention, treatment care andsupport, impact mitigation and response management. The NSF prioritized social and behaviourchange communication, condom management and distribution, prevention of mother to childtransmission of HIV and male circumcision in prevention. The priority focus for treatment, care andsupport includes provision of HTC, provision of Pre-ART and ART services and the management ofTB/HIV co-infection. The core focus for impact mitigation is to provide, education support,socialization and protection, provision of psychosocial support, food and nutrition for vulnerablehouseholds for Orphans and Vulnerable Children, (OVC) people living with and affected by HIV andcareers, while response management focused on community system strengthening, coordinationand partnership, strategic and action planning, program and project development, capacitydevelopment, mainstreaming policy development and advocacy, resource mobilization andmonitoring, evaluation and research.The country is currently engaged in the process of extending the NSF which will embrace theinvestment approach to improve efficiencies and effectiveness of the response. The Three OnesPrinciple is wholly embraced in Swaziland.Political supportPolitical commitment and support for the national HIV response has remained high with leadershipat all levels supporting HIV programs. Government budget for HIV and other social sectors weresustained during the fiscal financial challenges that the county faced after the political declarationon HIV and AIDS. The Government has continually increased the budget for ARVs, health sector, andsocial services on annual basis. The coordination of the response is funded through NERCHA who hasstrengthened the decentralized coordination mechanism resulting in a mature HIV and AIDSresponse. The country has created an enabling legal and policy environment to respond to HIV andAIDS including the National Prevention Policy (2012), Sexual and Reproduction Health Policy (2013),Gender Policy (2010) and the passing of the Sexual Offenses and Domestic Violence Bill (2013) byparliament.1.2 Overall development since the adoption of the Political DeclarationSince the adoption of the 2011 Political Declaration the country has ensured critical involvement ofkey stakeholders on achieving the agreed HLM targets. Subsequent to that a number of strategicinterventions were strengthened with adoption of new ones and these included development andimplementation of:HLM Mid-Term Review for Swaziland Page 2

Elimination of Mother to Child Transmission and Keeping their Mothers Alive Strategy andAction Plan (2011) Accelerated Saturation Initiative (ASI) for Medical Male Circumcision (2011) Joint Mid-term Review of the NSF (2011)Extended NSF embracing the Investment Approach.HLM Mid-Term Review for Swaziland Page 3

2. HLM Mid-Term Review Process and Methodology2.1 HLM Mid-term review processesThe High Level mid-term review process in Swaziland included an extensive preparation by NERCHAsupported by the UNAIDS country office and directed by the UNAIDS Guidelines. Literature reviewwas done and data collected from key informants. A stakeholder validation and consensus buildingexercise was also conducted, which led to the development of the road map with innovativestrategies to fast track progress towards achieving the targets by 2015. His Excellency the RightHonourable Prime Minister of Swaziland, Dr Barnabas Sibusiso Dlamini, graciously accepted to beinterviewed for this report including other senior Government officials from the Deputy PrimeMinister’s Office, Ministry of Finance and Education. Other stakeholders included Governmentofficials from different ministries development partners, private sector, non-governmentorganizations, faith based organizations, key populations and People Living with HIV.2.2 Utilization of the Ten Targets Tracking ToolThe UNAIDS ten target tracking tool was adapted as part of the interview guide and a summary ofthe key findings and recommendations were included.2.3 Scope of the stocktaking exerciseThe objectives of the stock taking exercise were:To assess the country’s progress towards meeting the ‘Ten Targets’ and if the country is ontrack to reach the targets;To define a set of recommendations to:o adopt or accelerate key programmatic actions necessary to stay on track and/orachieve priority targets;o trigger the changes in policy and/or enabling environment actions necessary to stayon track and/or achieve priority targets;o encourage new investments necessary to stay on track and/or achieve prioritytargets;To develop an acceleration roadmap to ensure the implementation of proposedrecommendations.HLM Mid-Term Review for Swaziland Page 4

2.4 Summary of Performance of National Response in intensifying efforts to meet Political Declaration Ten TargetsPolitical Declaration TargetsBaseline2011Mid-TermPerformanceSwaziland 2015TargetCountry Potential to meet 2015 targetTarget one: Halve sexual transmission of HIV by2015HIV incidence rateOverall: 2.6% Overall: 1.9% Overall: 1.3%Country needs to accelerate efforts to meet the2015 target, but is on course to reducingincidence.Target two: Reduce transmission of HIV amongpeople who inject drugs by 50% by 2015No baseline Not Applicable N/A N/A. Programme is not a priority for SwazilandNot applicableTarget three: Eliminate new HIV infections amongchildren.Percentage of infants who are born to HIV-infectedmothers who are HIV positive (modelled)16.4% 12.6% 5%Yes. Country has met target at 6-8 weeks andwill sustain the gains.Target four: Have 15 million people living with HIVon ART by 2015Percentage of eligible persons receivingALL: 81.6%%Children:84.3%Adults:53.2%ALL: 84.8%Children: 60.2%Children: 95%Adults: 90%Yes. Country has met target for adults and ismost likely to meet the target for children.HLM Mid-Term Review for Swaziland Page 5

antiretroviral therapy Adults: 88.3%Target five: Reduce tuberculosis deaths in PLHIV by50% by 2015Percentage of incident TB cases among PLHIV whohave successfully completed their TB treatment62% 65% 75% Yes. Country is most likely to meet the target.Target six: Close the resource gapPercentage of National expenditure spent onhealth, including HIVTarget seven: Eliminate gender inequalities (genderbased violence and abuse of young girls andwomen)Reduce number of women who experience GenderBased Violence (GBV) from their male partner7% 13% 15%No baseline 7.7% 5%Yes. The country is on track to meeting thetargetNo. Country is unlikely to meet the target. Thereare programs to reduce gender inequalitiesTarget eight: Stigma and discrimination47%No recent data65% No. Country is unlikely to meet the target.HLM Mid-Term Review for Swaziland Page 6

Percentage of people aged 15-49 that expressaccepting attitudes towards PLHIV is increasedfrom 47% in 2010 to 65% in 2015Target nine: Eliminate travel restrictionsNot ApplicableNo baseline Not Applicable N/A N/A. Programme does not apply for Swaziland.Target ten: Strengthen HIV integrationPercentage of National Sectoral Development Plans(SDPs) that allocate at least 5% of their totalbudget to HIV and AIDS activities40% No data 60% Yes. Sectors prioritizing HIV response.HLM Mid-Term Review for Swaziland Page 7

