Swaziland has the highest HIV prevalence in the world; an estimated one in three women and one in five men are HIV positive. And with a high rate of new infections, the epidemic continues to grow.
HIV testing and counseling (HTC) programs are an effective way to educate people about HIV prevention and to enroll them for treatment and support services if they are positive.
When it was established in 2002, Swaziland’s national HTC program focused only on providing voluntary testing and counseling (VTC), where individuals opt for these services voluntarily. However, by 2007, fewer than one in five people had ever taken an HIV test and received their results, and nearly 85% of Swazis did not know their HIV status. There was an urgent need to increase knowledge of one’s HIV status in the country and to assist people to access HIV treatment and support services.
In response, the U.S. Centers for Disease Control and Prevention (CDC) initiated a project, managed by University Research Co., LLC (URC), to increase HTC
in Swaziland. The URC HTC Project,which ran from 2006 to 2011, provided critical technical assistance to the Ministry of Health to develop and undertake the shift from VCT only to a dual approach that includes provider-initiated HTC.
With provider-initiated HTC, HIV testing and counseling is offered to patients during routine health visits regardless of their reason for accessing health services.
The Ministry of Health adopted the goal of integrating HTC into the existing general health system and to increase the number of HIV-positive individuals receiving antiretroviral therapy to 75% by 2008. To reach this goal, the health system needed innovative, ethical, and practical models for delivering HTC.
Because people living with HIV are more susceptible to developing TB infections, the URC HTC Project saw an opportunity to offer HTC services in TB clinics and to integrate TB-HIV services. In Swaziland, about 8 in 10 individuals who have TB are HIV positive.
Before the project’s launch in 2006, only one TB clinic provided HTC services to TB patients and less than 5% of TB patients accessed those services. Instead, TB patients who wanted to know their status were referred to VTC centers. These centers were often overburdened and struggled to provide high-quality counseling services and to adequately support patients through referrals to care and treatment. One patient said, “I came in the morning but after three hours, I am still waiting to be done an HIV test. I have been pushed from one queue to the other and I will be lucky to get transport [to return] home.”
Recognizing the need to address TB-HIV services collectively and under one roof, the project worked in close collaboration with the National TB Control Program to integrate provider-initiated HTC at TB clinics. Through the efforts of the project team and their local counterparts, by October 2011, 51 TB clinics had added HTC services.
Testimony from TB/HIV patient at a URC support site:
Today, I am back at work and my wife is working again, too: no more sleepless nights, night sweats, and all the like. I feel so healthy and confident, I feel like the sky is the limit yet again. I am glad I tested with my wife because I was not faced with the task of daunting disclosure of HIV status [alone].
He says his wife is very supportive and usually reminds him to take his pills.
Human resource challenges were a key constraint to providing HTC in busy clinics, so the project helped devise methods in high-volume clinics to shift tasks related to HTC from nurses to lay HTC counselors, giving nurses more time for other aspects of specialized patient care. The project also helped to integrate HTC information in the TB registers and TB patient cards and to train TB clinic health care workers in HTC. The project guided regional focal persons and facility managers to conduct meetings where focal persons from TB clinics would come together to share best practices and develop improvement plans related to HTC service provision in the region and health facility. Quality improvement teams (teams of health professionals who work together to improve care) were established in 10 facilities.
By project closure, the uptake of HTC among TB patients had increased to 90%. Now, more people in Swaziland are exercising the right to know their HIV status, and those who test positive benefit from increased access to HIV treatment, empowering them to actively participate in preventing HIV transmission. The URC HTC Project worked as a catalyst to integrate HTC in TB clinics and provided key technical assistance to the National TB Control Programme and the Swaziland National AIDS Program. HIV treatment is now being initiated within the TB clinics for patients co-infected with TB and HIV, saving time and lives.