Outcomes and Impact of HIV Prevention, ART and TB Programs in Swaziland - Early Evidence from Public Health Triangulation
South African Department of Science and Technology, National Research Foundation Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA, University of Stellenbosch, Cape Town, South Africa; Strategic Information Department, Swaziland Ministry of Health, Mbabane, Swaziland; Department of HIV/AIDS, World Health Organization, Geneva, Swaziland; Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, Netherlands; Strategic Intelligence and Analysis, UNAIDS, Geneva, Switzerland; Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
Introduction:Swaziland's severe HIV epidemic inspired an early national response since the late 1980s, and regular reporting of program outcomes since the onset of a national antiretroviral treatment (ART) program in 2004. We assessed effectiveness outcomes and mortality trends in relation to ART, HIV testing and counseling (HTC), tuberculosis (TB) and prevention of mother to child transmission (PMTCT).Methods:Data triangulated include intervention coverage and outcomes according to program registries (2001-2010), hospital admissions and deaths disaggregated by age and sex (2001-2010) and population mortality estimates from the 1997 and 2007 censuses and the 2007 demographic and health survey.Results:By 2010, ART reached 70% of the estimated number of people living with HIV/AIDS with CD4<350/mm3, with progressively improving patient retention and survival. As of 2010, 88% of health facilities providing antenatal care offered comprehensive PMTCT services. The HTC program recorded a halving in the proportion of adults tested who were HIV-infected; similarly HIV infection rates among HIV-exposed babies halved from 2007 to 2010. Case fatality rates among hospital patients diagnosed with HIV/AIDS started to decrease from 2005-6 in adults and especially in children, contrasting with stable case fatality for other causes including TB. All-cause child in-patient case fatality rates started to decrease from 2005-6. TB case notifications as well as rates of HIV/TB co-infection among notified TB patients continued a steady increase through 2010, while coverage of HIV testing and CPT for co-infected patients increased to above 80%.Conclusion:Against a background of high, but stable HIV prevalence and decreasing HIV incidence, we documented early evidence of a mortality decline associated with the expanded national HIV response since 2004. Attribution of impact to specific interventions (versus natural epidemic dynamics) will require additional data from future household surveys, and improved routine (program, surveillance, and hospital) data at district level. © 2013 van Schalkwyk et al.
antiretrovirus agent; CD4 antigen; nevirapine; acquired immune deficiency syndrome; adolescent; adult; article; biostatistics; CD4 lymphocyte count; child; demography; evidence based medicine; female; health care facility; health impact assessment; health program; health survey; HIV test; hospital admission; hospital patient; human; Human immunodeficiency virus infected patient; Human immunodeficiency virus infection; Human immunodeficiency virus prevalence; incidence; major clinical study; male; mixed infection; mortality; multidrug resistant tuberculosis; outcome assessment; population research; prenatal care; primary prevention; public health service; register; single drug dose; survival; Swaziland; tuberculosis; tuberculosis control; vertical transmission; virus transmission; Adolescent; Adult; Antiretroviral Therapy, Highly Active; Cause of Death; Comorbidity; Counseling; Female; HIV Infections; Hospitalization; Humans; Incidence; Infectious Disease Transmission, Vertical; Inpatients; Male; Middle Aged; National Health Programs; Prevalence; Public Health; Survival Analysis; Swaziland; Treatment Outcome; Tuberculosis; Young Adult