3. Target-by-Target Review and Analysis3.1 Target 1: Halve sexual transmission of HIV by 2015Swaziland Target: HIV incidence reduced from 2.6% in 2011 to 1.3% in 2015Preliminary HIV Estimates and Projections (2013) reveal HIV incidence in 2013 as 1.9%. The SHIMS(2011) revealed that among people aged 18-49 years HIV incidence is 2.38%, which is 3.14% forwomen and 1.65% for male. HIV incidence peaks in 3 age groups among women, 18 – 19, 20 – 24and 35 – 39, while there is one peak for men at ages 30 – 34. The SHIMS further shows hugereductions in prevalence amongst young people, with a 54% and 20% reduction observed amongstmales and females respectively .Findings from the Behavioural Sero-Sentinel Surveillance (BSSMARPS, 2010) revealed that HIV prevalence among female sex workers is high at 70.3% compared to31% for females in the general population and lower among men who have sex with men at 17.7%compared to 19% for males in the general population as observed in the SDHS (2007).The majority of HIV infections in Swaziland occur due to heterosexual transmission (MoT, 2009).Drivers of the epidemic include: Multiple and Concurrent Sexual Partners (MCP); Low andinconsistent condom use; Low levels of male circumcision; Sex work; Low levels of HTC; HIV Stigma& discrimination; Early sexual debut and intergenerational sex. Social-cultural factors, economicstatus and gender inequalities exacerbate the spread of HIV.The country has prioritized high impact interventions to reduce sexual transmission of HIV. Theinterventions include social and behaviour change (SBC), HIV testing and counselling (HTC), Condompromotion and distribution, Male circumcision and customized interventions for key populations(sex workers, men who have sex with other men, young people, prisoners and mobile populations)at higher risk of HIV infection. Vulnerable groups that include women and girls, people withdisability, and orphans and vulnerable children (OVC) are also targeted.Achievements:The following are key policies, interventions and strategies that Swaziland successfully put in placesince 2011;Policies, strategies and guidelines were developed and reviewed to support HIVprogrammes. These include National Prevention Policy (2012), SRH Policy (2013), GenderPolicy (2010) and the passing of the Sexual Offenses and Domestic Violence Bill (2013) byparliament, Stigma and Discrimination, SRH and eMTCT Strategies as well as PMTCT and HTCguidelines Scaling-up of HIV prevention services including HTC (238,791 HIV tests conducted in 2012compared to 163,964 in 2011). In an effort to scale up testing and counselling, MOHintroduced ‘a love test’ campaign targeting couples. Social and Behaviour Change Programshave been integrated across all HIV programmes.All primary and secondary schools have integrated HIV prevention into their schoolcurriculum, with over 300 schools implementing ‘Schools as Centres of Care Initiative 1 ’1 Holistic Approach to ensuring the welfare of childrenHLM Mid-Term Review for Swaziland Page 8

The male circumcision campaign known as Accelerated Saturation Initiative (ASI), targeting80% male adults was launched. Male circumcision prevalence has increased from 8% (SDHS,2007) to 21% (SHIMS, 2011).Studies and programmes for key populations like sex workers and MSM for instance wereimplemented. The government has initiated and is supporting interventions that target keypopulations including mobile populations, prisoners, sex workers and MSM.Youth friendly corners for SRH services have been establishedChallenges:Despite the progress made to reduce sexual transmission of HIV, the country still faces challenges tomeet the target, and these include:Limited interventions targeting young girls and existing programmes for youth are limited tourban areas.Limited targeted and evidence informed interventions to ensure scaling -up andintensification of programmes. Current programmes for key populations (sex workers, MSM,prisoners, mobile populations, women and girls) are not at scale.Limited prioritization and resource allocation for HIV prevention resulting in inadequatecoverage and distribution of HIV servicesStructural drivers of the epidemic are not adequately addressed in HIV preventionprogrammes. For example high unemployment in youth allows them the opportunity toengage in unproductive yet harmful behaviour.Recommendations:In order to accelerate progress towards meeting this target, the following were recommended;1. Implement targeted and evidence informed combination prevention strategies for womenand girls, mobile populations, youth and -key populations2. Ensure prioritization of and resource allocation for high impact HIV prevention programmes.3. Strengthen community systems and intensify community mobilization for HIV preventioninterventions uptake.3.2 Target 2 - Reduce transmission of HIV among people who inject drug by50% by 2015Swaziland Target: Currently Not applicable.Injecting Drug Use (IDUs) is not a significant driver to the epidemic in Swaziland and therefore thistarget is not a priority for the country. A rapid assessment among fifty drug users, found that 62.5%of these used injectable drugs and 92% self-reported ever sharing injectable devises (MOH, 2011).Although it is acknowledged that there are Injecting Drug Users (IDUs), there is insufficient data toprioritize this population group and therefore requires further surveys to determine the populationsize of IDUs.HLM Mid-Term Review for Swaziland Page 9

Recommendations:In order to accelerate progress towards meeting this target, the country will Commission studies todetermine the magnitude IUDs3.3 Target 3 - Eliminate HIV in children (PMTCT) and keep their mothersaliveSwaziland Target: Reduce Mother to Child Transmission of HIV from 16.4% in 2011 to 5% in 2015and maintained as 5% in 2018Swaziland has prioritized elimination of HIV in children and keeping their mothers alive. There isevidence that fewer children are getting HIV from their mothers and this is due to the PMTCTprogramme. According to the MOH annual report for 2012-13, the percentage of HIV infectedinfants born to HIV positive mothers decreased from 12% in 2011 to 3% by end of 2012 amongst 6-8weeks. The percentage of infants born to HIV-positive pregnant women who received a virologicaltest for HIV within two months of birth increased from 68.9% in 2011 to 78.9% in 2012.Achievements:Swaziland has done significantly well for this target and key achievements include:• Program scale up through implementation of the National Elimination Action Plan aimed ateliminating new HIV infections among children by 2015 and keeping their mothers alive. Thishas led to an increase in the PMTCT coverage with 150 out of 171 Maternal, Neonatal andchild health (MNCH) care facilities providing PMTCT services, and 91% HIV-positive pregnantwomen provided with PMTCT services.• Piloting of Option B+, with ART provided to all HIV positive pregnant women for their ownhealth• Strengthened integration of PMTCT with Maternal, Neonatal and child health services(MNCH) services, in an effort to address all the four (4) prongs of PMTCTChallenges:Despite the progress made to reduce mother to child transmission of HIV, the country still faceschallenges to meet the target, and these include:• High Maternal sero-conversion among pregnant women; with an estimated 8% initially HIVnegative pregnant women testing HIV positive during labour, delivery and post natal• High infant sero conversion post 8 weeks with limited interventions.• Weak health and community systems for longitudinal follow up of mother and infant pairs.• The Maternal Mortality Rate is estimated at 320 per 100,000 live births in 2010, with anestimated 60% of the deaths among HIV positive women.HLM Mid-Term Review for Swaziland Page 10

