Implementation of Cryptococcal Screening and Treatment in the Kingdom of Eswatini
Cryptococcal infection is caused by inhalation of spores from the fungus Cryptococcus. In immunosuppressed persons, particularly those with HIV, the latent infection, which causes inflammation of the tissues covering the brain and spinal cord, can reactivate and spread throughout the body. Cryptococcal infection can be fatal if not treated quickly. CrAg screening is a simple blood test to detect the fungus for diagnosis of cryptococcal meningitis.
The 2017 WHO Guidelines for managing advanced HIV disease and rapid initiation of antiretroviral therapy and the 2018 Eswatini Integrated HIV management guidelines recommend CrAg screening for both cryptococcal infection and TB with TB LAM testing as part of a package of care for people living with HIV (PLHIV) with advanced HIV disease (AHD). TB LAM testing, a urine-based diagnostic test for TB, is considered an effective point-of-care diagnostic tool for HIV-associated TB in low-resource settings.
As PLHIV enter advanced HIV disease, screening for these two comorbid diseases becomes increasingly important as they account for a significant proportion of HIV-related morbidity and mortality when undiagnosed and untreated.
Overview and Objectives
The project’s goal was to provide technical assistance to the Eswatini National AIDS Programme to support the implementation of the World Health Organization 2017 Guidelines for Managing Advanced HIV Disease and Rapid Initiation of Antiretroviral Therapy which recommends Cryptococcal Antigen (CrAg) screening and Tuberculosis Lipoarabinomannan Antigen (TB LAM) testing as part of a package of care for people living with HIV (PLHIV) presenting to care with advanced HIV disease.
URC worked closely with the Ministry of Health and other stakeholders to build Eswatini National AIDS Programme capacity to provide advanced HIV disease management services, facilitate training of health providers at select health facilities for provision of CrAg screening and TB LAM testing, and implement enhanced monitoring and evaluation (M&E) of project activities at the 16 priority sites to inform future Eswatini National AIDS Programme AHD services.
The project sought to:
- Provide technical support to the Eswatini National AIDS Programme to scale up AHD management in 16 selected facilities
- Scale up CrAg screening and treatment in the facilities
- Scale up TB LAM screening and treatment in the facilities
- Evaluate the implementation of CrAg screening and TB LAM testing and treatment as components of AHD care in Eswatini
- Provide technical assistance to the Eswatini National AIDS Programme to support the implementation of the ECHO project to build on the gains realized in AHD management and establish a virtual platform to address the identified gaps
The project achieved all objectives, including:
- Standards and Tools: Provided technical support to develop and amend policies, guidelines, standard operating procedures, job aids, M&E tools, and indicators, information, education, and communication materials, and other key documents in line with international standards on AHD management, including CrAg and TB LAM screening
- Health Workforce: Trained 42 health care workers to be trainers. 379 health care workers were subsequently trained in the regional facilities with an increase in AHD knowledge from an average of 60 to 90 percent. The project supported integration of AHD care and treatment services into training curricula. They also supported setting and monitoring of performance targets at project-supported facilities and conducted service delivery assessments in 16 health facilities across four regions.
- Supply Chain: Ensured availability of serum and cerebrospinal fluid CrAg and TB LAM test kits and AHD medications through inter-facility sharing during facility-level stockouts and with laboratories and pharmacies. Inter-facility sharing was embedded into regional health system processes
- Evaluation: Assessed the effectiveness, efficiency, and quality of the project, identified implementation gaps and challenges, documented lessons learned, and make recommendations to institutionalize and sustain the project’s gains
- Service Delivery: Increased the number of individuals screened for AHD and successfully linked to care services across the 16 project facilities
- Virtual platforms: Procured and installed virtual platforms in five sites, trained facility focal persons on how to use the virtual platforms, delivered training on AHDM, and transferred management of the virtual platforms to the MOH
URC assisted Georgetown University with the start-up of a follow-on project, entitled Support Eswatini to Achieve Sustained Epidemic Control Program. It builds on the gains realized in AHD management in the first project, leveraging the established virtual platforms to address identified gaps: additional health care worker training on AHD, systematic assessment of patients failing or interrupting treatment, and improved HIV testing and treatment.