Lessons drawn from implementing the HIV response: the eNSF evaluation
Lessons from implementing the HIV response: the eNSF evaluation
The Government of the Kingdom of Swaziland considers HIV as a health, development and human rights issue. Since the 1990s, the government has endeavored to provide comprehensive quality HIV and AIDS services to all Swazi citizens - a commitment that is expressed in the periodic national strategic frameworks. This far, the country’s HIV response has been guided by four national multisectoral strategic frameworks, each with its own strategic orientation. Since the past four years leading to 2018, the country’s roadmap in the HIV response is provided by the Extended National Strategic Framework (eNSF 2014 – 2018).
The 2014 to 2018 strategic framework focuses on high impact interventions targeting population groups that are vulnerable and at a higher risk with the goal to half new HIV infections, reduce AIDS deaths and provide efficient services. In terms of orientation, the eNSF aims to do better and more of the right things, at the right time and scale; while ensuring smart investment in priority programmes for greater impact and future resources. Compared to previous national strategic frameworks, the eNSF provides a paradigm shift, adopting the “investing for results” approach to improve efficiency and effectiveness in the national response.
With 2018 steadily approaching, in April 2017, the National Emergency Response Council on HIV and AIDS (NERCHA) commissioned a consultancy to conduct a critical analysis of the Swaziland HIV response’s overall performance in the implementation of the eNSF and Umgubudla: a fast-track programme towards a AIDS-free Swaziland, and draw lessons to inform the next strategy. This was to evaluate if the eNSF achieved its impact and outcome, and determining if the strategic orientation worked.
Relevance, Impact and performance of the eNSF programmes
The review team constituted of Mr. Tom Mogeni Mabururu (the International Consultant) and Mr. Ngwebendze Nhlabatsi (Local Consultant) who worked in consultation with the National Steering Committee and National Task Team.
Last week the consultants presented their findings and recommendations to various stakeholders. The stakeholders’ validation meeting held at the Royal Swazi Sun’s Convention Centre pointed out that there is a lot the country’s HIV response can be proud of since the eNSF programmes are relevant and effective to meeting the targets. The review team noted that the involvement of stakeholders in the development and dissemination of the eNSF helped ensure that HIV programmes running in the country were aligned to it, as the “One Strategic Framework”. Further, they found that the eNSF programmes were anchored, aligned and responsive to national and international frameworks and global realities – as seen in the adoption of new normative guidance in the course of its implementation.
In a nutshell, eNSF programmes’ performance and impact is as follows:
New HIV infections are gradually declining, though not at a rate that will achieve the 2018 set target of 1.4%. The Achilles heel remains that adolescents and young people aged 15-24 account for 45% of new infections – effectively making this group, the new centre of the epidemic.
AIDS deaths have declined by 24% between 2013 and 2016. Most deaths accrue amongst men, with the TB/HIV co-infected also making a telling contribution. Declining AIDS deaths will make a positive impact to the country’s socio-economy.
Life expectancy has marginally improved (from 44 years to 48.5 years), pointing to a successful antiretroviral treatment programme. However, it must be pointed out that this rate is the lowest among the neighboring countries (with Namibia having the highest at 65.1 years).
The Umgubudla fast-track targets are on track, with the Prevention of Mother-to-Child Transmission (PMTCT) and TB/HIV being the pole bearers. HIV stigma and discrimination remain major bottlenecks for HIV testing uptake even though HIV tests have increased from 178 823 in 2011 to 413 660 in 2015.
Unfortunately, viral load suppression and voluntary medical male circumcision (VMMC) lag behind.
HIV prevention services are progressing but not at the requisite rates to reduce new infections. On one hand, access, demand creation and distribution of condoms has been scaled up; but on the other hand, trends show increases in sexually transmitted infections, and teenage pregnancy rates which indicate either condoms are insufficient or inconsistent condom use. As well, the percentage of 15-49 reporting having sex with more than one person has increased.
Coordination of social behavior change is weak with low coverage among youth in primary school, tertiary institutions; and those who are out-of-school.
Service coverage for populations at highest risk of new infections or transmission (key populations (KPs) has increased, though the services are not uniform and some of the KPs’ sexual practices are criminalized. Due to self and external stigma, KPs in rural areas do not identify themselves and so are a difficult target.
Sadly, overall governance of the HIV response is sub-optimal with only 27% of key coordination targets being met.
The findings from this evaluation, along with other documents like the Swaziland HIV Incidence Measurement Report 2 - SHIMS II, will form the basis for the development of the next national strategic framework to take the country to Vision 2022 - An AIDS free Swaziland.
Important lessons from the findings
The biggest lessons came from the UNAIDS Country Director, Tim Rwabuhemba who closed the meeting by providing a sobering summary of the findings. Rwabuhemba warned that the current successes also mean a greater need to avoid complacency which could result in the disease rebounding.
He added that there is still much to do in the HIV response in the country, especially in the pursuit of the 2022 target of eradicating new HIV infections and ending AIDS, as called by His Majesty King Mswati III. The UNAIDS Country Director requested all HIV response stakeholders to consider the following as we develop the next strategic document to take us to the end of AIDS. Quotes from Rwabuhemba include;
“Well and good, new HIV infections are declining, but this does not mean that the tap is completely closed as the goal is to achieve zero new HIV infections. That new infections are highest among adolescents and young people should provide all with sleepless nights. It is totally unacceptable that adolescents and young people contribute 45% of total new infections. There is need for each one, to find a way to bring down new HIV infections in our families and our communities”.
“The quest is for zero AIDS related deaths therefore even one AIDS related death is too much. There is need to personalize the HIV and AIDS response and bring it closer to each one of us. To eliminate AIDS related deaths nationally, we need to eliminate it first in our families. Also, we need to mind the socio-economic impacts of HIV which will continue as a result of AIDS-related deaths. There is need to especially look at how to mitigate the impact of HIV on orphans and vulnerable children.”
“Men, men, men are dying. Can we imagine a country without men? There is need to determine which groups of men are dying and take men engagement a step further. The time to walk the talk is now!”
“It is not acceptable that life expectancy has marginally increased. There is need to get HIV out of isolation and fast track integration with other diseases, especially the non-communicable diseases. Other health challenges have to be considered but integration should be the new way of doing business in the country.”
Importantly, the expectation has always been that “Life shapes you, and if you do not respond accordingly, it breaks you!”. For the country, that is prevention - preventing new infections! It has become even more critical as it affects younger ages. As the country looks to develop the next HIV framework, which should realistically be the last opportunity to work towards the King’s Vision 2022, it is important that we learn from the eNSF evaluation.