RecommendationsIn order to accelerate progress towards meeting this target, the following were recommended;1. Scale-up implementation of the National Elimination Plan2. Intensify the integration of HIV and Sexual Reproductive Health (SRH) within healthprograms (FP, cervical cancer screening and ART), referral systems for eMTCT within SRH.3. Strengthen demand creation strategies for accessing quality and comprehensive PMTCTservices across the continuum of care (prenatal, ANC, intra partum, post-partum and FP)4. Mitigate the high sero-conversion of infants post 8 weeks.5. Invest in strategies for addressing social cultural barriers to access PMTCT (such as stigmaand discrimination, social norms, gender and culture)6. Improve research to inform efficiency and effectiveness of the MTCT programmes.3.4 Target 4 - Have 15 million people living with HIV on ART by 2015Swaziland Target: Increase the percentage of eligible adults and children who are currently receivingantiretroviral therapy from 84% in 2011 to 90% in 2015 and to 95% in 2018The aim of the ART programme is to reduce morbidity and mortality among people living with HIV. InSwaziland, ART is provided for free based on national eligibility criteria of CD4

• Food by Prescription is implemented for nutrition support for clients accessing ART or TBtreatment, improving uptake and retention on ART.Challenges:The major challenges faced in this target are as follows;• Weak referral system from HTC to ART programmes, resulting in lost to follow and poortreatment adherence.• Inadequate system for identifying children post 8 weeks to 14 years of age that are exposedto or have contracted HIV.• Weak monitoring systems for private facilities that provide ART interventions.RecommendationsThe recommendations for addressing the challenges identified are:1. Strengthen the referral system and tracking mechanisms for PLHIV to ensure timelyinitiation and retention on ART.2. Strengthen follow-up of HIV-exposed infants and identify children with HIV to improvelinkages to ART initiation and retention for both groups.3. Strengthen community systems to enhance continuum of care for HIV/ TB and support forPLHIV4. Strengthen Nurse-led ART initiation (NARTIS).3.5 Target 5 - Reduce tuberculosis deaths in PLHIV by 50 % by 2015Swaziland Target: Percentage of incident TB cases among PLHIV who have successfully completedtheir TB treatment has increased from 62% in 2011 to 75% in 2015 and 85% in 2018.The risk of developing TB is between 20 and 37 times greater in PLHIV than among those who do nothave HIV infection. Mortality is high among PLHIV with tuberculosis that are not timeously initiatedon TB treatment as well as those who are not initiated on ART within two months on anti-TBtreatment. According to the 2012 National TB Programme report, 92% of TB clients were tested forHIV and 80% tested HIV positive. Of those 94% were initiated on Cotrimoxazole prophylaxis and 68%were initiated on ART within 2 months of anti-TB treatment. The emergence of MDR-TB continuesto be a global challenge and Swaziland is no exception. The MDR-TB accounts for 8% of the TBtreatment failure cases in Swaziland. In 2012, over 300,000 TB screenings were conducted using thesymptom screening (which relies on five clinical symptoms) in HIV clinical settings and outpatientsdepartmentsAchievements:Swaziland has realized achievements in this target as evidenced by the following;TB/HIV integration at national and health facility level has improved uptake of HIV testingand counselling among TB patients (92% in 2012), and of ART among TB/HIV patients (from32% in 2010 to 68% in 2012), and this has reduced mortality among TB/HIV co-infectedpatients from 18% in 2007 to 9% in 2012HLM Mid-Term Review for Swaziland Page 12

Accelerated implementation of the 2012 Drug-Resistant TB Management Guidelines anddecentralization of MDR-TB management to include Community MDR ManagementDOTS coverage is national and community DOTs is supervised by community or familytreatment supporters. This has ensured improvements in treatment success which was 73%in 2012 and a reduction of default rate among TB patients to 5 % in 2012.Improveddiagnostic capacity for TB and MDR TB with the roll out of XpertMTB/RIF (GeneXpert) andLine Probe Assay technology.Challenges:Despite these programmatic achievements, challenges still remain;TB infection rates among PLHIV are still very high. TB screening for pre-ART patients is stilllow.The co-treatment rate is still low. Only 68% of TB patients co-infected with HIV receivedtreatment for both HIV and TB.The WHO framework of the 12 TB/ HIV collaborative actions are not fully operationalized atall levels especially coordination at regional level and full integration of HIV and TB services.Weak DR-TB recording and reporting in the HIV care services and inadequate integration ofTB in HIV electronic systems results in weak monitoring systems TB/HIV collaborativeactivities and outcomes.Inadequate implementation of the Three ‘I’s (TB Infection control, Isoniazid preventivetherapy, and Intensified TB case finding) causes ineffective infection control in congregateand health facility settings and risk for MDR-TB and XDR TB transmissionInadequate programmatic management of MDR-TB and XDR-TB. Not all patients diagnosedwith MDR-TB are put on MDR-TB treatment and diagnosis of XDR-TB is still weak.Inadequate diagnosis and enrolment of children on to TB, MDR-TB and TB/ART. Only 45% ofchildren with TB/HIV received ART in 2012.RecommendationsThe recommendations for addressing the challenges identified are:1. Strengthen active collaboration and integration between TB and ART programmes and scaleupdecentralized HIV/TB services at all service delivery levels2. Strengthen active and passive TB case detection and engagement of communities toimprove TB/HIV performance utilizing the nurse-led TB initiation in clinics in order toimprove the uptake of services.3. Strengthen the molecular testing (rapid testing) results turnaround time to ensure clientsget results within 24 hours to improve timely enrolment into treatment.4. Strengthen childhood TB/HIV interventions to increase diagnosis of TB among children coinfectedwith TB/HIV and uptake of ART.5. Strengthen the implementation of the Three ‘I’s (TB Infection control, Isoniazid preventivetherapy, and Intensified TB case finding)HLM Mid-Term Review for Swaziland Page 13

6. Strengthen monitoring of HIV/TB interventions, especially within the HIV program.3.6 Target 6 - Close the Resource gapSwaziland Targets:a) Increase the proportion of national budget on health to 15%b) Increase the proportion of total expenditure on HIV and AIDS provided from domestic resourcesfrom 43.1% in 2009 to 45% in 2015 and 60% in 2018Swaziland is committed to sustaining the cost of the HIV and AIDS response and reviewingoperations to cut costs without compromising the quality of the interventions.The accurate tracking of where HIV funds are sourced and how funds are spent is critical as thecountry continues to scale up the national HIV and AIDS response. Government‘s revenue is heavilydependent on SACU collections which are limited and fluctuate due to different variables. Accordingto the NASA report of 2011, Swaziland revenues for HIV and AIDS are heavily dependent oninternational partners at 57% while 40% comes from public funds and only 3% is contributed by theprivate sector. This raises risks on the sustainability of the response.Achievements:Swaziland had made progress which includes:The NASA 2011, showed that spending on HIV and AIDS activities rose from E308 million inFY2007/08 to E583 million in FY2009/10.Government maintained resources for HIV and AIDS programmes - ARVs and access toimpact mitigation including education, food security and psychosocial support despite theeconomic crisis in the countryDevelopment and implementation of the Private Public Partnership Strategy and theEconomic Recovery Roadmap.The country maintains the “setting price ceiling” principle to keep the prices of HIV/AIDScommodities down; hence it procures from manufacturers that apply Good ManufacturingPractice (GMP). Applying this best practice was recognized and published by UNAIDS andsaved the country $20 million worth of HIV commodities.Challenges:Even though achievements have been observed, there are also some challenges that have beennoticed and these include the following;Lack of a HIV sustainable financing strategyFiscal dependence on fluctuating SACU revenuesThe cost of the HIV response is high for a small country with a population of just over amillion.International funding and donor funds are shrinking.HLM Mid-Term Review for Swaziland Page 14

Recommendations:The following recommendations were made;1. Develop an HIV sustainable financing framework and strategy that will also articulate thelonger term investment case for Swaziland.2. Strengthen strategies that promote efficiencies and cost effectiveness of the nationalresponse.3. Institutionalize tracking of all resources earmarked for the HIV and AIDS response inSwaziland and improve allocation of the resources.4. Implementation of the Private Public Partnership Strategy and the Economic RecoveryRoadmap.3.7 Target 7 - Gender Inequalities:Swaziland Target: Reduce prevalence of intimate partner violence among women aged 15 – 49from 7.7% in 2010 to 5% in 2015The country has made positive strides in addressing gender inequalities in the policy and legalframeworks. In the HIV response however, male involvement continues to be inadequate and thenumber of women who experience gender-based violence (GBV) from their male partners is highand the vulnerability of women and girls remains deeply rooted in gender inequalities. Thereforeaddressing gender inequalities is one of the country’s priorities in its endeavour to reduce HIVinfection.Achievements:The following are some of the achievements made to reach this target:Swaziland has demonstrated political will to address gender issues through adoption ofseveral policies to alleviate gender disparities and curbing the HIV epidemic. Amongst theseare the National Gender Policy, the Children’s Protection and Welfare Act and the SexualOffenses and Domestic Violence Bill passed by parliament in 2010, 2012 and 2013respectively.In 2011, Swaziland carried out a Gender HIV mainstreaming responsiveness assessment ofthe NSF and developed a Gender Mainstreaming Checklist to guide HIV programming.Capacity building initiatives have been undertaken to orient stakeholders on the checklist.The decentralization of social work services and the development of the National ViolenceSurveillance System in 2011 for survivors of GBV, child friendly courts, capacity building ofduty bearers on sensitive handling of GBV cases are some of the key milestones.Challenges:The target also faces some challenges such as the following;HLM Mid-Term Review for Swaziland Page 15

The complex relationship between violence against women and HIV is embedded andperpetrated largely by structural factors.The capacity of stakeholders to mainstream HIV and gender remains inadequate.The high adolescent pregnancy rate is an indication of the risky sexual behaviours amongstyouth and can be linked to gender inequalities.Recommendations:The recommendations for addressing the challenges identified in this target include;1. Scale-up implementation of targeted and evidence informed gender programmes in the HIVresponse.2. Mainstreaming of gender issues into National Development Plans with clear targets andsufficient resource allocation.3. Continue to advocate for gender equality to address structural drivers of HIV thatcompromise the quality of the national response.4. Intensify programmes targeting empowerment of young girls to reduce vulnerability in thisgroup.5. Strengthen comprehensive male engagement strategies on services for male partners atboth community and facility level and improve their health seeking behaviours.3.8 Target 8 - Eliminate Stigma & Discrimination:Swaziland Targets: Increase percentage of people aged 15 – 49 that express accepting attitudestowards PLHIV from 47% in 2010 to 65% in 2015Eliminating stigma and discrimination against people living with and affected by HIV is important toimprove access to prevention, treatment, care and support services. External stigma is still relativelyhigh, with only 47% of people in 2010 reporting accepting attitudes towards PLHIV, slight increasefrom 44% in 2007.The country conducted a stigma index in 2011 and it showed that internal stigma amongst PLHIV ishigh, with issues of guilt for being HIV positive (26%), isolation (14%), stopping sex and marriage(22% and 18% respectively), not wanting to have children (45%) and fear to access health care (4%).Achievements:Through the country’s efforts to reduce stigma and discrimination in national HIV response thefollowing have been achieved:The country conducted a stigma index in 2011 to determine and document the experiencesof stigma among People Living with HIV. The index informed the development of theNational Strategy for Combating HIV and AIDS Related Stigma and Discriminationinterventions and is being implemented.A legal, social and environment policy Assessment to identify the key barriers to HIVresponse and punitive laws against people living with HIV is on-going.HLM Mid-Term Review for Swaziland Page 16

Greater involvement of people living with HIV has improved at policy, programme andcommunity levels. Expert client programmes continue to be implemented at community andfacility level to improve access to and adherence to treatmentSupport groups have been scaled-up at community level, with over 400 support groups andover 7,000 PLHIV enrolledChallenges:Major challenges noticed for this target include;Low uptake of HTC (40%), indicating high levels of stigma.Inadequate knowledge about stigma and discrimination in HIV adversely affects disclosure topartners, health care providers and family members.Slow implementation of the recommendations from the stigma index.Recommendations:The recommendations for addressing the changes are;1. Improve access to legal services for PLHIV, girls and women, affected family members,communities and key populations to know their rights, policies and laws in the context ofthe HIV epidemic.2. Scale-up implementation of the Stigma index recommendations and the National Strategyfor Combating HIV and AIDS Related Stigma and Discrimination.3. Advocacy at national and community level to eliminate stigma and discrimination.4. Undertake a Legal environment assessment for stigma and discrimination.3.9 Target 9 - Eliminate Travel RestrictionsSwaziland Target: -The target is not considered applicable to the epidemic situation in the country.Swaziland does not have travel restrictions for PLHIV. Where travel restrictions exist they are notrelated to one’s HIV status but related to failure to fulfil the immigration requirements. Thereforethis target is not a priority for Swaziland.3.10 Target 10 - Strengthen HIV Integration:Swaziland Target: Percentage of national sectoral development plans that allocate at least 5%of their total budget to HIV and AIDS activities is increased from 40% in 2011 to 60% in 2014The Ministry of Health has made progress in integrating HIV services within the general health caresystem. HTC is provided at all service points as a basic health care service, PMTCT has beenintegrated within MNCH and there is improved integration of TB and HIV. All health care workers areworking within the Government Establishment Register, which rationalizes conditions of services.The Central Medical Stores in the country is the central procurement and distribution agent for allhealth commodities and drugs for all diseases. The Ministry of Health’s HIV Programme Monitoringand Evaluation (M&E) system has been integrated into the Health Management Information System(HMIS) aligned to the National Multisectoral M&E System coordinated at NERCHA.HLM Mid-Term Review for Swaziland Page 17

Alignment of HIV and AIDS policies, programs and services with national development plans isessential for meeting HLM targets. Development sectors have been mobilized and are implementingHIV responses based on their comparative advantages.Achievements:Since the 2011 Political Declaration efforts have been made to encourage sectors mainstream HIV,gender and human rights. The progress below has been made:Ministry of Health has successfully integrated HIV interventions with other health careservices. Family Planning, ART and PMTCT services are integrated with Maternal, Neonataland Child Health (MNCH).Among many other development sectors that have integrated HIV within their programs areMinistry of Agriculture and Ministry of Education (MoE). Within the MoE access to freeprimary education are mitigating the impact of HIV among Orphaned and VulnerableChildren (OVCs) and the Ministry of Agriculture has also integrated HIV and AIDS within theirannual plans and budgets through implementing food security program.The Ministry of Tinkhundla Administration and Development (MTAD) have strengthenedregional and lower level coordination for delivery of services including HIV and AIDSThe draft extended NSF (2014 – 2018) embraces the investment approach to improveefficiency and effectiveness of the national HIV response through integration and creatingsynergies with development sectors.Challenges:Despite these efforts the potential for further integration of HIV across all sectors has not yet beenfully realized. This is attributed to number of challenges including:While the MoH has made notable progress in integrating HIV in other health services therestill remain challenges, which include inadequate human resources and heavy reliance ofexternal support for HIV human resource requirement and inadequate integration of HIVwith other health services across boardFrom an aid coordination perspective there is limited coordination of donor funding for theHIV response and the health sectorInadequate understanding and capacity of the need for development sectors to integrateHIV, gender and human rights in the context of HIV and AIDS response.Inadequate commitment of leadership at senior sector management necessary to drive theprocess and in particular commit resources to support these initiatives.Absence of a vibrant national M&E framework for the national development strategyRecommendations:HLM Mid-Term Review for Swaziland Page 18

Swaziland needs to strengthen the sector system and capacity to ensure meaningful participation inthe HIV response through:1. Prioritize and strengthen key sectors to address HIV and gender issues based on theirinstitutional mandate and support capacity building for senior management to provideleadership in integration.2. Develop a national M&E framework to track progress in the implementation of the nationaldevelopment strategy3. Continue strengthening HIV integration within other health services4. Improve donor coordination and harmonization in order to develop sustainable financingstrategies for health and HIV5. Develop national mainstreaming guidelines to guide sectors in the development of theirresponse to HIV and AIDsGeneral Recommendations:The recommendations are:Finalize and accelerate implementation of the eNSF that will scale-up implementation of theHLM targets.Monitor implementation of the eNSF and the HLM MTR Acceleration Roadmap and ensuremobilization of adequate resourcesHLM Mid-Term Review for Swaziland Page 19

AnnexesAnnex 1Ten-by-Ten Target Matrix10 Key Questions1. Is this aprioritytarget forthe country?YN/A.Programme isnot a priorityfor SwazilandY Y Y Y Y Y N/A.Programmedo notapply forSwazilandY2. Does theNationalStrategicPlan orequivalentaddress thistarget?YN/A.Programme isnot a priorityfor SwazilandY Y Y Y Y Y N/A.Programmedo notapply forSwazilandY3. What keyactions havebeen takento reach thistarget since2011?Developed the National HIVPrevention PolicyDevelopment of the neweNSF which applies theinvestment thinkingHigh National leadershipand commitment ensuringcustomized HIV preventionprogrammes and servicesare accessible to keypopulations.Study on IDUshas beencarried outCountry isacknowledgingexistence ofIDUs. MoHand partnershavedevelopedproject forIDUsImplementationof the virtualeMTCTstrategyLaunch of theeMTCTstrategyPiloting ofOption B+Over 90% of peoplein need accessing lifesaving treatment.Governmentcommitmentfunding(sustainability)toARVsPiloting of Treatmentas Prevention• TB/HIV integrationhas improved uptakeof ART in TB clinics(from 68% in 2010 to73% in 2012) andthis has reducedmortality from 18% to9%AccelerationMDR/XDRtreatmentofTBThe ART enrolmentof co-infectedpatients has equallyimproved from 35%in 2010 to 66% in2012Government maintainedresources for HIV andAIDS programmes -ARVs and increase inaccess to impactmitigation includingeducation, food securityand psychosocialsupportNASA, resourcemapping, allocation andcostingThe country adheres toWHO TRIP guidelinesto ensure thatprocurement of criticalHIV commodities arestandardised.Amendments tothe SexualOffences andDomestic ViolenceBill of 2009Political will to dealwith gender issuesDecentralizedsocial workservices forsurvivorsNational Strategyfor Combating HIVand AIDS RelatedStigma andDiscriminationinterventionsdevelopedStigma IndeximplementedAdvocacyprogrammesPLHIVimplementednationally.forareHIV clinical serviceshave been integratedinto general healthcare servicesDevelopment of a neweNSF, applying theinvestment thinkingcreates an opportunityfor better HIV programintegration undersynergies withdevelopment sectorMDG 4,5 and 6integrationoperationalizedHLM Mid-Term Review for Swaziland Page 20

4. What keychallengesorconstraintshave beenencounteredinaddressingthis target?5. Is thecountry ontrack toreach thistarget?6. What are thekeyprogrammatic actionsnecessary tostay ontrack and/orachieve thistarget?Limited targeted andevidencebasedinterventions to ensurescaling -up and intensity ofprogrammesInadequate coverage anddistribution of HIV services(I.e. condoms tocommunities)Limited prioritization andresource allocation for HIVpreventionNo. However country is oncourse to reduce incidenceby 2015Ensure interventions aretargeted and evidencebased and implementedwithin the combinationprevention strategiesEnsure prioritization ofresource allocation to HIVprevention programmeStrengthen communitysystems for HIV preventioninterventionsNo specificinterventionsfor IDUsN/A.Programme isnot a priorityfor SwazilandIntervention tobe informed bythe studyfindingsHigh infantseroconversionpost 8 weeksHigh maternalmortality rate:estimated over60% ofmaternalmortality casesare among HIVpositivewomen.Weak M&EsystemsYes. Countryhas met targetand will sustainthe gainsStrengthen theintegration andreferralsystems foreMTCT withother HIV andhealth careservices.Strengthenintegration ofSRH the M&Esystems forfollow up andretentionScale-upimplementationoftheeliminationWeak referral andpatient trackingsystemWeak Paediatric andadolescent ARTprogrammeWeak monitoringsystems for HIV andTB co-infectionprogrammeYes. Country has mettarget for adults andis most likely to meetthe target for childrenStrengthen thereferral and patienttracking systemthroughout HIVservicesStrengthen follow-upof HIV-exposedinfants and childrenwith HIV to improvelinkages to ARTinitiation andretention for bothgroups.Strengthencommunity systemstoenhancecontinuum of care forTB infection rates arestill very highTB screening amongHIV pre-ART patientsstill lowWeak monitoringsystems for HIV andTB co-infectionprogrammeYes. Country is mostlikely to meet thetargetStrengthen activecollaboration andintegration betweenTB and ARTprogrammes andscale-updecentralized HIV/TBservices at all servicedelivery levelsStrengthen activeand passive TB casedetection; andengagement ofcommunities toimprove TB/HIVperformanceStrengthenmonitoring of HIV/TBinterventions,especially within theLack of sustainablefinancing strategyDependence of thecountry on SACUrevenues is high risk inclosing the resourcegapThe burden of fightingthe epidemic isprohibitively expensivefor a small country witha population just overone million.Yes. The country is ontrack to meeting thetargetDevelop a SustainableFinancing StrategyAdvocateforGovernment to continuemaking HIV aninvestment case forSwazilandStrengthen synergiesfor HIV with all sectorsGender BasedViolence still highin the countryHigh Adolescentpregnancy rateSocial-Culturaland traditionalnorms thatnegativelyinfluence genderrelationsNo. Country isunlikely to meetthe targetScale-upimplementation ofHIV genderprogrammes withclear targets andresource allocationScale-upinterventions formale involvementinHIVprogrammes toaddress genderinequalitiesMainstreamingandImplementation ofthe genderStigma still veryhigh. OVC that arePLHIV face doublestigma.Inadequateinvolvement ofPLHIV in thenational responseInadequateknowledge ofstigma anddiscrimination inHIV service uptakeNo. Country isunlikely to meet thetargetImplementation ofthe NationalStrategy forCombating HIV andAIDS RelatedStigma andDiscrimination.Strengthen effectiveparticipation andinvolve of PLHIV inHIV programmes toaddress stigma anddiscriminationUndertake a Legalenvironmentassessment forstigma andN/A.Programmedo notapply forSwazilandN/A.Programmedo notapply forSwazilandN/A.Programmedo notapply forSwazilandSomeprogrammesparallelHIVareSystems in the MoHnot fully integratedYes.prioritizingresponse.SectorsHIVAdvocate for betterlinkagesandintegration of HIVservicesandprogrammes into allsectors includingsufficient allocation ofresources as part ofthenationaldevelopment agendaEnsurethecoordination,management andimplementation of themultisectoral responseby all sectorsHLM Mid-Term Review for Swaziland Page 21

7. Whatpolicy/enablingenvironmentchanges arenecessary tokeep ontrack and/orachieve thistarget?8. What newinvestmentsarenecessary tokeep ontrack and/orachieve thistarget?9. What areyourrecommendImplement HIV PreventionPolicyProvide and prioritization ofresource allocated to HIVprevention programmeCreate synergies tostrengthening of serviceintegrationFocusing on high impactand cost effectiveprevention interventionsPrioritise resourceallocation for HIVpreventionEnsure linkages andintegration with other keysectorsFocusing on high impactand cost effectiveprevention interventionsplanImplementationof the SRHPolicyAccelerate theimplementationof the virtualeMTCTstrategyStrengthenMaleinvolvementStrengthencommunityinvolvementStrengthenParticipation ofcommunityHIV/ TB and supportfor PLHIVContinue committingfunds for ARVsIntegration of ARTwithotherprogrammesAdoption of B+OptionStrengthen linkageswithotherprogrammesStrengthen referralmechanismsImplement the ARTfor preventionHIV programmeContinued politicalcommitmenttranslated intoimmediate actionespecially withregards to increasingdomestic funding forTB.Encourageprivatepartnershipspublic,sectorEnsuretheintegration of HIV/TBcare at all levelsImplementation of thePrivatePublicPartnership strategyand the EconomicRecovery roadmapContinuous nationalpolicy dialogues onsustainable financing forHIV response.Developmobilizationandresourcestrategyprioritizedtargetedprogrammes in theHIV response ofgender issues intothe NationalDevelopment Planwith clear targetsand resourceallocation.Scale-upimplementation ofthe Gender Policyand NationalAction PlanGenderMainstreamingstrategy andchecklist for theHIV responseDevelop andimplement HIVand AIDSresponsiveGender policyImplementation ofthe gendertargeteddiscriminationThe country’s legalenvironment issupportive towardsaddressing stigmaand discriminationincluding NationalConstitution.Legal empowermentfor those affectedby HIV to know theirrights and laws inthe context of theepidemicDevelop Legalreform programmesto monitor lawsrelating to HIV.Strengthen stigma &discriminationreductionprogramme.Advocacy for lawreformThere is a need tomainstream HIV andAIDS programmesmultisectoral.Strengthening ofintegration within theNational Health Policy.Existence of cleartargeted nationalpolicies outliningguidance andstrategiesforintegration effort atscale.Sectors to Developcommon action planstoenhanceprogramme integrationandreduceverticalizationAlign sector planningto enhance integrationofresponsesHLM Mid-Term Review for Swaziland Page 22

ations toensure theimplementation ofsuggestedchanges?10. What are yourrecommendations forsustainingprogressalong thistargetbeyond2015?Integration of theinvestment approach inplanningandimplementation at all levels.Strengthen communitysystems to sustain thegains and improve linkageswith the health sectorImprove resource allocationfor high impact preventioninterventionsIncrease collaboration withexisting structures, andinnovating and identifyingthe support staff from thevarious regions and subregions.leaders programme ensure programmes programmes in theHIV responseCreate a socialmovement foreMTCTResourcemobilization forimplementationof the eMTCTstrategyDevelopinnovativestrategies forpreventinginfant seroconversionsuch asexploring otherinfant feedingoptionsStrengthenretention ofHIV positivemother in theARTprogrammeDecentralize services Mainstreaming ofgender issues intothe NationalDevelopment Planwith clear targetsand resourceallocation.Scale-upimplementation of theB+ Option; Continuemobilizing resourcesAdvance the nurseledTB initiation inclinics in order toimprove the uptake ofservicesMaintain and enhancestrategic partnershipsfor sustainable financingContinuous advocacyfor the government tocontinue committing therequired budget for HIVresponseGovernment to continuemaking HIV aninvestment case forSwazilandGovernment toallocate sufficientresources for thegender responseImprove targetingfor better andevidence basedgender responsiveprogrammingAdvocacy forgender equality interms of equal andfair allocation ofresourcesProvide legalservices for PLHIVand affectedmembers and keypopulationsTraining of dutybearers andstrengthening of thelegal responsetowards eliminationof stigma anddiscriminationUndertake a Legalenvironmentassessment forstigma anddiscriminationStrengthen andintensifytheintegration HIVinterventions withinhealthotherdevelopmentresponsesIncrease capacity ofthe health system tofunction smoothlyacross all keytechnical domainsEnsurethecoordination andmanagement of theimplementation of themultisectoral responseby all sectorsAdvocatefordecentralization andintegrationofHIV/AIDSprogrammes within allthe governmentsectors and at alllevels.Build capacity for allrole players within theHIV response tounderstand andembrace the conceptof integration.HLM Mid-Term Review for Swaziland Page 23

Annex 2Road MapHLM Target Key Steps Benchmark or Milestones Timelines by Year Responsible2013 2014 2015Implement targeted and evidence based combination prevention Increased numbers from the target group reached with SBC interventions with clearXNERCHA1. Halve sexual strategies for women and girls, mobile populations, youth and messages.transmission of HIV sex workersSocial and cultural norms that fuel the epidemic addressed. X X Xby 2015Linked and integrated HIV prevention programmes scaled up – SBCC, HTC, VMMC, X X XCondom, STIs, ART for preventionPrioritization of resource allocation for high impact HIV Cost and benefit analysis for prevention programs carried out X NERCHAprevention programmesHIV prevention expenditure using NASA has increased from 8% to 16% X Gov’t and Dev’tPartners, PPPKey sectors have integrated/mainstreamed HIV prevention in their annual plans andXGov’tbudgetsStrengthen community systems and intensify community Effective community based systems identified and documented. X NERCHA, MOHmobilization for HIV prevention interventions uptake2. ReduceCommission studies to determine the magnitude IDUs Baselines on IDUs carried out X NERCHA, MOHtransmission of HIVamong people whoinject drugs 50%3. Eliminate new HIV Implement integration of HIV and SRH interventions (FP, FP, Cervical cancer screening, MNCH and ART programmes are integrated and linked X MOHinfections among cervical cancer screening and ART), referral systems forchildreneMTCT within SRN and specifically other health care servicesResearch to inform efficiency and effectiveness of the MTCTprogrammes.Research to inform efficiency and effectiveness of the MTCT programmes conductedX4. Have 15 million PLHIVon ART by 20155. Reduce TB deaths inPLHIV by 50% by2015Strengthen the referral/ linkages and patient tracking systemthroughout HIV servicesStrengthen community systems to enhance continuum of carefor HIV/ TB and support for PLHIVStrengthen follow-up of HIV-exposed infants, identify childrenwith HIV, and improve linkages to ART initiation and retentionStrengthen active collaboration and integration between TB andART programmes and scale-up decentralized HIV/TB servicesat all service delivery levelsStrengthen active and passive TB case detection andengagement of communities to improve TB/HIV performanceutilizing the nurse-led TB initiation in clinics in order to improvethe uptake of servicesStrengthen monitoring of HIV/TB interventions, especially withinthe HIV programFindings from the ongoing pilot for the national referral system adopted X MOHFull implementation of the Referral and linkages SOPXPre-ART services include TB screening, Prophylaxis cotrimoxazole & isoniazidXstrengthenedCommunities engaged through RHMsXServices decentralized up to the community levelXStrengthened retesting at 12 and 18 months by promoting full utilization of the under-fiveXregisterImproved ART uptake and retention in care by strengthening family approach X X XTB/HIV collaboration framework for decentralize services reviewed X MOHTB/ HIV decentralization guide disseminatedXTB/HIV services to the clinic level and sample collection system decentralizedXMolecular testing (rapid testing) to ensure clients get results within 24 hoursXACSM advocacy, communication and social mobilization strategy in place andXdisseminatedEnsure adherence to ART and TB treatment and DR-TBAdvocacy for political commitment for domestic funding to reduce donor dependence ofXXHLM Mid-Term Review for Swaziland Page 24

6. Close the resourcegap7. Eliminate genderinequalities8. Eliminate stigma &discriminationDevelop an HIV sustainable financing framework and strategythat will also articulate the longer term investment case forSwaziland.Strengthen strategies that promote efficiencies and costeffectiveness of the national response.Scale-up implementation of targeted and evidence informedgender programmes in the HIV responseMainstreaming of gender issues into National Dev’t Plans withclear targets and sufficient resource allocation.Scale-up implementation of the Stigma index recommendationsand the National Strategy for Combating HIV and AIDS RelatedStigma and Discrimination.Improve access to legal services for PLHIV, girls and women,affected family members, communities and key populations toknow their rights, policies and laws in the context of the HIVepidemicUndertake a Legal environment assessment for stigma anddiscrimination9. Eliminate travelrestrictions10. Integration Continue strengthening HIV integration within other healthservicesDevelop national mainstreaming guidelines to guide sectors inthe Dev’t of their response to HIV and AIDsTB/HIV programs conductedConsensus on the system for capturing HIV and TB data reachedXCascade from screening, treatment and patient follow up implemented.XWell-resourced and sustainable HIV response based on needs X NERCHAEfficiency and cost effectiveness studies conductedIncreased uptake of prevention services such as HTC, MMC and condom use amongst XDPM Officemen.Gender based violence cases reduced.XGender sensitive policies that impact on the response to HIV are implemented.XInternational and regional instruments which have a bearing on HIV and AIDS are XdomesticatedStigma strategy implemented X NERCHA,Stigma and Discrimination mitigation activities mainstreamed in all planningXSWANNEPHAIncreased number of PLHIV, women and girls, affected family members and keypopulations accessing legal servicesLegal environment assessment conductedRecommendations of the assessment findings implementedCapacity built for coordination and integration X NERCHA, MOHMore facilities integrating SRH and HIVXMinistry plans clearly mainstreaming HIVXXXXHLM Mid-Term Review for Swaziland Page 25

Annex 3Key informants1. Senator T. Msane - Parliament2. Victoria Masuku - PSI3. Ntsiki Malindzisa - Church Forum4. Zandile Mnisi - MOH – MARPS/SID5. Sindy Shongwe - MOH – SNAP MARPS6. Muhle Dlamini - MOH – SNAP7. Sandile - MOH – TB Control Program8. Janet Ongole - URC9. Dr Sithembile Dlamini - MOH – SNAP ART10. Dr Velephi Okello - MOH – SNAP ART11. Rev Senzo Hlatshwayo - CCM12. Rudolph Maziya - AMICAALL13. Thembi Nkambule - SWANNEPHA14. Nicole Miller - PACT15. Khanya Mabuza - NERCHA16. Thembi Dlamini - NERCHA17. Innocent Maziya - NERCHA18. Emmanuel Ndlangamandla - CANGO19. Futhie Dennis-Langa - NERCHA20. Allen Waligo - NERCHA21. Nozipho Mkhatshwa - NERCHA22. Sicelo Dlamini (PS) - Prime Minister’s Office23. Thembi Gama - NERCHA24. Rosemary Fakudze - NERCHA25. Muriel Mafico - UNICEF26. Dr Kwame Ampoah - UNAIDS27. Pepukai Chikukwa - UNAIDS28. Thembisile Dlamini - UNAIDS29. Sneli Ntshangase - UNDP30. Sanelisiwe Tsela - UNFPA31. Khangeziwe Mabuza (PS) - DPM’s Office32. Thobile Dlamini - SWABCHA33. Lucille Bonaventure - PEPFAR34. Bonisile Nhlabatsi - SRHU35. Dumsani Kunene - NERCHA36. Nokwazi Mathabela - NERCHA37. Mduduzi Ndlovu - NERCHA38. Dr Steven Shongwe (PS) - MOH39. Rejoice Nkambule (Director) - MOH40. Pat Muir (PS) - MOE41. KhaboninaMabuza (PS) - MOF42. Bheki S. Bhembe (Director Budgeting) - MOF43. Majahenkhaba Dlamini (AG) - MOJCAHLM Mid-Term Review for Swaziland Page 26

44. Sabelo Matsebula (Deputy AG) - MOJCA45. Vusi Dlamini (Acting PS) - MOEPD46. Natalie Kruze-Levy - PEPFAR47. Xolile Mabuza/Sibusiso Maziya - Rock of Hope/LGBTHLM Mid-Term Review for Swaziland Page 27

Annex 4Stakeholders in Validation MeetingsList of Stakeholders in Attendance meetings held on the 28 th May 2013 and 11 th June 2013:1. Muhle Dlamini - MOH2. Dr Sikhathele Mazibuko - MOH3. Muriel Mafico - UNICEF4. Rudolph Maziya - AMICAALL5. Victoria Masuku - PSI6. Sandile Mweli - PSHACC7. Pinky Dlamini-Simelane - SWABCHA8. Phindile Masango MOEPD9. Dickson Mkhonta - DPM’s Office10. Dr Haumba - URC11. Sunny Xi - CHAI12. Dr Serge Kabore - MSF13. Sipho Kunene - PEPFAR14. Mandla Luphondvo - NERCHA15. Thembi Dlamini - NERCHA16. Senzo Hlatshwayo - CCM17. Futhi Dennis-Langa - NERCHA18. Pepukai Chikukwa - UNAIDS19. Nokwazi Mathabela - NERCHA20. Thembisile Dlamini - UNAIDS21. Nana Mdluli - NERCHA22. Mduduzi Ndlovu - NERCHA23. Allen Waligo - NERCHA24. Nsindiso Dlamini - NERCHA25. Nozipho Mthande - NERCHA26. Faith Dlamini - UNISWA27. Fortunate Magagula - UNISWA28. Khangeziwe Mabuza - DPM29. Khanya Mabuza - NERCHA30. Zwanini Shabalala - Church Forum31. Thobile Dlamini - SWABCHA32. Tengetile Simelane - CCM33. Gloria Bille - UNAIDS34. Thembisile Gama - NERCHA35. Emmanuel Ndlangamandla - CANGO36. John Hlophe - MOE37. Bonisile Bhembe - PSI38. Phindile Masango - MOEPD39. Lucas Jele - NERCHA40. Musa Dlamini - SNNCHLM Mid-Term Review for Swaziland Page 28

Annex 5References1. Global Response AIDS Reporting 2013: Construction of Core Indicators for monitoring the2011 UN Political Declaration on HIV/AIDS2. HIV Estimates and Projections Reports, Service Availability Mapping Report3. HIV Sentinel Surveillance Reports 2010 and 20124. Ministry of Health Annual Report, April 20135. Modes of Transmission Study Report6. Multiple Indicator Cluster Survey (MICS)7. National AIDS Spending Assessment (NASA) 20108. Preliminary results of the Behavioural Sentinel Surveillance for Most at Risk Populations(BSS MARPS)9. Preliminary Results of the Swaziland HIV Incidence Measurement Survey (SHIMS), 201110. Swaziland Demographic and Health Survey 2006/711. Vulnerability Assessment Report12. WHO/UNAIDS, Towards Universal Access: Progress Report 2010HLM Mid-Term Review for Swaziland Page 29